关于艾滋合并丙肝感染是否延长窗口期的研究

angelgomes

曾经有过丙肝艾滋合并感染，一年后才查处抗体的案例 引起了很多恐友的恐慌
对此 我通过大量的国内外资料研读 给大家做一个汇报。
首先看一个案例 这是一个被很多专家拿来说事的典型案例 原文如下
In July 1990, a 48-year-old health care worker in good health sustained a deep injury with a blood-contaminated needle while performing phlebotomy on a patient with the acquired immunodeficiency syndrome (AIDS). Blood also spilled from the collection tube into the spaces between the cuffs of the health care worker's gloves and her wrists and onto her hands, which were chapped with open cracks. Immediately after the incident, the worker removed the gloves and washed her handsThe patient had a history of injection-drug use. HIV infection had been diagnosed in 1987, and Pneumocystis carinii pneumonia in December 1989. At the time of the exposure, the patient was receiving zidovudine therapy, was not recognized as having HCV infection, and had no clinical evidence of liver disease. In March 1991, the CD4 T-lymphocyte count was 32 cells per cubic millimeterThe health care worker declined zidovudine prophylaxis. No base-line testing for anti-HCV was done because the source patient was not initially identified as HCV-infected. Eight months after the incident, the worker reported low-grade fever, chills, myalgia, nausea, vomiting, diarrhea, sweating, headache, and loss of appetite. Her temperature was 38.2°C, hepatic tenderness was noted, and her serum aminotransferase levels were elevated (Table 1). The white-cell count was 3500 per cubicmillimeter, with a differential count of 7 percent band forms, 32 percent segmented forms, 36 percent lymphocytes, 14 percent atypical lymphocytes, 8 percent monocytes, and 3 percent basophils. She was admitted to the hospital with a diagnosis of dehydration and acute hepatitis. Serum was negative for IgM antibody to hepatitis A virus, IgM antibody to hepatitis B virus core antigen, and anti-HCV. Serologic tests for other infectious agents, including Epstein–Barr virus, cytomegalovirus, and leptospira species, were negative. The erythrocyte sedimentation rate and tests for antinuclear antibodies and cold agglutinins were normal. Five days after admission, her symptoms resolved. Two months later (10 months after exposure), fever (temperature, 38.8°C), photophobia, and a diffuse pruritic rash with dryness of lips and mouth, which was diagnosed as erythema multiforme, developed. Serum obtained 11 months after exposure was positive for anti-HIV antibodies by enzyme immunoassay, and the result was confirmed by Western blotting. Table 2 shows the results of HIV-antibody testing by enzyme immunoassay for controls and all specimens tested at the hospital. Specimens reported as negative (those obtained six weeks, seven months, and eight months after exposure) had optical densities well below the values for positive controls. The health care worker had persistently abnormal serum aminotransferase levels; 16 months after exposure, a test ordered by her health care provider was positive for anti-HCV, and a diagnosis of chronic HCV infection was made (Table 1). Twenty-one months after exposure, the health care worker's CD4 T-lymphocyte count was 414 cells per cubic millimeter, and her platelet count was 31,000 per cubic millimeter. HIV-induced thrombocytopenia was diagnosed, and therapy with zidovudine was started. Interferon therapy for chronic HCV infection was started but could not be continued because of thrombocytopenia. Three months later, the health care worker presented with hematemesis; endoscopy revealed esophageal varices. Eighteen months after the documented seroconversion to HIV and 28 months after the needle stick, hepatic coma and progressive renal failure developed, and she died.
大致意思是：1990年7月 一个医务工作者被一根针头刺伤 用过这根针头的患者是个hiv hcv合并感染者 暴露8个月左右出现低烧等症状 hiv hcv抗体阴性 5天后症状消失 2个月后 暴露后10个月左右 再次出现发烧症状 hiv抗体阳性 hcv阴性 1991年9月hcv抗体转阳 感染后28个月死于肝炎发作和肾功能衰竭但是这个案例有着极大的特殊性 无论从抗体检测和病程发展来看都非常特殊 事实上 有许多合并感染的案例（在共用针头和男同中有很大一部分合并感染hiv和hcv）都在正常时间内出现抗体转阳 并且存活了好几年。因此仅以次例判断和并感染会导致窗口期延长并且病情迅速发展显然是不正确的，我推测这个案例的发生可能于她本人免疫系统和基因有关。当然除次之外还有一些窗口期超常的案例 有些是并没有感染丙肝的，具体原因至今没有定论。但全世界这也的案例也不过几例（我查阅大量资料，却世界范围内我所查到这样的案例的数量小于10）。

