Jpn. J. Infect. Dis., 52, 1999

Laboratory and Epidemiology Communications

Hepatitis A Virus Outbreak; a Possible Indicator of High Risk Sexual Behavior among HIV-1 Infected Homosexual Men

Taro Kojima, Natsuo Tachikawa, Sadako Yosizawa, Chie Yasuoka, Yoshihiko Yamamoto, Ikumi Genka, Katsuji Teruya, Yoshimi Kikuchi, Makoto Aoki, Akira Yasuoka, and Shinichi Oka*

AIDS Clinical Center, International Medical Center of Japan,
Toyama 1-21-1, Shinjukuku-ku, Tokyo

Communicated by Hiroshi Yoshikura

(Accepted September 13, 1999)

Hepatitis A virus (HAV) is transmitted orally. In non-endemic Japan, HAV
infection occurs mostly in winter through ingestion of raw oysters. HAV is also as a sexually transmitted disease (STD) among homosexual men (1-3), and is transmitted through transfusion of factor VIII among hemophiliacs (4,5).

We recently encountered an HAV outbreak among HIV-positive homosexuals in the AIDS Clinical Center, International Medical Center of Japan. In the last 12 months, 22 HIV-positive patients were admitted to our ward because of acute HAV infection (Fig. 1). All were homosexual men. About 420 HIV-positives, estimated to be one-tenth of the reported HIV-positive patients in Tokyo and its suburbs, have in the last year made monthly visits to our out-patient clinic. Forty percent were hemophiliacs infected through HIV-contaminated coagulant factors. Fifty-five percent were known to be infected through sexual intercourse; 30% were homosexuals and 25% heterosexuals. It was roughly estimated that 15% of the HIV-positive homosexual men in our clinic had HAV infection (21 HAV-infected individuals among homosexuals whose population corresponded to 30% of 420 seropositives). In contrast, none of the hemophiliac and heterosexual groups had HAV infection. The appearance profile of HAV patients (Fig. 1) clearly shows the presence of the outbreak which started in July, 1998.

The clinical features of HAV infection in HIV patients were similar to those of usual HAV infection. All the patients were diagnosed with liver dysfunction and showed elevated anti-HAV IgM. None of them were exacerbated to fulminant hepatitis.

The CD4 count of these patients ranged from 96 to 716/mm3 (median, 447/mm3). All were asymptomatic except two cases (one had developed AIDS and the other had symptoms of acute primary HIV infection when HAV infection was diagnosed). Eleven patients had been treated with anti-HIV drugs, nine with highly active anti-retroviral therapy (HAART), and two with a combination of two reverse-transcriptase (RT) inhibitors. The plasma HIV RNA, viral load (VL) of seven patients ranged from 580 to
4,800 copies/ml. The VL in the other four patients was below the quantifiable level (<400 copies/ml). In five patients in the former group, viruses with anti-HIV drug-related resistant mutations in either the RT or protease regions were detected.

Though two patients denied having sexual intercourse in the preceding three months, 19 patients affirmed that they continued to have sexual intercourse with multiple unspecified partners. This HAV outbreak indicates that the sexual activity of these homosexuals entails the risk of transmitting not only HAV but HIV to their partners. It should be noted that nine of them were put on HAART and five were regarded as a virological failure (VL higher than 400 copies/ml). As some of them had HIV with resistance-related mutations, these patients run the risk of transmitting HIV with multiple-drug resistance as Hecht et al. has suggested (6). As HAART has dramatically improved the prognosis of HIV infection (7), the fear of HIV infection may have diminished in certain high risk homosexual groups. HAV outbreak could be used as an indicator of such high risk homosexual activities.

This work was supported by the Ministry of Health and Welfare of Japan, and the Organization of Pharmaceutical Safety and Research (OPSR) of Japan.

REFERENCES

  1. Corey, L. and Holmes, K.K.(1980): Sexual transmission of hepatitis A in homosexual men. Incidence and mechanism. N. Engl. J. Med., 320, 435-438.
  2. Kani, J., Nandwani, R., Gilson, R.J.C., Johnson, A.M., Maguire, H.C. and Tedder, R.S.(1991): Hepatitis A virus infection among homosexual men. Br. Med. J., 302, 1399.
  3. Centers for Disease Control and Prevention (1998): Hepatitis A vaccination of men who have sex with men-Atlanta, Georgia, 1996-1997. Morbid. Mortal. Wkly. Rep., 47, 708-711.
  4. Mannucci, P.M., Gdovin, S., Gringeri, A., et al.(1994): Transmission of hepatitis A to patients with hemophilia by factor VIII concentrates treated with organic solvent and detergent to inactivate viruses. Ann. Intern. Med., 120, 1-7.
  5. Chudy, M., Budek, I., Keller-Stanislawski, B., McCaustland, K.A., Neidhold, S., Robertson, B.H., Nubling, C.M., Seitz, R. and Lower, J. (1999): A new cluster of hepatitis A infection in hemophiliacs traced to a contaminated plasma pool. J. Med. Virol., 57, 91-99.
  6. Hecht, F.M., Grant, R.M., Petropoulos, C.J., Dillon, B., Chesney, M.A., Tian, H., Hellmann, N.S., Bandrapalli, N.I., Digilio, L., Branson, B. and Kahn, J.O. (1998): Sexual transmission of an HIV-1 variant resistant to multiple reverse-transcriptase and protease inhibitors. N. Engl. J. Med., 339, 307-311.
  7. Palella, F.J., Delaney, K.M., Moorman, A.C., Loveless, M.O., Fuhrer, J., Satten, G.A., Aschman, D.J., Holmberg, S.D. and the HIV Outpatient Study Investigators (1998): Declining morbidity and mortality among patients with advanced human immunodeficiency virus infection. N. Engl. J. Med., 338, 853-860.

*Corresponding author: Fax: +81-3-5273-5193, E-mail: oka@imcj.hosp.go.jp

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