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EDITORIAL
The study article follows this Editorial.
Norah A. Terrault, M.D., M.P.H. 1
1Division of Gastroenterology, University of California at San
Francisco, San Francisco, California
While there is sufficient evidence to support the conclusion
that sexual transmission of hepatitis C virus (HCV) occurs,
quantifying the magnitude of an individual's risk of HCV
acquisition by sexual contact has been more challenging. The
available data suggest the efficiency of transmission by the
sexual route is low. Nonetheless, since sex is a common behavior
and the reservoir of HCV-infected individuals is substantial,
sexual contact likely contributes to the total burden of HCV
infection in the United States. However, for individuals in
long-term monogamous relationships, <3% of sexual partners are
found to be HCV-infected and, in prospective studies, the
incidence is reported to be <0.1% per year. The current study
confirms these prior prevalence and incidence estimates. This
low frequency of HCV in the steady sexual partners of HCV-infected
individuals is what underlies the recommendation that these
couples need not change their sexual practices.
Sex as a mode of HCV transmission remains a subject of debate.
The issue is not whether the virus can be transmitted by sexual
contact but rather what the magnitude of the risk is and what
factors influence the risk of transmission. Since sexual
transmission cannot be observed directly or experimentally
manipulated, establishing sex as the mode of transmission
requires the demonstration of new infection in a susceptible
partner following sexual contact, the confirmation of the same
viral stains in the sexual partner, and the exclusion of
nonsexual modes of HCV acquisition. Several detailed case
reports meet these minimal requirements and provide convincing
evidence that HCV can be transmitted by sexual contact (1-3).
However, these case reports do not define the magnitude of risk.
To evaluate this, the rate of HCV infection in different risk
groups including those engaged in high-risk sexual behaviors,
those with newly acquired HCV infection, and those in long-term
partnerships have been evaluated. The apparently disparate
estimates of risk from these different populations have fueled
the ongoing controversy regarding the role of sex in HCV
transmission.
In 20% of persons with newly acquired acute hepatitis C, sex
with multiple partners or sex with an anti-HCV-infected person
in the preceding 6 months is the only identifiable risk factor
for infection (4). Indeed, in the United States, sex is the
second most common risk factor for HCV acquisition among those
with acute hepatitis C. At apparent odds with this figure, is
the relatively low prevalence of HCV infection reported in
groups at high risk for sexually transmitted diseases, such as
sex workers, attendees at sexually transmitted disease clinics,
and men having sex with men. In these "high-risk sex" groups,
the prevalence of anti-HCV ranges from 4% to 6% (5), a rate
somewhat higher than the general population but much lower than
other sexually transmitted viruses such as hepatitis B virus and
human immunodeficiency virus. Among those engaged in higher-risk
sexual activities, lack of condom use, total number of lifetime
sexual partners, anal intercourse, intercourse with mucosal
trauma, and HIV infection are linked with presence of anti-HCV.
These associations are consistent with HCV being a sexually
transmitted virus. However, the frequent coexistence of
injection drug use in persons who engage in high-risk sexual
activities complicates the picture and, in these settings,
defining the independent contribution of sex to HCV acquisition
can be difficult. For example, the rates of HCV infection among
persons who engage in higher-risk sexual activities but deny
injection drug use are not dissimilar to those of the general
population (5).
Heterosexual couples in long-term monogamous relationships
represent the most common form of sexual partnership. While the
available data indicate that the risk of HCV transmission in
persons in steady monogamous sexual relationships is lower than
those with multiple partners or those at risk for sexually
transmitted diseases, the question of "how low is the risk"
remains. Earlier studies reported HCV prevalence rates as high
as 24% in steady sexual partners of those with chronic HCV
infection, but these studies suffered from several
methodological flaws that led to an overestimation of the rate
of HCV transmission by sex (5). In particular, the lack of
detailed virological analysis of HCV antibody concordant couples
was a major limitation of earlier studies. More recent studies
of monogamous couples that utilized sequence analyses of the
virus in the partners to determine whether antibody concordant
couples are infected with a similar viral species report
prevalence rates of HCV of 2% or less in the partners (6-9).
