Prevalence and incidence of hepatitis C virus infection in men who have sex with men: a systematic review and meta-analysis

Establishing a framework towards monitoring HCV microelimination among men who have sex with men living with HIV in Germany: A modeling analysis

BACKGROUND

Prior to direct-acting antivirals (DAAs), HCV incidence rose among men who have sex with men (MSM) living with HIV infection in Germany despite high hepatitis C virus (HCV) treatment rates. We establish a HCV elimination modeling framework to evaluate whether existing treatment rates can achieve the World Health Organization (WHO) incidence target among MSM living with HIV in Germany.

METHODS

To evaluate progress towards HCV elimination in Germany, we adapted a previously published HCV transmission model among MSM living with diagnosed HIV. We modelled HCV incidence and prevalence until 2030 (relative to 2015) under existing treatment and DAA scale-up and explored potential impacts of disruptions in treatment and behavioral risk reduction due to the COVID-19 pandemic.

RESULTS

Continuing current treatment rates will result in stable HCV incidence among MSM living with HIV in Germany between 2015-2030. The WHO HCV incidence target is achievable under DAA scale-up to 100% treatment combined with treatment of those previously diagnosed and untreated (at a rate of 15%/year) and would result in greater reductions with early treatment (3 vs 6 months) reducing incidence from 4.0/100person-years to 0.8/100person-years by 2030. A 12-month disruption to HCV treatment (20% reduction) and risk behaviors (25%,50%,75% reduction) during the COVID-19 pandemic would result in a 15% relative increase in total HCV incidence in 2030 compared to that expected under the status quo.

CONCLUSIONS

HCV elimination among MSM living with HIV in Germany requires further DAA scale-up among those newly diagnosed combined with efforts to treat those previously diagnosed but untreated. Prospective monitoring will establish whether Germany is on track for HCV microelimination.

Hepatitis C prevalence among men who have sex with men attending a gay bathhouse

Background and Aim

Related research has found that men who visit public sex environments such as a gay bathhouse engage in unprotected anal intercourse and tend to have multiple sexual partners during their visit. We aimed to assess the risk of hepatitis C virus (HCV) transmission among men attending a gay bathhouse.

Methods

A prospective study of the prevalence of HCV among men attending a gay bathhouse was conducted in Bangkok, Thailand, from October 2019 to March 2020. HCV risks and risk perceptions were evaluated using a self-administered questionnaire. HCV testing with result notification was provided on site.

Results

Of the 40 participants (median age 30 years), one subject (2.5%) was positive for HCV antibody. Bathhouse patrons reported engaging in high-risk sexual behavior, including sexually transmitted infection history and Chemsex experience. The subject tested positive for HCV antibody reported a frequency of attending gay bathhouse of around 2-4 times monthly and had multiple partners while attending a gay bathhouse. Only 15% of subjects realized that hepatitis C can be transmitted through sexual intercourse.

Conclusion

Our findings support HCV transmission-reducing guidelines recommending providing selective HCV testing among men who have sex with men (MSM). Bathhouse patrons reported low literacy levels on HCV transmission. Nevertheless, HCV screening should cover a population exhibiting high-risk sexual behaviors such as attending a gay bathhouse.

Methods and indicators to validate country reductions in incidence of hepatitis C virus infection to elimination levels set by WHO

One of the main goals of the 2016 Global Health Sector Strategy on viral hepatitis is the elimination of hepatitis C virus (HCV) as a public health problem by 2030, defined as an 80% reduction in incidence and 65% reduction in mortality relative to 2015. Although monitoring HCV incidence is key to validating HCV elimination, use of the gold-standard method, which involves prospective HCV retesting of people at risk, can be prohibitively resource-intensive. Additionally, few countries collected quality data in 2015 to enable an 80% decrease by 2030 to be calculated. Here, we first review different methods of monitoring HCV incidence and discuss their resource implications and applicability to various populations. Second, using mathematical models developed for various global settings, we assess whether trends in HCV chronic prevalence or HCV antibody prevalence or scale-up levels for HCV testing, treatment, and preventative interventions can be used as reliable alternative indicators to validate the HCV incidence target. Third, we discuss the advantages and disadvantages of an absolute HCV incidence target and suggest a suitable threshold. Finally, we propose three options that countries can use to validate the HCV incidence target, depending on the available surveillance infrastructure.

Low prior exposure and incidence of hepatitis C in HIV negative gay and bisexual men taking PrEP: findings from the EPIC-NSW prospective implementation study

BACKGROUND

The use of pre-exposure prophylaxis (PrEP) for the prevention of HIV has raised concerns of increased sexual risk behaviours. These behaviours may be associated with increased incidence of sexually acquired hepatitis C (HCV) among gay and bisexual men (GBM).

