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Hep C infection may be on the rise among men using PrEP

December 31, 2018

By Will Boggs MD

NEW YORK (Reuters Health) - The incidence of sexually acquired hepatitis C virus (HCV) infections appears to be rising among men who have sex with men (MSM) and use pre-exposure prophylaxis (PrEP) against HIV, U.S. researchers report.

"With the advent of PrEP, we hypothesized that HIV-uninfected men would now be having sex without a condom and receiving HCV-containing sexual body fluids into their rectums from HIV-infected MSM, who have a much higher prevalence of HCV, and that we would then see HCV infections among MSM taking PrEP," Dr. Daniel S. Fierer from Icahn School of Medicine at Mount Sinai, New York told Reuters Health. "This turned out to be the case."

Before PrEP became common, only about one in 50 sexually acquired HCV infections was in an HIV-uninfected MSM.

Dr. Fierer and colleagues now report 15 likely sexually acquired HCV infections among 14 MSM using PrEP between 2013 and 2018 (including one man who was re-infected after clearance of his primary HCV infection).

The median duration of PrEP before the primary HCV diagnosis was 12 months. Half of the men reported an increase in behaviors that could result in HCV exposure after starting PrEP, including decreased condom use and an increased number of sexual partners.

All but two infections were asymptomatic and were diagnosed during routine laboratory screening, the researchers reported in The Journal of Infectious Diseases, online November 20.

All of the men had engaged in receptive anal intercourse, 12 (80%) reported having at least 10 sexual partners during the three months prior to their HCV diagnosis, and six had a bacterial sexually transmitted infection at the time of their HCV diagnosis.

Ten men reported recreational drug use in the past six months, including five who reported injection use.

Three of the HCV infections cleared spontaneously, and the rest were either treated and cured, referred for treatment with unknown outcome, or are currently undergoing treatment.

The one man who was reinfected had spontaneously cleared his primary genotype 1a HCV infection and presented 71 weeks later with genotype 4d viremia and elevated ALT after a trip to Europe that included sex with another man. He cleared this infection spontaneously as well.

"Based on our and others' studies of HCV in the sexual body fluids of semen and rectal fluid, we tell patients that they can prevent acquiring hepatitis C during sex by using a condom to keep semen out of their rectum and off their penis," Dr. Fierer said. "Since few MSM (in the U.S., anyway) are aware that they can acquire HCV through sex in which there is no obvious blood, this simple statement makes two educational points at the same time."

"Most consider HCV a lot bigger problem than gonorrhea or even syphilis," he said. "Knowledge through education about the problem is the first step to making change."

Dr. Fierer added, "Since there was not universal routine HCV surveillance among all men on PrEP in New York City and San Francisco, we were unable to calculate an incidence rate of HCV in this population. Therefore, more research is needed with prospective cohorts (which we are now doing). However, this information that we already have is needed not just for public health departments to be aware and track new infections but also to determine whether messages about transmission prevention and timely treatment of newly diagnosed infections are effective at reducing the spread of the virus."

Dr. Pierre Pradat and Dr. Laurent Cotte from Croix-Rousse Hospital, Hospices Civils de Lyon, in France, who recently reported the incidence of HCV in HIV-infected and PrEP-using MSM there, told Reuters Health, "These results demonstrate that HCV infection is currently spreading in the U.S. from HIV-infected to HIV-negative MSM, as previously observed in Europe."

"Physicians should discuss with their MSM patients about their sexual life, including the use of drugs," they said in a joint email. "HCV screening should be offered as frequently as HIV screening in patients engaged in at-risk activities, enrolled or not in PrEP programs. Harm-reduction interventions, early diagnosis, and early treatment should be considered in this population.‚Äč"


J Infect Dis 2018.

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