angelgomes

然后来看一下 专家对丙肝合并感染艾滋的观点
healing well网站id为apple92681的医生的观点
This is a complicated answer and I apologize ahead of time:There are VERY FEW times when I would recommend waiting for 3 months to get an HIV antibody test, but in a case that may also  involve Hepatitis C-Virus, I certainly do! Why?Well, for one, having Hep C may lower the immune system's ability to quickly produce antibodies to HIV because it would be overwhelmed already in trying to produce them for Hep C. So, while most people with otherwise uninhibited immune systems would show positive on a 6-week test, a person whose immune system is already bogged down with Hep C should wait out for three months -- just to be 100% certain!
So, to my knowledge, it would be safe to test for both at three months. Where I work, a Hep C antibody test is done by the County of Los Angeles and we only recommend it (along with an HIV test) if the person in question has admitted to sharing drug equipment.
A person who has Hep C might take an HIV-ELISA (antibody test) and show up "positive", which would then have to be confirmed by a Western Blot test. If the person is only infected with Hep C, not HIV, then the Western Blot would rule that out.
So, all in all, if you are concerned about a possible co-infection, then test for both at 3 months.
P.S. -- HIV/Hep C co-infection is rarely seen outside of the population that abuses drugs. This is because people who share  needles and may be Hep C carriers, might also be HIV-positive due to their habits.
If someone re-uses a needle hours later, the HIV virus will have died due to its fragility when exposed to air. However, Hep C, being a sturdier virus, can live longer and therefor infect.
如果合并感染了hiv和hcv  会使得免疫力为了对付而肝炎不堪重负 延缓了hiv抗体产生 那么建议在3月时检查排除 hiv hcv合并感染多见于公用针头吸毒者

thebody网站DR. BABARA
The CDC recommends that health care workers who are exposed to a HIV/HCV coinfected patients get HIV testing at baseline, six, and 12 weeks after exposure. However, if - and only if - the healthcare worker becomes ill with ACUTE HEPATITIS C INFECTION - THEN AND ONLY THEN - is additional testing for HIV recommended at 12 months. If the healthcare worker does not get acute hepatitis C infection, testing is complete for both infections at six months.
医护工作者在接触HIV/HCV合并感染的病人，并发生职业暴露之后，在接触后当时，6周，12周进行HIV抗体检测只有且仅有一种情况--当医护工作者因为感染而发展为急性丙肝病人的时候，才需要推荐在12个月后进行额外的HIV抗体测试

何大一教授
I'm not sure if we would have data to speak to that. And I haven't read anything that's convincing to me that Hepatitis C slows down creation of HIV antibodies…what's called "seroconversion."
我不能肯定因为没有数据能说明这点 我也没有看到任何可靠的数据说明hcv会减缓hiv抗体的产生

原深圳市疾病预防控制中心今深圳市慢性病医院主任医师：冯铁建教授
因为这是一个个案，所以说，普通的恐友，只要3个月阴，就可以放心了，退一步来说，你实在不放心，也可以检测到6个月，但那个只是为了你的放心，而不是说窗口期要延长到六个月

时代强
你看的那份资料，估计我也看过，目前没有很确切的资料研究表明丙肝会影响抗体的产生，如果是因为某个病人的确因为丙肝延长窗口期，那并不排除病人有另外的原因，比如复高，或者服用了阻断药物，但那个只是个案而已。