METHODS

The Expanded PrEP Implementation in Communities-New South Wales (EPIC-NSW) study was a cohort study of daily co-formulated tenofovir disoproxil fumarate and emtricitabine for HIV prevention. We recruited 9596 people at high risk of HIV acquisition from 31 clinics across New South Wales and the Australia Capital Territory in Australia. We report prior exposure to HCV and incidence in this cohort between 2016 and 2019.

RESULTS

At least one HCV test result was available for 8658 (90.2%) participants. These individuals had a median age of 34 years (IQR 28-43), most of whom were male (8530, 98.5%), identified as gay (7944, 91.8%), and were born in Australia (51.8%). Prior exposure to HCV was detected among 81 participants at baseline (0.9%, 95% CI 0.7 to 1.2%). Twenty of 8577 participants were diagnosed with incident infection (rate 0.2/100 person years (95%CI 0.1 to 0.3/100py)). They were significantly older (median age 41 years vs 34 years, p=0.044), and more likely to report methamphetamine use at baseline (IRR 2.7 (95%CI 1.00-7.2)) than those without incident infection.

CONCLUSIONS

In this population of PrEP users, HCV prior exposure and incidence were low. With high levels of HCV and HIV testing and treatment, the dual goals of HIV and HCV elimination could be achieved in this population.

Liver Disease Screening and Hepatitis C Virus Elimination in Taiwan Rural Indigenous Townships: Village-By-Village Screening and Linking to Outreach Hepatology Care

Medical resources are limited for hepatitis C virus (HCV) elimination in rural indigenous areas of Taiwan. This study aimed to investigate liver disease risk and conduct a HCV elimination program in two rural indigenous townships. A program of village-by-village screening tests was conducted including hepatitis B virus surface antigen (HBsAg), antibody to HCV (anti-HCV) and gamma-glutamyl transferase (GGT), linking to outreach hepatology care at two indigenous townships (Laiyi and Mudan). Adult residents were invited to join this program. One hepatology specialist assessed liver disease risk, provided HCV treatment counselling and initiated direct acting antivirals (DAA) at an outreach hepatology clinic in primary health centers. A total of 3503 residents attended this program with a screening coverage of 73.5%. The prevalence of HBsAg, anti-HCV, and high GGT level was 8.2%, 10.0% and 19.5%, respectively. Laiyi had significantly higher prevalence of anti-HCV than Mudan. While males had significantly higher prevalence of HBsAg and high GGT in both townships, females in Laiyi had higher anti-HCV prevalence. HBsAg and high GGT prevalence peaked at 40–59 years of age and anti-HCV prevalence increased significantly with age. Two hundred and sixty-three residents visited the outreach hepatology clinic for HCV treatment evaluation, with 121 (46%) residents having active HCV, while 116 received DAA, with 111 (95.7%) achieving HCV elimination. For rural indigenous townships in southern Taiwan, HCV infection and alcohol consumption were two major liver disease risks. While HCV infection was predominant in old females, chronic hepatitis B virus infection and habitual alcohol consumptions predominated in middle-aged males. HCV elimination was achieved by the village-by-village screening model and linked to outreach hepatology care.

Usability, acceptability, and self-reported impact of an innovative hepatitis C risk reduction intervention for men have sex with men: A mixed methods study

Hepatitis C virus (HCV) elimination among men who have sex with men (MSM) is unlikely to be feasible without effective behavioural interventions. We developed a multilevel intervention to reduce HCV transmission among MSM in Amsterdam. The intervention includes a toolbox to facilitate risk reduction among MSM and support health care professionals in risk reduction counselling. To assess the use of the toolbox and its impact on behavior, we conducted a mixed-methods study. We collected data through online questionnaires (n = 49), and in-depth interviews with MSM at risk of HCV (n = 15) and health care professionals (n = 7). We found that the toolbox has been well received by MSM, increased awareness of HCV risks and has facilitated preventive behaviours and risk-reduction communication with peers. Professionals reported the toolbox to be a useful aid for discussions about HCV risk and risk reduction strategies with their clients.

