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Risk of hepatitis C reinfection following successful therapy among people living with HIV (MSM): a global systematic review, meta-analysis, and meta-regression
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June, 2022 Samira Hosseini-Hooshyar, Behzad Hajarizadeh, Sahar Bajis, Matthew Law, Naveed Z Janjua, Daniel S Fierer, David Chromy, Jürgen K Rockstroh, Thomas C S Martin, Patrick Ingiliz, Chien-Ching Hung, Gregory J Dore, Marianne Martinello*, Gail V Matthews*
We aimed to systematically review the existing evidence of HCV reinfection risk after treatment among people living with HIV, including people who inject drugs and men who have sex with men (MSM), and to identify the factors that explain heterogeneity in the incidence of HCV reinfection.
The incidence of reinfection was 3⋅76 cases per 100 person-years of follow-up (95% CI 2⋅80-5⋅05; I2 85⋅9%) among people living with HIV overall, 6⋅01 (4⋅54-7⋅95; 74⋅1%) among MSM, and 3⋅29 (2⋅01-5⋅39; 83⋅9%) among people who inject drugs.
Risk of HCV reinfection following treatment in people living with HIV was highest among MSM and those with recent HCV infection. Continued scale-up of HCV treatment and ongoing HCV screening and treatment of infection in this patient population should reduce viraemic burden and risk of reinfection.
In conclusion, the observed incidence of HCV reinfection following successful treatment among people living with HIV was highest among HIV-positive MSM and among those with recent HCV infection.
Changes in sexual behaviour among MSM have been reported following advances in HIV treatment and prevention (eg, pre-exposure prophylaxis), including increases in so-called chemsex and reductions in consistent condom use with casual male partners.
These findings highlight the importance of addressing contemporary sexual and drug use risk behaviours. Screening for and treatment of HCV reinfection, education focused on reinfection prevention, and access to safe sex and harm reduction services are essential. Sustained treatment uptake and innovative models of care aimed at preventing infection and reinfection must be assured to achieve HCV elimination among people living with HIV.
This study presents a comprehensive overview of the incidence of HCV reinfection among people living with HIV, overall and among key populations at risk. The pooled estimates of HCV reinfection incidence following successful therapy were 3⋅76 cases per 100 person-years follow-up among people living with HIV, 6⋅01 among HIV-positive MSM, and 3⋅29 among HIV-positive people who inject drugs. Among HIV-positive MSM, a similar incidence of HCV reinfection was observed in individuals with no history of injecting drug use and in those with a history of injecting drug use. In meta-regression analyses, a higher proportion of MSM in the study population and recent HCV infection were associated with an increased risk of reinfection, whereas a longer duration of follow-up after treatment was associated with a decreased risk.
The pooled estimate of HCV reinfection incidence among HIV-positive MSM (6⋅01 cases per 100 person-years of follow-up) was higher in our analysis than in reports of primary HCV infection in this population.
Ongoing higher HCV risk behaviour almost certainly explains higher HCV reinfection incidence compared with primary infection among HIV-positive MSM, which is not surprising given that all of this population have previously been infected. These findings are similar to a previous review among HIV-positive MSM, indicating an incidence of reinfection that was 20 times higher than that of primary infection.
Incidence of HCV reinfection was similar among HIV-positive MSM with and without a history of injecting drug use, although higher among MSM with an unknown history of injecting drug use. Reinfection might be related to recurring high-risk sexual exposures, unsafe injecting practices, or both. Changes in sexual behaviour among MSM have been reported following advances in HIV treatment and prevention (eg, pre-exposure prophylaxis), including increases in so-called chemsex and reductions in consistent condom use with casual male partners.
Behavioural interventions that reduce risk of HCV transmission, in combination with high uptake of direct-acting antivirals, are a central part of continuing efforts to eliminate HCV among MSM.
Thus, strategies that enable individuals to form and maintain safe sexual and injecting practices are essential, despite perceived difficulties in enacting behavioural modification. Furthermore, in this study, reinfection incidence was higher among people living with HIV with a recent history of injecting drug use (5⋅49 cases per 100 person-years of follow-up) than in those with a lifetime history of injecting drug use (3⋅29 cases per 100 person-years of follow-up), indicating the importance of optimising access to harm reduction for those with ongoing injecting risk behaviours. Little evidence is available on the incidence of HCV reinfection among people living with HIV who inject drugs. However, our estimates of HCV reinfection incidence among those with recent injecting drug use are consistent with those reported among people who have recently injected drugs (6⋅2 cases per 100 person-years of follow-up).
Continued monitoring following treatment (with a minimum of annual HCV RNA testing in the setting of ongoing risk behaviours) and rapid retreatment of reinfection among people living with HIV are required for HCV elimination targets to be met. Optimised strategies, including education on risk reduction, counselling before and during treatment, and facilitating access to harm reduction services among individuals with an increased risk of reinfection, should be adopted.
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