05年的全国丙肝高峰论坛暨HIV论坛，顶尖的专家都达成一致意见 丙肝不会影响窗口期
参加本次会议的世界卫生组织官员有WHO艾滋病司司长：Jim Yong Kim（美国）、WHO助理总干事：刘培龙（中国）、WHO总部高级技术官员：Peter Graaff（荷兰）、WHO驻华代表处高级顾问：Connie Osborne（赞比亚）、 WHO驻华代表处项目官员：陈红（中国）。WHO总部Donald Suther Land教授。与会的国内知名专家有：中华医学会感染病学会名誉主任委员、北京大学第一人民医院斯崇文教授，中华医学会感染病分会主任委员、上海复旦大学华山医院翁心华教授，中华医学会感染病分会副主任委员、北京地坛医院成军教授，中华医学会感染病分会常委兼学术秘书、上海长征医院缪晓辉教授，中华医学会感染病分会常委、北京协和医院李太生教授，中国医学科学院、北京协和医科大学艾滋病研究中心曹韵贞教授，中华医学会感染病学分会艾滋病和丙型病毒性肝炎学组副组长、北京大学第一人民医院徐小元教授，北京地坛医院郎振为教授，上海市公共卫生中心卢洪洲主任，上海复旦大 学华山医院潘孝彰教授，广州市第八人民医院唐小平院长，首都医科大学附属佑安医院吴昊教授，上海市公共卫生中心孙洪清教授，中国人民解放军第302医院王福生教授等

angelgomes

第三部分 丙肝于性
healing well网站id为TalktomeHIV的版主
Which Hepatitis C is really not a risk sexually. B is, though even if infected, 90-95 percent of adults will clear it naturally in time.
性行为没有丙肝风险 乙肝有风险 但即使接触到乙肝病毒 90%到95%的成年人能及时消灭它（指的是性行为 接触病毒量小的情况下）

美国cdc
The hepatitis C virus (HCV) is transmitted primarily by large or repeated direct percutaneous (i.e., passage through the skin by puncture) exposures to contaminated blood. Therefore, coinfection with HIV and HCV is common (50%-90%) among HIV-infected injection drug users (IDUs). Coinfection is also common among persons with hemophilia who received clotting factor concentrates before concentrates were effectively treated to inactivate both viruses (i.e., products made before 1987). The risk for acquiring infection through perinatal or sexual exposures is much lower for HCV than for HIV. For persons infected with HIV through sexual exposure (e.g., male-to-male sexual activity), coinfection with HCV is no more common than among similarly aged adults in the general population (3%-5%).

丙肝主要是通过破损(皮肤的伤口通道)接触感染血液造成的.所以,合并感染在共用针头人群中很普遍(50%-90%).合并感染也会在同时获得两种病毒的血液制品在血友病患者中传播.在性接触和围产期的感染远远低于HIV的感染率 通过性行为感染艾滋的人中 感染hcv的比率与普通人群没有什么差别(3%-5%)

HCV Sexual Transmission Revisited: A Look at the Latest Research
Liz Highleyman
Most studies indicate that sexual transmission of HCV is very uncommon among long-term, monogamous, HIV negative heterosexual couples, with rates in the range of 0%-3%. As reported in the May 2004 American Journal of Gastroenterology, for example, Carmen Vandelli and colleagues followed 895 HCV negative individuals who had monogamous sexual relationships with HCV positive partners. Over 10 years of follow-up, just three new HCV infections occurred, for an incidence rate of 0.37 per 1,000 person-years (PY). The authors concluded that “the risk of sexual transmission of HCV within heterosexual monogamous couples is extremely low or even null.” Likewise, V. Tahan and colleagues reported in the April 2005 American Journal of Gastroenterology that none of 216 HCV negative individuals with opposite-sex HCV positive spouses seroconverted during an average follow-up period of about three years.
夫妻间hiv传播不常见在0~3%之间（长期的夫妻性生活 不是指一次性的概率）