[Development approaches for vaccines against hepatitis C virus infections]

Mehr als 10 Jahre nach der Zulassung der ersten direkt wirkenden antiviralen Wirkstoffe zur Behandlung der Hepatitis C bleibt die Inzidenz der Hepatitis-C-Virus-(HCV-)Infektion ungebrochen hoch. In manchen Ländern stecken sich mehr Menschen neu mit dem Virus an, als Patienten durch eine erfolgreiche Therapie geheilt werden. Die Entwicklung eines prophylaktischen Impfstoffes könnte die Transmission des Virus unterbinden und dadurch einen wesentlichen Beitrag zur Kontrolle dieser weltweit verbreiteten Infektion leisten. In diesem Artikel werden die besonderen Herausforderungen und die aktuellen Ansätze der HCV-Impfstoffentwicklung dargestellt.

HCV ist ein hochgradig diverses und wandlungsfähiges Virus, das zumeist dem Immunsystem entkommt und chronische Infektionen etabliert. Andererseits heilt die HCV-Infektion bei bis zu einem Drittel der exponierten Individuen aus, sodass eine schützende Immunität erreichbar ist. Zahlreiche Untersuchungen zu den Determinanten einer schützenden Immunität gegen HCV zeichnen ein immer kompletteres Bild davon, welche Ziele ein Impfstoff erreichen muss. Sehr wahrscheinlich werden sowohl starke neutralisierende Antikörper als auch wirkungsvolle zytotoxische T‑Zellen gebraucht, um sicher vor einer chronischen Infektion zu schützen. Die Schlüsselfrage ist, welche Ansätze besonders breit wirksame Antikörper und T‑Zellen heranreifen lassen. Dies wird erforderlich sein, um vor der großen Fülle unterschiedlicher HCV-Varianten zu schützen. Die jüngsten Erfolge von mRNA-Impfstoffen öffnen neue Türen auch für die HCV-Impfstoffforschung. Kombiniert mit einem tieferen Verständnis der Struktur und Funktion der viralen Hüllproteine, der Identifizierung kreuzprotektiver Antikörper- und T‑Zellepitope sowie der Nutzung standardisierter Verfahren zur Quantifizierung der Wirksamkeit von Impfkandidaten ergeben sich neue Perspektiven für die Entwicklung eines Impfstoffes.

Global Burden and Changing Trend of Hepatitis C Virus Infection in HIV-Positive and HIV-Negative MSM: A Systematic Review and Meta-Analysis

Background: The disease burden of hepatitis C virus (HCV) infection in HIV-positive and HIV-negative men who have sex with men (MSM) is changing. We aim to provide an updated comprehensive estimate of HCV prevalence and incidence among the HIV-positive and HIV-negative MSM population at the country, regional, and global levels and their changing trends over time. Methods: PubMed, Embase, PsycINFO, CINAHL, and conference databases were searched and eligible records on the prevalence and incidence of HCV antibodies were selected and pooled via a random-effects model. Meta-regression was performed to demonstrate the association between the pooled rates and study year. Results: A total of 230 articles reporting 245 records from 51 countries with 445,883 participants and 704,249 follow-up person-years were included. The pooled prevalence of HCV in MSM was 5.9% (95% CI: 5.1-6.8), with substantial differences between countries and regions. Low- and lower-middle-income countries (12.3 and 7.0%) manifested a larger disease burden than high- and upper-middle-income countries (5.8 and 3.8%). HCV prevalence in HIV-positive MSM was substantially higher than in HIV-negative MSM (8.1 vs. 2.8%, p < 0.001). The pooled incidence of HCV was 8.6 (95% CI: 7.2-10.0) per 1,000 person-years, with an increasing trend over time, according to meta-regression (p < 0.05). Conclusion: Global HCV prevalence in MSM varies by region and HIV status. Behavior counseling and regular HCV monitoring are needed in HIV-positive subgroups and high-risk regions. Given the upward trend of HCV incidence and sexual risk behaviors, there is also a continued need to reinforce risk-reduction intervention. Systematic Review Registration: PROSPERO, identifier CRD42020211028; https://www.crd.york.ac.uk/prospero/.

Comparison of Polydrug Use Prevalences and Typologies between Men Who Have Sex with Men and General Population Men, in Madrid and Barcelona