Thus, studies lacking virological analyses of antibody
concordant couples have substantially overestimated the
frequency of HCV transmission by sex.
Prospective cohort studies also suggest the risk of HCV
acquisition in monogamous couples is low. Prior studies reported
incidence rates of 2.3-6 per 1,000 person-years (10, 11). In the
study Veysel et al. in this issue of The American Journal of
Gastroenterology, none of the 216 HCV-negative spouses
seroconverted over the 3-yr mean follow-up period. This low
incidence of new infections among monogamous couples supports
the current clinical practice of not recommending that such
couples change their sexual practices (4, 12).
Most published studies of HCV and sex lack information on the
frequency and types of sexual practices engaged in by the
population studied. Based upon what is known about transmission
of other sexually transmitted viruses, the risk of HCV
transmission by sex would be predicted to be higher in those
engaged in anal intercourse, sex with trauma to the genital
mucosa, or in the presence of other sexually transmitted
diseases. Unfortunately, information on risk of HCV acquisition
with specific sexual practices is unavailable. The current study
evaluated frequency of sexual contact. All couples denied condom
use and "various sexual practices," but additional details on
specific sexual practices were not included. The authors found
anti-HCV positive couples had a higher sexual contact frequency
than couples without evidence of HCV in the spouse in the
retrospective cohort, and suggested that frequency of
intercourse influenced risk of HCV infection. However, in the
prospective cohort, none of the HCV-negative spouses
seroconverted during the follow-up even though the frequency of
sexual contact was reportedly ~6-fold higher than in the
retrospective study. These results likely reflect differences in
accuracy of recall of sexual practices and point toward the
challenges in evaluating frequency of sexual contact and types
of sexual practices in retrospective studies.
Where does this leave physicians in terms of counseling patients
with HCV infection about sex? First and foremost, the issue of
sex and HCV transmission needs to be discussed with each HCV-infected
person and recommendations tailored to the individual's specific
sexual situation. For those in monogamous partnerships, the
partner should be offered HCV testing (4). The couple should be
counseled that the risk of sexual transmission is very low and
because of this very low risk, use of condoms is not
specifically recommended. However, due to an absence of
information on certain types of sexual practices, those engaged
in sexual practices that may be more permissive of transmission,
such as anal intercourse or sex with trauma to genital mucosa,
should be advised to use condoms during these activities. I also
recommend the use of condoms if the couple is having sex during
a woman's menses. For HCV-infected persons with multiple sexual
partners, use of condoms is recommended not only for prevention
of HCV transmission but also for all sexually transmitted
diseases. Finally, for those HCV-infected persons with new
sexual relationships that evolve to longer-term monogamous
relationships, specific recommendations regarding if and when
condom use can be discontinued are not available. Ultimately,
each monogamous couple must decide upon whether a "low risk" of
transmission translates into a need of condom use or not.
Physicians can facilitate this decision by assisting patients
and their partners to interpret the available data regarding sex
and HCV, and providing them with the most current guidelines
regarding prevention of sexual transmission.
REFERENCES
1. Capelli C, Prati D, Bosoni P, et al. Sexual transmission of
hepatitis C virus to a repeat blood donor. Transfusion 1997;37:
436-40. Synergy Abstract MEDLINE Abstract ISI Abstract
2. Sanchez-Beiza L, Bravo R, Toribio R, et al. Sexual
transmission of two different HCV types causing acute hepatitis
C. Vox Sang 1996;71: 244-5. Synergy Abstract MEDLINE Abstract
CSA Abstract
3. Quer J, Murillo P, Esteban J, et al. Sexual transmission of
hepatitis C virus from a patient with chronic disease to his sex
partner after removal of an intrauterine device. Sex Transm Dis
2003;30: 470-1. MEDLINE Abstract ISI Abstract
4. CDC. Recommendations for prevention and control of hepatitis
C virus (HCV) infection and HCV-related chronic disease. MMWR
1998;47: 1-38.
