- Category: Gay & Bisexual Men/MSM
- Published on Thursday, 13 April 2017 00:00
- Written by Roger Pebody
Around 1 in 5 HIV-positive gay men who recently acquired hepatitis C virus (HCV) report anal sex without a condom as the only behavior that could explain their infection. At the same time, a third of people acquiring HCV were gay men who did not have HIV, clinicians from the Mortimer Market Centre in London reported at the British HIV Association (BHIVA) conference last week in Liverpool. The data suggest that prevention messages around sexually transmitted hepatitis C need to change.
Hepatitis C prevention advice has tended to focus on sexual practices which could result in trauma to the rectum (such as fisting and use of sex toys), sometimes with additional reference to behaviors commonly reported by gay men who acquire HCV, such as group sex and chemsex (sex while using recreational drugs).
However, several studies have identified receptive anal sex without condoms as a risk factor. American researchers have recently demonstrated that HCV can be found at infectious levels both in semen and in rectal secretions. This fundamentally challenges the belief that hepatitis C can only be transmitted in blood.
Moreover, until now, most cases of sexually transmitted HCV have been seen in gay men living with HIV, but clinicians have begun to identify cases of apparently sexually transmitted hepatitis C in HIV-negative gay men, especially among men using HIV pre-exposure prophylaxis (PrEP).
It is possible that, previously, hepatitis C was concentrated in networks of HIV-positive men due to serosorting. Increasing knowledge of HIV treatment as prevention and use of PrEP may now mean that more HIV-negative gay men are having condomless sex with HIV-positive men. While those HIV-negative men will be protected from HIV, they may be vulnerable to HCV.
Clinicians at the Mortimer Market Centre in central London noticed that some of their patients diagnosed with acute or recently acquired hepatitis C did not fit the expected profile. They therefore reviewed the case notes of the 48 patients diagnosed with acute HCV at the clinic between April 2015 and April 2016.
Of the 48 cases, 81% were among gay and bisexual men, 6% were in heterosexual men, and 13% were in women. While 67% were in people with HIV, 33% were in HIV-negative people.
Among the HIV-positive people who acquired hepatitis C, anal sex without a condom was commonly reported (75%). Many HIV-positive people reported recognized HCV risk factors, including injection drug use (31%), chemsex (53%), and snorting drugs (53%). Only 3% reported fisting.
Significant numbers of HIV-positive people with acute hepatitis C had sexually transmitted infections (59%), including rectal infections (28%).
However, 19% of the HIV-positive people with acute HCV infection had sex without a condom as their only risk factor.
Risk factors for HIV-negative people were somewhat different. In particular, none in this group reported anal sex without a condom as their only risk factor, although 44% did report this behavior alongside other risk factors. Hepatitis C in HIV-negative people appeared to be driven by injection drug use (44%), chemsex (38%), and snorting drugs (38%). Again, fisting was infrequently reported (6%).
One-quarter of HIV-negative people who acquired hepatitis C were using PrEP. In contrast to those with HIV, sexually transmitted infections were quite rarely reported in the HIV-negative group (6%).
The researchers recommend that HIV-negative gay men who can be identified as being at a higher risk for hepatitis C be offered testing for the virus. This would include PrEP users, men reporting chemsex or injection drug use, and the sexual partners of people with hepatitis C. They also recommend that gay men living with HIV be advised that HCV can be passed on through anal sex without a condom.
L Midgley, SA Filson, P Pearson, et al. Acute hepatitis C infection in lower risk MSM: an evolving picture. 23rd Annual Conference of the British HIV Association. Liverpool, April 4-7, 2017. Abstract O24.