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HPTN 078: High Prevalence of HCV Antibodies Among Urban U.S. Men Who Have Sex with Men (MSM) Independent of HIV Status
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The data from our study again raise concern that HCV may be broadly spreading in MSM networks, irrespective of HIV status. This study revealed that approximately 1 in 5 MSM screened for HPTN 078 have been infected with HCV. This is consistent with an increasing incidence of HCV infection among MSM without HIV in the era of PrEP and U=U (Undetectable=Untransmittable) perhaps due to higher risk sexual practices in overlapping networks of MSM with HIV and MSM without HIV.
In an era where HCV treatment is oral, safe, and has the ability to cure, screening to identify unknown HCV infection may be an important part of an elimination strategy in HCV-uninfected MSM as it is possible that HCV transmission risk could increase as PrEP implementation expands and condom use declines among MSM.
This work is in line with a growing body of evidence that HCV is circulating in MSM networks broadly due to the overlapping nature of the networks of MSM with and without HIV. This is especially concerning as HCV transmission could increase as therapeutic optimism grows (i.e. the perception that HIV is highly manageable), PrEP expands and condom use declines. The further introduction of HCV into networks could increase rates of HCV in a wider array of MSM subgroups and supports aggressive HCV screening and counseling among MSM regardless of HIV infection status.
A systematic review of HCV infection from 38 cross-sectional studies of MSM in industrialized countries and published in English from 2000 to 2015 reported that pooled HCV prevalence was substantially higher in MSM with HIV (8.3%, 95% CI 6.7-9.9) than in MSM without HIV (1.5%, 95% CI 0.8-2.1).[9] While our study also revealed a higher rate of HCV antibody positivity in MSM with HIV (20%) versus MSM without HIV (17%), this was not statistically significant and the rates were high in both groups. This is consistent with an increasing incidence of HCV infection among MSM without HIV in the era of PrEP and U=U (Undetectable=Untransmittable) perhaps due to higher risk sexual practices in overlapping networks of MSM with HIV and MSM without HIV.[18, 28, 29] This concern for higher rates of HCV prevalence among MSM without HIV supports HCV testing among MSM without HIV with higher frequency. Current HCV guidelines in the US developed by the America Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommend annual HCV testing in all sexually active MSM living with HIV and in MSM without HIV on PrEP.[19] However, for MSM without HIV not on PrEP, there are no recommendations beyond the standard one-time test although HCV guidelines do note that MSM may be tested more frequently for HCV infection if high-risk sexual or drug use practices are occurring.[19] This is in contrast to European guidelines that recommend HCV testing every 3-6 months in MSM engaging in high risk activities regardless of HIV status.[30] While data have suggested that MSM without HIV being screened for PrEP are at higher risk of HCV infection than MSM without HIV in the community not on PrEP, it may also be true that there are populations of HCV-uninfected MSM that are being missed in standard HCV screening or who may be apprehensive about sharing their sexual or drug use practices with healthcare professionals.[28, 29] In an era where HCV treatment is oral, safe, and has the ability to cure, screening to identify unknown HCV infection may be an important part of an elimination strategy in HCV-uninfected MSM as it is possible that HCV transmission risk could increase as PrEP implementation expands and condom use declines among MSM.
Our study also revealed that HCV antibody positivity was higher in those receiving substance use (drug or alcohol) counseling or treatment (36%) than those that had not (15%)(P=<0.01). This is consistent with other studies, which have revealed that injection drug use, nasal drug use, and alcohol use disorder are risk factors for HCV acquisition.[31, 32] These data suggest the need to co- locate HCV screening and treatment, alcohol, and other drug treatment in order to make care easily accessible.[33, 34] MSM-IDU cohorts have higher rates of HCV infection than MSM cohorts that fully exclude IDU.[35, 36] Notably, in some states, drug and alcohol use may also pose barriers to accessing HCV treatment although studies have shown that individuals with substance use disorders
In this study, we determined the prevalence of HCV antibodies among MSM with and without HIV and evaluated factors associated with HCV antibody positivity among MSM screened for HPTN (HIV Prevention Trials Network) 078. HCV antibodies reliably reflect the sum of all infection (past and current) and therefore provide information on the level of risk of HCV acquisition in MSM. HPTN 078 was designed to develop and assess the efficacy of an integrated case manager intervention strategy to identify, recruit, link to care, retain in care, and attain and maintain viral suppression among MSM with HIV in the US as previously described.[20] The study was developed in response to the sustained and even growing HIV epidemics among gay men and other MSM given complex interactions of individual, network level, and structural HIV risks.[21, 22]
HPTN 078: High Prevalence of HCV Antibodies Among Urban U.S. Men Who Have Sex with Men (MSM) Independent of HIV Status
Clinical Infectious Diseases 21 December 2020
Abstract
Background
Sexual transmission of hepatitis C virus (HCV) is uncommon, yet documented among men who have sex with men (MSM), primarily among those with HIV.
Methods
In HPTN 078, which assessed an integrated strategy to achieve HIV viral suppression, 1305 MSM were screened across four geographically diverse US cities. At screening, demographic/behavioral/psychosocial questionnaires were completed, along with HIV and HCV testing. Multivariable logistic regression was used to evaluate associations with HCV antibody positivity.
Results
Of the 1287 (99%) MSM with HCV antibody results, median age was 41, 69% were Black, 85% had a high school diploma or more, 35% were employed, 70% had HIV, and 21% had undergone substance use counseling. The median lifetime number of male sexual partners was 17 (IQR: 6, 50) and 246 (19%) were HCV antibody positive. HCV antibody positivity was high in MSM with HIV (20%) and MSM without HIV (17%) (P=0.12) and was higher in those receiving substance use counseling (36%) than those that had not (15%)(P=<0.01). Substance use counseling [OR 2.51, 95% CI 1.80-3.51] and unstable housing [OR 2.16, 95% CI 1.40-3.33] were associated with HCV antibody positivity.
Conclusion
Nearly 1 in 5 MSM screened for HPTN 078 have been infected with HCV. The prevalence is high regardless of HIV status and is high even in those who did not undergo substance use counseling. In HIV burden networks, high HCV infection prevalence may occur in MSM without HIV. As PrEP implementation expands and condom use declines, routine HCV counseling and screening among MSM is important.
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