5. Terrault N. Sexual activity as a risk factor for hepatitis C.
Hepatology 2002;36: S99-105. CrossRef Abstract MEDLINE Abstract
ISI Abstract
6. Vandelli C, Renzo F, Romano L, et al. Lack of evidence of
sexual transmission of hepatitis C among monogamous couples:
Results of a 10-year prospective follow-up study. Am J
Gastroenterol. 2004;99: 855-9. Synergy Abstract MEDLINE Abstract
ISI Abstract
7. Lai K, Young K, Cheng P, et al. Interspousal transmission of
hepatitis C virus: Application of comparing the variability of
HVR1 nucleotide region. Hepatogastroenterology 2004;51: 791-5.
MEDLINE Abstract ISI Abstract
8. Boonyarad V, Chutaputti A, Choeichareon S, et al.
Interspousal transmission of hepatitis C in Thailand. J
Gastroenterol 2003;38: 1053-9. CrossRef Abstract MEDLINE
Abstract ISI Abstract
9. Terrault NA, Busch M, Murphy E, et al. Sexual transmission of
hepatitis C virus in heterosexual monogamous couples-The HCV
partners. Hepatology 2003;38(Suppl 1):A183. CrossRef Abstract
10. Piazza M, Sagliocca L, Tosome G, et al. Sexual transmission
of hepatitis C virus and efficacy of prophylaxis with
intramuscular immune serum globulin. Arch Intern Med 1997;157:
1537-44. CrossRef Abstract MEDLINE Abstract ISI Abstract CSA
Abstract
11. Kao J, Chen P, Yang P, et al. Intrafamiliar transmission of
hepatitis C virus: The important role of infections between
spouses. J Infect Dis 1992;166: 900-3. MEDLINE Abstract ISI
Abstract
12. Consensus Development Panel. National Institutes of Health
Consensus Development Conference Statement: Management of
Hepatitis C: 2002-June 10-12, 2002. Hepatology 2003;36: S3-S20.
Sexual Transmission of HCV between Spouses
The American Journal of Gastroenterology
April 2005
Veysel Tahan, M.D. 1 , Cetin Karaca, M.D. 1 , Beytullah Yildirim,
M.D. 1 , Aysun Bozbas, M.D. 1 , Resat Ozaras, M.D. 1 , Kadir
Demir, M.D. 1 , Erol Avsar, M.D. 1 , Ali Mert, M.D. 1 , Fatih
Besisik, M.D. 1 , Sabahattin Kaymakoglo, M.D. 1 , Hakan Senturk,
M.D. 1 , Yilmaz Cakaloglu, M.D. 1 , Cem Kalayci, M.D. 1 , Atilla
Okten, M.D. 1 , and Nurdan Tozun, M.D. 1 1Marmara University
School of Medicine, Department of Gastroenterology Altunizade;
Istanbul University Medical Faculty, Department of
Gastroenterohepatology; Istanbul University Cerrahpasa Medical
Faculty, Department of Gastroenterohepatology; and Marmara
University School of Medicine, Department of
Gastroenterohepatology, Istanbul, Turkey
--Our study did not find an increased risk of acquiring HCV for
the spouses.
-- the number of total sexual intercourse is important and may
be an independent risk factor for sexual transmission
--The role of sexual route in the transmission of the virus is
controversial.
--The prevalence of HCV infection is higher among prostitutes,
male homosexuals, sex partners of patients infected with both
HCV and HIV, and partners of injection drug use, suggesting a
route of sexual transmission.
-- The prevalence of anti-HCV among the spouses of chronic
hepatitis C patients ranges between 0% and 27%. Our study showed
a relatively lower seroprevalence rate of 2% between the spouses
of CHC patients, a figure similar to the reported rate of
general population seropositivity of 1.8% in our country.
