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This article appeared in The Georgia Straight, May 4-11, 2000.
by Gail Johnson
Advances in the treatment of HIV and AIDS have had a tremendous impact on the quality of life of those living with the disease. But many HIV-Positive people are struggling with another epidemic that threatens their health, hepatitis C. Although the chief means of transmission of the disease, which is a viral infection of the liver, is direct contact with blood or blood products, new findings by a group of Vancouver researchers reveal a frightening possibility: hepatitis C could occur due to sexual transmission far more often than people think, according to Kevin Craib, data-centre director with the BC Centre for Excellence in HIV/AIDS.
Blood transfusions are a major risk factor for hepatitis C, particularly those received before 1990 in Canada, when donor screening for hep C began. Yet the most common risk factor for the condition, which causes inflammation of the liver, is injection drug use. In Canada, the rate of infection among those who have used injection drugs is 30 percent, according to the July 1995 Canadian Communicable Disease Report Supplement. The same report estimated the risk of infection through sexual intercourse with a carrier to be a mere 2.5 percent. That's low compared to the rate put forward by the World Health Organization, which pegs sexual transmission as accounting for about 15 percent of infections.
However, Craib-the leading researcher in a study of sexual transmission of the virus in homosexual men-suspects the actual rate may be much higher.
"There are approximately 200 million people infected worldwide," Craib said in an interview with the Georgia Straight. " Is there far more injection-drug use going on than we think? How is it being spread? I don't think injection-drug use explains the vast number of cases. There is something else going on. There's no question injection-drug use is a risk factor, but we need to ask, 'What is the role of sexual transmission?'"
Craib, who presented his results at the Canadian Conference on HIV/AIDS in Montreal on April 29, set out to determine the prevalence of hepatitis C virus and to identify risk factors for HCV infection in a cohort of homosexual men, using Vancouver Lymphadenopathy-AIDS Study. The VLAS, which started in 1982, is an ongoing study of HIV rates, risk factors, and the disease progression in a cohort, or group, of 1000 gay men in Vancouver. Craib drew on questionnaire data and blood specimens from 662 VLAS participants and took several variables into account: substance abuse (such as Cocaine use), injection-drug use, and specific sexual practices, including such factors as the number of male sexual partners, anal intercourse, oral-anal contact, and fisting.
Craib found that six percent of the men were HCV-positive and the prevalence of hepatitis C was significantly higher in HIV-positive men than HIV-negative men. Not surprisingly, a history of injection-drug use was a significant risk factor for HCV infection. Those who reported injection-drug use between 1982 and 1985 were 12times more likely to have hep C, and those who reported use during their lifetime were 30 times more likely.
But here's where things get interesting: 49 percent HCV-positive did not report injection-drug use during their lifetime. And among those men, certain sexual practices were identified as significant risk factors for HCV infection. Men who reported more than 100 male partners in their lifetime were 2.5 times more likely than those who had fewer partners to be HCV-positive; those who reported receptive and intercourse in more than 25 percent of sexual encounters were two more likely; those who reported oral-anal contact in more than 25 percent of encounters were more likely; and those who reported insertive fisting were nearly three times more likely.
What does it all mean? That there is evidence of the sexual transmission of HCV independent of injection drug use.
"Any sexual practices where there is a likelihood of blood-to-blood contact or tearing of the skin, such as fisting, could account for the transmission of hepatitis C," Craib said. " My suspicion is the role of sexual transmission is being underestimated. It's biologically plausible; certain sexual practices involve tearing of skin or mucosal lining. This suggests perhaps there is a sexual component to the transmission of this virus."
Craib emphasized that more research is needed to substantiate his findings. Nonetheless, the fact remains that the number of people suffering from both HIV and hep C is staggering. In the States, nearly one in two people with HIV is also infected with hep C, according to the New York based Community Research Initiative on AIDS. In Vancouver, 25 percent of the city's approximately 9000 injection-drug users are HIV-positive, and 90 percent of those total users are HCV-positive, according to the BC Centre for Disease Control. As a result, health care organizations are starting to find ways to help people cope with coinfection.
Health Canada this year approved funding for a coinfection outreach and support program that is jointly operated by the BC Persons With Aids Society and the Vancouver Native Health Society. The three-year project is to begin in mid May out of an office at 449 East Hastings Street (above the VNHS). There, people can get counseling as well as information and resources related to both hepatitis C and AIDS. It will fill an enormous hole, said Brian McKinnon, treatment-information program director of the BCPWA.
"Everyone I'm seeing now is coinfected with hepatitis C," McKinnon told the Straight. "But it's like the early '90s with AIDS again; no one knows what it [hep C] is what the treatments are, what the symptoms are. There's no time to learn the avalanche of information about it." He credited groups like the Canadian Liver Foundation and AIDS Vancouver with providing excellent support groups for people dealing with specific diseases, but he said there's still a lack of resources focusing on the implication of being coinfected with AIDS and hepatitis C.
"People who are coinfected need to know there is hope and that there is better treatments available," McKinnon said. "They need to be empowered to take treatment advocacy on themselves."
Like those who have HIV or AIDS, many people who have hep C may not have symptoms and may actually feel quite healthy. However, about 80 percent of people infected with hepatitis C develop chronic infection, according New York's CRIA. They may experience symptoms such as fatigue, abdominal discomfort, and nausea, as well as other disease progression, such as cirrhosis (liver disease) and fibrosis (scarring) of the liver. Some will develop cancer.
"Hep C is like HIV in that people can walk around for a long time and not know they have it," said Chester Morris, as assistant professor at UBC and medical director of HIV service at Vancouver Hospital and Health Sciences Health Centre. "When we think hep C, we think of jaundice or people being very ill, but, in fact, the symptoms are very mild, and some people don't have any symptoms at all. So it's a very insidious disease.
Typically, hepatitis C is a slowly progressive disease; in combination with HIV or AIDS, though, it becomes increasingly virulent. Hep C sufferers stand a 20 percent chance of having serious liver damage after 20 years, but that damage may occur after only 10 years if they're coinfected with HIV, Morris added.
"Hepatitis C seems to be magnified by HIV, but the converse doesn't seem true. Hepatitis C doesn't seem to make HIV progressive faster, but HIV appears to make hep C faster."
Morris said medical professionals don't know why that is the case and that more research on the disease as a whole is needed-especially since the hep C virus was only characterized in 1989.
In April, Health Canada approved funding for Morris to lead
a two-year study on the sexual transmission of hepatitis C in
BC. "Right now, we tell people to use condoms.," Morris
added. "There is a low chance they may acquire hep C, but
we don't know what the chance is. The question of sexual transmission
is still in the air." Morris said that having more definitive
answers on the role sexual transmission would help the medical
profession come up with standard procedures, and recommendations
for testing-such as screening in STD clinics-prevention, and treatment.
For more information, contact:
Vanguard Project Coordinator
608 - 1081 Burrard Street
Vancouver, BC, Canada, V6Z 1Y6