| |
|
Sexually Acquired Hepatitis C Infection in HIV-Uninfected Men Who Have Sex With Men Using Preexposure Prophylaxis Against HIV
|
| |
| |
Download the PDF here
Between 2013 and 2018, we diagnosed 15 likely sexually acquired HCV infections among 14 MSM using PrEP. Most (87%) were asymptomatic, detected by routine alanine transaminase (ALT) or HCV monitoring. Half reported increasing sex partners and drug use after starting PrEP; 5 reported injection of methamphetamine. Interventions are needed to prevent sexually acquired HCV infections by MSM using PrEP. ....again 7 years ago I warned this was a problem then but no one listed. Jules
JID 20 November 2018 - Jennifer C. Price,1 Jeffrey E. McKinney,1 Pierre-Cedric Crouch,2 Stephen M. Dillon,3 Asa Radix,4 Alicia Stivala,4 Jesse R. Carollo,5 and Daniel S. Fierer5
1Division of Liver Diseases, University of California, San Francisco; 2San Francisco AIDS Foundation, California; 3Langone Medical Center, New York University; 4Callen- Lorde Community Health Center, New York; and 5Division of Infectious Diseases, Icahn School of Medicine at Mount Sinai, New York
Preventing HIV is crucial, and PrEP is a critical but not sole element of the strategy. We need to develop prevention messages to help decrease the risks of sexual acquisition of HCV in addition to the STI more commonly encountered with the larger-scale adoption of PrEP. To prevent further transmission of HCV, including into HIV-uninfected MSM who are not using PrEP, we therefore suggest that treatment of HCV in HIV-uninfected men be initiated quickly. While baseline HCV screening among MSM prior to PrEP initiation is recommended by the Centers for Disease Control and Prevention (CDC) and baseline ALT is often performed, neither of these tests are part of the CDC recommendations during follow-up PrEP visits [14]. In contrast, the American Association for the Study of Liver Diseases/ Infectious Diseases Society of America (AASLD/IDSA) HCV guidelines recommend HCV testing at least annually at follow-up PrEP visits, with more frequent testing warranted depending on sexual or drug use behavior [15]. Hence, while most of the PrEP clinics involved in our cases series performed routine follow-up ALT or HCV testing, this practice was not uniform. As quarterly HIV testing is recommended during PrEP prescribing and elevated ALT is more sensitive than HCV antibody during acute infection, we strongly encourage incorporating ALT testing into this quarterly panel to facilitate earlier HCV diagnoses. However, because mild ALT elevations may be caused by a number of factors besides HCV, ALT cutoffs to prompt HCV RNA testing among PrEP users are needed. Finally, we support the AASLD/IDSA guidelines to perform HCV antibody screening at least annually for all MSM using PrEP who report multiple sex partners to prevent what might otherwise become an undetected expansion of sexually transmitted HCV infection into HIV-uninfected MSM.
Abstract
Sexually acquired hepatitis C virus (HCV) infections among human immunodeficiency virus (HIV)-uninfected men who have sex with men (MSM) have been rare. With the introduction of preexposure prophylaxis (PrEP) against HIV, we hypothesized that these infections would increase. Between 2013 and 2018, we diagnosed 15 likely sexually acquired HCV infections among 14 MSM using PrEP. Most (87%) were asymptomatic, detected by routine alanine transaminase (ALT) or HCV monitoring. Half reported increasing sex partners and drug use after starting PrEP; 5 reported injection of methamphetamine. Interventions are needed to prevent sexually acquired HCV infections by MSM using PrEP. Centers for Disease Control and Prevention guidelines for monitoring during PrEP should include regular ALT and HCV testing. The median age of the 14 men at the time of their primary HCV infections was 35 years, and they had been taking PrEP for a median of 12 months before their primary HCV diagnoses (Table 1).
In the decade before the FDA approval of emtricitabine/tenofovir for PrEP in 2012, sexual acquisition of HCV infection was rare in HIV-uninfected MSM compared to HIV-infected MSM. However, since the FDA approval and the increasing prescription of PrEP in our regions we have now documented 15 sexually acquired HCV infections among 14 HIV-uninfected MSM after their initiation of PrEP.
Thirteen (87%) of the 15 HCV infections were asymptomatic, diagnosed during routine laboratory screening, either due to alanine transaminase (ALT) levels (60%) or HCV surveillance testing with HCV antibody or HCV RNA (27%) (Table 2). Only 2 (13%) were symptomatic. Recreational drug use in the past 6 months, primarily of crystal methamphetamine, was reported by 10 (67%), 5 of whom reported injection use, all of which was methamphetamine. All of the men engaged in receptive anal intercourse, with 12 (80%) reporting at least 10 sexual partners during the 3 months prior to the HCV diagnosis. Six (40%) men had a bacterial sexually transmitting infection (STI) at the time of HCV diagnosis. Three (20%) of the HCV infections cleared spontaneously, as determined by multiple undetected HCV RNA measurements over 12 weeks. The remainder of infections were either treated and cured (n = 8, 53%), referred for treatment with unknown outcome (n = 1), or are currently undergoing treatment (n = 3). The 1 man who was reinfected had spontaneously cleared his primary genotype 1a HCV infection and presented 71 weeks later with new genotype 4d HCV viremia and elevated ALT after a trip to Europe that included sex while in Germany; he spontaneously cleared this infection as well.
We have previously hypothesized [2] that the relative rarity of HCV infections among HIV-uninfected MSM compared to HIV-infected MSM was largely due to 2 factors: serosorting, the HIV risk-reduction practice of choosing partners with concordant HIV serostatus with whom to have sex without a condom; and stochasticity. Once HCV entered the population of HIV-infected MSM, serosorting, without condom use, would result in a higher HCV prevalence within this group. Then, in the setting of HIV- and HCV-discordant partnering, the likelihood of MSM becoming HIV-infected before HCV-infected through unprotected sex with HIV and HCV coinfected MSM is stochastic, resulting in a ratio of HIV to HCV infections roughly corresponding to the differential infectivity between HIV and HCV during anal sex.
There may also be an additional element of biological susceptibility to HCV infection in those with HIV, due to the massive and nearly permanent memory CD4 cell depletion from the colonic mucosa during acute HIV infection, resulting in a significantly more porous barrier to small molecules [4], which could include HCV that was introduced into the rectum in semen [5] or rectal fluid coating the penis, fist, or object inserted [6].
| |
| |
| |
|
|
|