--Several studies on HCV transmission have compared RNA sequence
homologies showing <100% homology between spouses. This finding
makes the role of sexual intercourse per se for HCV transmission
between spouses debatable.
ABSTRACT
BACKGROUND AND AIMS: The sexual transmission of hepatitis C
virus (HCV) is debated. By excluding other risk factors, the
role of sexual intercourse in the transmission could be detected
more accurately. We screened HCV prevalence and risk factors in
the spouses of chronic hepatitis C (CHC) patients and followed
the seroconversion rate of anti-HCV negative spouses.
PATIENTS AND METHODS: Six hundred spouses of CHC patients were
recruited. The spouses' HCV risk factors were questioned and the
spouses were tested for anti-HCV. The 216 spouses who were anti-HCV
negative were checked annually for anti-HCV.
RESULTS: Anti-HCV was positive in 12 of 600 (2%) of the spouses.
Of the 12 anti-HCV positive spouses, 11 were HCV-RNA positive.
Of anti-HCV positive and negative spouse groups, mean age was
52.3 ± 9.8 and 49.8 ± 12.4 yr; duration of marriage was 1521 ±
506.7 and 1532.4 ± 670.2 wk (p> 0.05); and the number of total
sexual intercourse was 434 ± 295 and 307 ± 333 (p= 0.055),
respectively. In our prospective study, none of the spouses
developed anti-HCV seroconversion in mean 35.7 ± 6.3 months and
257.9 ± 72.2 sexual intercourse.
CONCLUSIONS: Anti-HCV was found positive in 2% of the spouses.
None of the seronegative spouses developed seroconversion in the
3-yr follow-up period. This is the first study that stresses the
importance of the total number of sexual intercourse in sexual
transmission (p= 0.055). Our results of special monogamous group
with very limited risk factors support the role of number of
total sexual intercourse in HCV transmission. However, the
seroprevalence rate of the spouses was still within the upper
limit of our country population.
INTRODUCTION
Hepatitis C virus (HCV) is transmitted mainly by contact with
infected blood. However, in up to 50% of cases the transmission
route cannot be identified. The role of sexual route in the
transmission of the virus is still controversial. The prevalence
of anti-HCV antibody among the sexual partners of chronic
hepatitis C (CHC) patients ranges between 0% and 27% (1-8). The
duration of marriage has been correlated with the rate of HCV
infection (4) and the presence of HCV in semen has been reported
(9). Male-to-female transmission seems to be more common than
female-to-male transmission (10).
The different rates of sexual transmission may be the result of
sexual behaviors such as frequency and type of sexual
activities. Previous studies reported that anti-HCV positivity
in partners increased with the duration of marriage or
partnership, suggesting the risk of sexual transmission
correlates with frequency of contact (4). To assess the risk of
heterosexual HCV transmission, we examined 600 patients with
chronic HCV-associated liver disease and their spouses
retrospectively with respect to their estimated total sexual
intercourse in the follow-up of index cases, and activity with
duration of marriage, duration of CHC follow-up period, and
other risk factors that could affect the couple for HCV
transmission by sexual and nonsexual routes. We also followed
the 216 anti-HCV negative partners of CHC patients
prospectively.
AUTHOR DISCUSSION
The prevalence of HCV infection is higher among prostitutes,
male homosexuals, and partners of intravenous drug abusers.
There seems to be a positive correlation between the HCV
infection and the number of sexual partners, sexual activities
involving a trauma or anal intercourse, history of other
sexually transmitted diseases, and those coinfected with HIV.
HCV is known to be transmitted primarily by exposure to infected
blood. However, in up to 50% of cases, no recognizable
transmission route could be detected. Furthermore, the
implementation of HCV screening in blood banks has virtually
eliminated the risk of HCV infection by transfusion in most
countries. The role of sexual route in the transmission of the
virus is controversial. The prevalence of HCV infection is
higher among prostitutes (11), male homosexuals (12-14), and sex
partners of patients infected with both HCV and HIV (15),
suggesting a route of sexual transmission. Sexual exposures for
a period of 6 months prior to the onset of illness were reported
by 15% of persons who recently acquired hepatitis C, and
two-thirds of them had a sexual contact with an anti-HCV
positive partner (16).
