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Rough Group Sex--Not Just Anal Sex--May Explain HCV Epidemic in HIV+ Gays
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12th European AIDS Conference, November 11-13, 2009, Cologne, Germany
Mark Mascolini
Receptive anal intercourse in itself did not explain the climbing rate of hepatitis C virus (HCV) infection in gay German men with HIV, according to results of a case-control study [1]. Rather, a cluster of risky sex factors centered around rough anal sex explained much of the difference between the "cases" with HCV and the "controls" without HCV.
Several groups report an expanding HCV epidemic among HIV-infected gay men in Europe, with sexual transmission as a likely cause [2,3]. But specific factors contributing to HCV transmission in men with HIV remain poorly defined.
The Study Group on Sexual Risk Factors for Hepatitis C aimed to pin down HCV risks in gay men with HIV through a case-control study conducted from 2006 through 2008. The 34 cases, all recruited from a University of Bonn study of acute HCV infection, were gay men with HIV and HCV who did not inject drugs. The investigators matched them by age to 67 HIV-infected controls without HCV being treated for HIV by the clinicians who referred the cases. The investigators confirmed HCV serostatus by antibody testing from dried blood specimens. The researchers used multivariate regression analyses to isolate factors independently linked to HCV coinfection.
Four factor independently predicted HCV infection, and a model combining those factors explained for 35% of the difference between cases and controls:
· Frequent receptive "fisting" (anal penetration with the fist) without gloves: odds ratio [OR] 6.50, 95% confidence interval [CI] 1.71 to 24.68, P = 0.006
· Frequent rectal trauma with bleeding: OR 5.67, 95% CI 1.13 to 28.60, P = 0.035
· Use of snorted drugs like cocaine, amphetamines, and ketamine: OR 4.02, 95% CI 1.37 to 11.82, P = 0.012
· Group sex: OR 3.96, 95% CI 0.97 to 16.16, P = 0.055
Frequent receptive anal intercourse with casual partners did not independently predict HCV. Other nonpredictive factors included dilating sex toys, number of sex partners, a history of recent bacterial sexually transmitted infections, or a history of major surgery. However, rectal bleeding in the men with HCV was often severe enough to require surgery.
The researchers suggested that sexual transmission of HCV appears to occur in groups of gays who practice serosorting (having sex only with men of the same HIV status) and when anal mucosal integrity is disrupted by rough sex such as fisting.
The investigators proposed that use of gloves or condoms by the insertive male partner may enhance the spread of HCV if the glove or condom is not changed between partners. In this scenario, the insertive partner himself may not have HCV, but may act as a vector, picking up HCV from one man and transmitting it to another during group sex. The researchers also speculated that sharing of equipment for nasally administered drugs may be at play.
The Study Group proposed that "public health interventions for HIV-positive gay men should therefore be intensified and partly refocused" to reflect their findings. They believe sex-party hosts should be educated "about the need to avoid blood contamination of shared lubricant" and to provide "individual elastic (non-traumatising) snorting tubes [and] condoms" to sex party attendees.
References
1. Schmidt AJ, Vogel M, Krznaric I, Rochstroh J, Radun D, Study Group on Sexual Risk Factors for Hepatitis C. The trouble with bleeding: why do HIV-positive gay men get hepatitis C? 12th European AIDS Conference. November 11-13, 2009. Cologne, Germany. Abstract BPD1/7.
2. Urbanus AT, van de Laar TJ, Stolte IG, Schinkel J, Heijman T, Coutinho RA, Prins M. Hepatitis C virus infections among HIV-infected men who have sex with men: an expanding epidemic. AIDS. 2009;23:F1-F7.
3. van de Laar T, Pybus O, Bruisten S, et al. Evidence of a large, international network of HCV transmission in HIV-positive men who have sex with men. Gastroenterology. 2009;136:1609-1617.
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