This study compares the prevalence of drug use and the typologies of polydrug use (PDU) in men who have sex with men (MSM) and general population men (GPM). Participants were men aged 16–64, living in the provinces of Madrid and Barcelona: 1720 were recruited in a GPM survey, and 2658 were HIV-negative MSM from HIV/STIs diagnosis services. Lifetime and last-year prevalence of drug use and prevalence ratios (PRs) of MSM to GPM for the different drugs were calculated using Poisson regression. Latent class analysis (LCA) was performed to identify typologies of PDU. Lifetime use of the drugs considered was higher in MSM, and even higher for drug use in the last-year: PRs for cannabis, hallucinogens and cocaine ranged from 2–5; for amphetamine, ecstasy and methamphetamine 12–16; and above 60 for ketamine, GHB/GBL, inhalants and mephedrone. In the LCA for lifetime PDU four classes arose from the GPM (No-PDU (79.6%); Conventional PDU (13.8%); Intensive conventional PDU (4.9%); Heavy PDU (1.8%)) and four among MSM (No-PDU (57.7%); Conventional PDU plus poppers (18.8%); PDU preferring chemsex drugs (6.4%); Heavy PDU (17.2%)). For PDU during the last-year, three classes arose in the GPM: No-PDU (94.7%); Conventional PDU (4.3%); Heavy PDU (0.9%). For MSM, we identified four classes: No-PDU (64.7%); Conventional PDU plus poppers (15.6%); PDU preferring chemsex drugs (6.2%); Heavy PDU (13.5%). MSM should be considered a priority group for the prevention of the use of all drugs but the heterogeneity of PDU typologies regarding users’ preference towards conventional and/or sexualised drugs needs to be taken into account.

The Incidence of Hepatitis C Among Gay, Bisexual, and Other Men Who Have Sex With Men in Australia, 2009-2019

BACKGROUND

Hepatitis C virus (HCV) infection has been reported among gay, bisexual, and other men who have sex with men (GBM) globally including GBM with human immunodeficiency virus (HIV) and HIV-negative GBM, particularly those using HIV preexposure prophylaxis (PrEP). In Australia, HCV direct-acting antiviral treatment (DAA) was government-funded from 2016. Large implementation studies of PrEP also began in 2016. We examined HCV incidence among GBM to assess whether HCV incidence has changed since 2015.

METHODS

Data were drawn from the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance. We included GBM who tested HCV antibody negative at their first test and had ≥1 subsequent test. Generalized linear modeling (Poisson distribution) was used to examine HCV incidence from 2009 to 2019 stratified by HIV status, and among HIV-negative GBM prescribed PrEP from 2016 to 2019.

RESULTS

Among 6744 GBM with HIV, HCV incidence was 1.03 per 100 person-years (PY). Incidence declined by 78% in 2019 compared to 2015 (incidence rate ratio [IRR], 0.22 [95% confidence interval {CI}: .09-.55]). Among 20 590 HIV-negative GBM, HCV incidence was 0.20/100 PY, with no significant change over time. Among 11 661 HIV-negative GBM prescribed PrEP, HCV incidence was 0.29/100 PY. Compared to 2016, incidence among GBM prescribed PrEP declined by 80% in 2019 (IRR, 0.20 [95% CI: .06-.64]).

CONCLUSIONS

HCV incidence among GBM living with HIV declined following DAA availability. There was no observed change in HCV incidence among HIV-negative GBM overall. Among GBM prescribed PrEP, incidence declined since the early years of PrEP implementation in Australia. Australia is on track to eliminate HCV among GBM before global 2030 targets.

Sexualized drug injection among men who have sex with men in Madrid and Barcelona as the first episode of drug injecting

BACKGROUND

We estimate the prevalence of drug injection, the variables associated with having ever injected and the proportion of ever injectors whose first drug injection was for having sex; we describe the first drug injection episode, analyze the drugs most frequently injected and estimate the prevalence of risky injecting behaviors.

METHODS

The participants were 3387 MSM without a previous HIV diagnosis attending four HIV/STI diagnosis services in Madrid and Barcelona. Lifetime prevalence and prevalence ratios (PRs) by different factors were calculated using Poisson regression models with robust variance. We compared the characteristics of first drug injection episode, lifetime injection and risky injecting behaviors of those whose first injection was for sex (FIS) with those whose was not (non-FIS).

RESULTS

Lifetime prevalence of injection was 2.1% (CI 1.7-2.7). In the multivariate analysis, it was strongly associated with having been penetrated by more than five men in the last 12 months (aPR = 10.4; CI 2.5-43.4) and having met most of their partners at private parties (aPR = 7.5; CI 4.5-12.3), and less strongly with other factors. Of those who had ever injected drugs, 81.9% injected for sex the first time they injected drugs (FIS). At first injection, FIS participants had a mean age of 31 years, 62.7% used mephedrone and 32.2% methamphetamine on that occasion. Of this FIS group 39.0% had ever shared drugs or equipment and 82.6% had always shared for sex. Some 30.8% of non-FIS reported having also injected drugs for sex later on.