The worldwide prevalence of HCV infection is almost 3%,
equivalent to 170 million infected persons. The prevalence rates
are lowest in the United Kingdom and Scandinavian countries
(0.01-0.1%), slightly higher in America, Western Europe, (0.2,
0.5%) and intermediate in Eastern Europe, the Mediterranean, the
Middle East, and the Indian subcontinent (1-5%) (17). The
prevalence of anti-HCV among the spouses of chronic hepatitis C
patients ranges between 0% and 27% (1-8). Our study showed a
relatively lower seroprevalence rate of 2% between the spouses
of CHC patients, a figure similar to the reported rate of
general population seropositivity of 1.8% in our country (18).
Several studies on HCV transmission have compared RNA sequence
homologies showing <100% homology between spouses. This finding
makes the role of sexual intercourse per se for HCV transmission
between spouses debatable.
The duration of marriage has also been correlated with the rate
of HCV infection (4). Guadagnino et al. (19) showed that the
spouses who had been married to the index cases for longer than
20 yr had a 7.5-fold risk of HCV seropositivity compared to
those married for less than 20 yr. They concluded that sexual
contact plays an independent role in the spread of HCV infection
in the family setting. Caporaso et al. (20) reported an
incidence of anti-HCV seropositivity of 15.6% in their studies
evaluating the transmission of HCV between spouses in HCV
positive subjects; however, after adjusting for various
confounders, the authors concluded that sexual transmission does
not seem to play a role in the intrafamilial spread of HCV
infection. In contrast, a study from Japan found spouses with
anti-HCV positive partners to be twice as likely to have anti-HCV
positivity than spouses with anti-HCV negative partners;
however, 50% of the couples harbored different HCV genotypes
(7).
Studies in monogamous couples demonstrate a lower risk of sexual
transmission in this group (21). In our previous study, we
reported anti-HCV positivity between all monogamous spouses as
0.78% (8). Since those studies involved mostly monogamous
couples and showed a low risk of sexual transmission, our
colleagues did not recommend the use of condoms for monogamous
sexual relationships. Although 14 partners (2.3%) were in
multipartnerships, none of them were anti-HCV positive; there
was no condom usage in any of the couples. Anal intercourse,
sexual activity involving a trauma, and the presence of other
sexually transmitted diseases such as coinfection with HIV are
thought to increase the rate of transmission of HCV infection
but these conditions were not present in our groups. Although no
transmission parameter has been found to be statistically
significant, total number of sexual intercourses was close to
significance level in the group of anti-HCV positive spouses (p=
0.055) and the sexual transmission may be related to a slightly
higher prevalence of anti-HCV positivity than that of our
general population. Another evidence in favor of low probability
of HCV transmission via sexual route is the low viral load
detected in semen (9, 22). Results from Asian countries indicate
that interspousal transmission becomes more critical with longer
duration of a partnership (4, 6, 7); however, similar data from
Western countries are rare (19, 20, 23). In our study, duration
of marriage was not correlated with the rate of transmission;
although the age of the spouse tends to correlate with anti-HCV
positivity, it did not reach statistical significance.
The HCV genotypes were the same between infected couples; they
all were genotype 1b, as it is the most prevalent genotype in
Turkey (24).
Whether the risk of HCV transmission differs between sexes is
unclear (1). Male-to-female transmission may be more common than
female-to-male transmission (10). However, in our study, the
ratios of female-to-male versus male-to-female couples were 2.5
versus 1.4, respectively, and this was not statistically
significant. On the other hand, "index" case may not be the
first one to be infected and then transmit the virus to his/her
spouse. Even the development of the infection in the spouse does
not necessarily mean a sexual transmission. This is the main
pitfall of such cohort studies; the spouses may be infected from
other sources like the rest of the population. Molecular studies
that are not the aim of the current study may detect whether the
virus in the spouses is the same or not. To the best of our
knowledge, our retrospective study constitutes one of the
largest series on CHC patients and their spouses (600 index CHC
patients and 600 spouses).
