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Hepatitis C Virus Reinfection Among Men Who Have Sex With Men With HIV in New York City
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Clinical Infectious Diseases 18 July 2024.
Daniel S. Fierer,1, Jesse R. Carollo,1 Gabriela Rodriguez-Caprio,1, Asa Radix,2, Rona Vail,2, Robert Chavez,3 Krisczar J. Bungay,4 and Stephen M. Dillon4; for the New York Acute Hepatitis C Surveillance Networka
1Icahn School of Medicine at Mount Sinai, Department of Medicine, Division of Infectious Diseases, New York, New York, USA; 2Callen–Lorde Community Health Center, Department of Medicine, New York, New York, USA; 3NYU Grossman School of Medicine, Department of Medicine, New York, New York, USA; and 4Gotham Medical Group, New York, New York, USA
A number of other important issues are highlighted by our results. We found no decline in the reinfection rate in NYC over the first 4 years after Food and Drug Administration approval of truly effective DAA regimens.
Risk factor behaviors collected from >1200 visits indicated that receipt of semen into the rectum with CRAI was strongly associated with reinfection, while in contrast with our study of primary HCV, sexualized noninjection methamphetamine use was not associated with reinfection, and neither was use by the injection route.
Our data suggest that preventing semen ejaculation into the rectum would prevent most HCV infections, but MSM with HIV have not accepted condom use as a means to prevent HCV infection [41]. Finally, even with unrestricted access, DAA treatment cannot reach those who do not attend care. MSM with HIV in the United States whose HCV remained untreated have been less engaged in HIV care and more likely to engage in sexualized drug use and CRAI [42], perpetuating high-prevalence sexual networks.
In this prospective cohort study of HCV reinfection among MSM with HIV in NYC, the incidence rate of reinfection was high, 4.7 per 100 PY. In addition, receiving semen in the rectum during CRAI was strongly associated (HR, 9.7) with this high reinfection rate, not only demonstrating that transmission of HCV was sexual but also suggesting that this sexual transmission was neither inefficient nor unusual among these MSM with HIV.
Abstract
Background
Hepatitis C virus (HCV) reinfection rates are substantially higher than primary infection rates among men who have sex with men (MSM) with human immunodeficiency virus (HIV) in European cohorts. The behaviors mediating this high rate of transmission among MSM are poorly characterized.
Methods
We performed a prospective cohort study in New York City (NYC) of MSM with HIV who cleared HCV to determine the incidence of and risk factors for HCV reinfection. We assessed the risk behaviors for primary HCV in NYC: receipt of semen in the rectum, and sexualized methamphetamine use, along with route of use. Multivariable analysis was performed with Andersen-Gill extension of the Cox proportional hazards model.
Results
From 2000 through 2018, among 304 MSM with HIV who cleared HCV, 42 reinfections occurred over 898 person-years, for an incidence rate of 4.7 per 100 person-years. Assessing 1245 postclearance visits, only receipt of semen into the rectum was associated with reinfection (hazard ratio, 9.7 [95% confidence interval: 3.3–28.3], P < .001); methamphetamine use was not.
Conclusions
The high HCV reinfection rate over almost 2 decades demonstrates that sexual transmission of HCV is not inefficient or unusual and that direct-acting antiviral treatment is not sufficient for HCV elimination among MSM in NYC. The contrasts between both the rates of and risk factors for primary and HCV reinfection suggest that HCV prevalence is highly heterogenous among sexual networks and that sexualized methamphetamine use, rather than mediating transmission, is instead a surrogate marker for the highest HCV prevalence networks. As neither condoms nor treatment have been successful strategies for HCV prevention in NYC, novel interventions are needed to stem this sexually transmitted HCV epidemic.
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