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Response to Drs. Toyoda et al.

TO THE EDITOR: Garcı́a-Samaniego et al. (1) reported that hepatocellular carcinoma (HCC) develops at a younger age and shorter period of hepatitis C virus (HCV) infection in subjects coinfected with HIV. This seems to be an important observation in the management of these populations. However, the seven HCV-HIV coinfected patients in whom they observed the development of HCC had a biased background. Among seven patients, six were i.v. drug users and the other one patient was homosexual. They had been at higher risk of exposure to parenteral-transmitted viruses, such as hepatitis B virus (HBV), HCV, or HIV, than most patients with HCV infection. There was therefore a high possibility of their having been exposed to and infected with HBV in the past (i.e., transient infection), even if they did not have hepatitis B surface (HBs) antigen at the diagnosis of HCC. In addition, there was a high possibility they were exposed to and infected with multiple HCV genotypes, including genotype 1b, because reinfection with a different HCV genotype has been reported to be possible (2) and mixed infection with multiple HCV genotypes was more frequent in patients who had been at high risk for exposure to parenteral-transmitted viruses (3). A recent report (4) indicated that past HBV infection was an important factor for the development of HCC without cirrhosis in patients with chronic hepatitis C, which would result in the development of HCC in a shorter period of HCV infection. In addition, other reports (5, 6) indicated a higher incidence of development of HCC in patients infected with HCV genotype 1b; the HCV genotype is also one of the most important factors in predicting the response to interferon therapy, which the authors emphasized as a necessity for patients with HCV-HIV coinfection. In five patients without HBs antigen, with the exception of patient 1 the authors did not analyze HBs or hepatitis B core antibody status. Also, except for patient 7 the authors did not analyze HCV genotype. A possible higher prevalence of past HBV infection or persistent infection with HCV genotype 1b in patients with HCV-HIV–coinfected patients may have a role in the development of HCC at a younger age in this population. And these factors have been reported to be associated with hepatocarcinogenesis in patients with chronic HCV infection. We should consider these factors before concluding the association between HIV coinfection and development of HCC at a younger age in patients with chronic hepatitis C.