In a recently published study, Vandelli et al. examined 895
monogamous heterosexual partners of CHC patients and followed
776 couples for a 10-yr period prospectively. The average weekly
rate of sexual intercourse was 1.8 and three spouses became
anti-HCV and HCV-RNA positive after 7, 8, and 9 yr,
respectively. In one couple, the genotype of the spouse was
discordant from that of her husband, and in another two cases,
genotypes were concordant; however molecular analysis of the HCV
isolates was not linked. Their data indicate the risk as
extremely low or even null. They also screened 967 sexual
partners of CHC patients and 33 (3.4%) were anti-HCV positive
but they were not questioned and were excluded from their study;
so the detailed data are lacking for the differences between
anti-HCV positive and negative partners in their study (25).
In our prospective study, the average weekly rate of sexual
intercourse was 1.9, which accounted for a higher rate than the
previous study. In about 3-yr follow-up, none of the partners
acquired HCV infection and our data also supported the belief
that the risk of HCV infection by the sexual transmission is
very low or even null. In our retrospective study, the average
weekly rate of sexual intercourse was 1.73 and anti-HCV positive
and negative partners were questioned and examined thoroughly
for the number of their previous sexual intercourses and HCV
transmission parameters. Although a partner's anti-HCV
seroprevalence rate of 2% was within the upper normal limit of
our population, the number of sexual intercourse was close to
statistical significance (p= 0.055).
Our study did not find an increased risk of acquiring HCV for
the spouses. This finding was even more significant with the
consideration of the high percentage of long-lasting sexual
partnerships; the duration of marriage being 1,521 ± 506.7
versus 1532.4 ± 670.2 wk in anti-HCV positive and negative
spouse groups, respectively, all with unprotected sexual
intercourse and without any additional risk factors for HCV
transmission. Evaluation of the questionnaires and statistical
analysis revealed very low risk for HCV transmission in the
everyday life of couples.
In conclusion, the number of total sexual intercourse is
important and may be an independent risk factor for sexual
transmission. Neither other sexual nor nonsexual behaviors had
an influence on the risk of interspousal transmission in our
spouse groups.
Moreover, our prospective study with 216 CHC patients and their
spouses revealed no sexual transmission in about 3 yr of
follow-up. We therefore suggest that the risk of HCV
transmission between monogamous sex partners may be related to
the number of sexual intercourse, when evaluated
retrospectively. The absence of any evidence of transmission in
the spouses of HCV patients in the 3-yr follow-up period
suggests that this relation is not very strong.
RESULTS
All spouses reported sexual activity with the study patient.
Anti-HCV positivity was found in 12 of 600 (2%) of spouses (F/M:
4/8). This rate was 8 of 320 (2.5%) and 4 of 280 (1.4%) in male
and female spouses, respectively. All anti-HCV positive spouses
but one were HCV-RNA positive and the genotypes were all 1b.
Three of the anti-HCV positive spouses were diagnosed with
cirrhosis. The average weekly rate of sexual intercourse was
1.73 in the retrospective study. Of anti-HCV positive and
negative spouses, the duration of marriage was 1521 ± 506.7 and
1532.4 ± 670.2 wk (p> 0.05); the number of total sexual
intercourse was 434 ± 295 and 307 ± 333 (p= 0.055); and the
follow-up period of the corresponding CHC patient was 209.6 ±
137.5 and 147 ± 165.5 wk (p= 0.035), respectively.