H. Hunter Handsfield这位相信很多恐友认识 medhelp上很知名的医生
There is no controversy.  HCV may rarely be transmitted sexually, but it is uncommon.  The frequency of HCV in the regular sex partners of persons with hepatitis C is no higher, on average, than the frequency in the general population--unless those sex partners also regularly share blood, e.g. through injection drug use with shared equipment.  The uncommon cases of sexual transmission probably do involve blood, e.g. traumatic anal sex.  There is no evidence that vaginal intercourse transmits HCV.
  不存在争论。HCV有可能通过性传播，但是不普遍。丙肝患者的固定性伴侣的丙肝患病率平均看来并没有高于普通人群，除非这些性伴侣与丙肝患者经常存在血液交换，例如共用注射器注射毒品。少见的通过性传播的病例可能与血液交换有关，例如外伤性的肛交。并没有证据表明阴道交会传染丙肝。

中国某地区对456名性服务人员调查
乙肝 33人 丙肝 4人 hiv 1人 梅毒 48人 hsv 148人
有40例同时感染2种及以上的病例 未发现同时感染丙肝及艾滋

肝炎窗口期
The body网站Dr. McGovern
In general, patients with acute hepatitis C develop antibodies in about 8 weeks. Yes seroconversion can take longer, up to 12 weeks and very uncommonly as long as six months. However, the last scenario is extremely rare and I think is overemphasiz
大部分在8周内转阳 有时会12周 非常少见的有6个月，我认为这种情况太少见但被过分强调了
总结
1 个别窗口期超常案例没有代表性
2 专家的观点1 不会影响窗口期 2 有一定影响 但3个月足够检测出 3 只有发展为急性丙肝病人 需要延长窗口期 否则3个月
3 精液与阴道分泌物中丙肝病毒含量很低 不易通过性行为传播
一次无保护性交感染艾滋概率在1/500至1/1000 一次无保护性交感染丙肝概率小于艾滋 所以一次性交同时感染艾滋和丙肝几乎不可能

本文大部分资料为本人查阅并总结
引用了不少性艾论坛的资料 在此感谢


                                                                 by angelgomes

jkk1966

老大，你发的这个文章太吓人了。我又恐这个了。
我和小姐接吻，对方口腔出血，当然不是满嘴是血，我舌头上有很小的溃疡。那么这样这样就有可能合并感染了。我已经是八周阴了。是不是要继续检测三个月的啊？还有我这有没有必要检测丙肝啊（是不是也有窗口器啊？多久？）？？谢谢

健康QQ

不需要过度担心，影响不大的。

健康QQ

老大，你发的这个文章太吓人了。我又恐这个了。
我和小姐接吻，对方口腔出血，当然不是满嘴是血，我舌头上有很小的溃疡。那么这样这样就有可能合并感染了。我已经是八周阴了。是不是要继续检测三个月的啊？还有我这 ...
jkk1966 发表于 2009-4-26 12:36 PM

艾滋病已经排除，如果对方是丙肝患者，你的情况存在感染丙肝风险。

qq加油

感谢如此全面的总结！

4楼的板油，angelgomes的帖子是为了帮助大家脱恐，整理大量的资料非常辛苦，也请你不要曲解LZ的本意，尊重他人的劳动成果。HCV的抗体产生确实需要比较长的时间，如果你非常恐惧，可通过检测HCV-RNA排除；检测前请先咨询你的医生，确定你的行为是否有检测的必要。

tgfcer

在丙肝領域里 性交屬于低風險行為，一生人和一個HCV患者性交感染幾率只有5%不到，這就是為什么很多性病都不會討論丙肝的原因，某種程度上來說性交傳染丙肝的條件更苛刻

cheng

你就是来吓唬人的是吧，我只好去查丙肝