The mean duration of marriage did not correlate with anti-HCV
positivity. The couples were divided into three groups according
to their age: <40 yr (n = 116); 40-59 yr (n = 355); >60 yr (n =
140). The percentage of rates of anti-HCV positivity showed an
increasing trend with age; 0.9, 2, and 3.7%, respectively (Table
2). This increase probably reflects the cohort effect rather
than the effect of sexual transmission, since in the subjects
older than 60 yr, the number of sexual intercourse is clearly
lower than that of the remaining. No spouse reported liver
disease prior to the marriage. All couples reported unprotected
sexual intercourse, without condom. They denied various sexual
practices or intravenous drug abuse. Four women reported having
several needle-stick injuries, 17 partners (2.8%) had received
blood transfusions, 14 partners (2.3%) have been in
multipartnerships, however, none of them were anti-HCV positive.
Seven couples reported the use of nondisposable syringes in
their past, however, only one of them was anti-HCV positive.
Thirty spouses shared personal items such as razor, toothbrush,
nail clipper, and two of them were in the anti-HCV positive
group. Forty-five spouses (7.5%) had a history of previous
surgical procedures, two of them were anti-HCV positive (one
appendectomy and one dental procedure).
In our prospective study, none of the 216 spouses developed
anti-HCV seroconversion in a mean follow-up period of 35.7 ± 6.3
months and a total number of 257.9 ± 72.2 sexual intercourses.
The average weekly rate of sexual intercourse was 1.9 in the
prospective study.
There was no statistical difference in mean age, and in sexual
and nonsexual risk factors for acquiring HCV infection between
study patients with anti-HCV-positive and anti-HCV negative
spouses.
METHODS
A total of 600 patients with chronic HCV infection (320 male
(53%) and 280 female (47%), mean age 49.9 yr, ranging between 18
yr and 79 yr) were followed by three university hospitals from
January 1999 to November 2002 and were enrolled in this study.
Chronic HCV-associated liver disease was defined as elevated
liver enzymes for at least 6 months and a positive anti-HCV
antibody test with a second-generation ELISA. One hundred and
seventeen patients (19.5%) had cirrhosis and 483 (80.5%) had
chronic hepatitis. The diagnosis was confirmed by liver biopsy
in 546 patients (91%). In 306 (51%) cases, the route of
transmission of HCV infection was unknown; parenteral exposure
was considered as the source of infection in the remainder. No
index case was coinfected with HIV.
Informed consents were obtained from all patients both in the
prospective and the retrospective studies. The couples completed
a questionnaire representing sexual risk factors such as
duration of marriage, number of estimated total sexual
intercourse and various sexual practices, condom usage,
multipartnership and nonsexual risk factors such as the presence
of liver disease prior to marriage, history of blood transfusion
or needle stick injury, surgery, intravenous drug abuse, share
of personal instruments infected with blood.
Our special group of chronic hepatitis C patients consisted of
naive, untreated patients who had normal ALT levels or who
rejected interferon therapy.
In our retrospective study, 600 CHC patients' spouses with a
mean age of 49.8 yr (range: 18-76 yr) were included. The spouses
were divided into two groups according to anti-HCV status and
their data were compared.
In our prospective study, we excluded both the patients who were
given any interferon as the treatment of chronic hepatitis C,
and the 216 anti-HCV negative partners of CHC patients (F/M:
101/115; mean age: 51.1 ± 14.5 yr) who could be checked annually
for anti-HCV seroconversion. The same questionnaire was applied.
In both studies, serum samples from the spouses were collected
and tested for anti-HCV with a second-generation ELISA (Abbott
Laboratories, Abbott Park, IL). Every spouse and his/her
corresponding patient was tested for HCV-RNA by
reverse-transcription polymerase chain reaction (PCR) with
primers deduced from the 5'-noncoding region (Amplicor HCV
Monitor Test, version 2.0 Roche Diagnostic Systems, Brancburg,
NJ, USA). HCV genotypes were determined by a PCR typing assay (Inno-Lipa
HCV 2, Innogenetics, Gent, Belgium).
Frequencies between groups were compared using the chi 2 test
and Fisher's exact test. A p value of <0.05 was considered
significant.
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