CONCLUSIONS

Only two out of a hundred had ever injected, most to have sex and with frequent drug or injecting equipment sharing. Injecting for sex is the most common first episode of drug injection and is the most efficient risky behavior for the transmission of HIV, hepatitis B or C and other blood-borne infections. MSM participating in private parties should be considered a priority group for prevention policies.

Hepatitis C Viral Infection Among Beta-Thalassemia Patients: A Study From the Centre for Excellence in Thalassemia and Other Blood Disorders

Background

Hepatitis C virus (HCV) is a single-stranded RNA virus, which is frequently transmitted through blood transfusions, contact with infected blood or blood products, and vertical transmission. Injectable drug abusers and transplant recipients are predisposed to HCV infection. It causes acute hepatitis, which may progress to chronic hepatitis, and in severe untreated cases, patients may develop cirrhosis and hepatocellular carcinoma (HCC). Since there is no vaccine available against HCV infection, prevention remains the mainstay, at least among the susceptible populations that include thalassemia patients.

Methods

A prospective case-control study was conducted at the center for excellence in thalassemia and other blood disorders attached to the Prathima Institute of Medical Sciences (PIMS), a tertiary care teaching hospital at Karimnagar, Telangana, India. Blood samples of 100 beta-thalassemia patients and age-matched non-thalassemic persons were screened for antibodies against HCV by an enzyme-linked immunosorbent assay (ELISA) based rapid immunochromatographic method, and the chemiluminescence assay using the Abbott AxSYM (Abbott Laboratories, Abbot Park, IL, USA). During the same period, the prevalence of HCV was assessed among non-thalassemic patients attending in-patient and out-patient wards of PIMS hospital.

Results

Of the 100 cases of beta-thalassemia, 28 (28%) were HCV positive. All the age-matched non-thalassemic controls were negative for HCV antibodies. Among the positives, 20 (71%) were males, and eight (29%) were females. The prevalence of HCV among non-thalassemic patients attending the hospital during the same period was found to be 0.19%.

Conclusions

HCV infection among the beta-thalassemia patients was abnormally high as compared to the others. Thalassemia patients are potentially predisposed to HCV infection and other blood-borne viral infections. Thorough screening of blood before transfusion is warranted. HCV infection may further increase the morbidity and mortality of beta-thalassemia patients and other patients with blood disorders who acquire the infection due to frequent blood transfusions.

Outcomes of an HCV elimination program targeting the Viennese MSM population

Background and aims

Recent reports suggest an increasing incidence of hepatitis C virus (HCV) infections among MSM (men-who-have-sex-with-men). Early treatment with direct-acting antivirals (DAAs) achieves high cure rates and prevents further HCV transmission. We offered barrier-free HCV screening in the Viennese MSM population and immediate access to DAA treatment.

Methods

In collaboration with gay health specialists, we screened for HCV seropositivity in Viennese MSM between 2019 and 2020. Barrier-free HCV-RNA-PCR tests, transient elastography (TE) and immediate access to DAA treatment were offered.

Results

A total of 310 HCV-seropositive patients were identified. Of those, 145 could be contacted and 109 attended their appointment at our clinic. HIV-coinfection was highly prevalent in our cohort (n = 86/145; 78.9%), while pre-exposure prophylaxis (PrEP) was taken by 21.7% (n = 5/23) of non-HIV patients. Sexual risk behavior and (history of) intravenous drug use was reported by 32.1% and 13.8% of patients, respectively. Most MSM had already achieved sustained virological response (SVR) to previous antiviral treatment (n = 72, 66.1%) or experienced spontaneous clearance (n = 10, 9.2%). Advanced fibrosis was only detected in 3/109 (2.8%) patients. 30 MSM tested positive for HCV-RNA and DAA treatment was initiated in 29 patients – all achieved SVR.

Conclusion

A targeted HCV test-and-treat program revealed a high prevalence of HCV seropositivity among Viennese MSM, potentially associated with high-risk sexual behavior and drug use. Early DAA treatment seems warranted in viremic HCV-MSM as SVR was 100%, which in turn prevents further HCV transmission.

The cost-effectiveness of case-finding strategies for achieving hepatitis C elimination among men who have sex with men in the UK

Modelling suggests hepatitis C virus (HCV) elimination is possible among men who have sex with men (MSM), with key screening groups including HIV-diagnosed MSM and MSM using pre-exposure prophylaxis (PrEP). Mathematical modelling was used to determine the cost-effectiveness of HCV case-finding strategies among MSM from the provider perspective, and to determine which interventions could achieve a 90% reduction in HCV incidence over 2015-2030. At baseline, we assumed symptomatic screening in HIV-negative MSM (including PrEP users) and 12-monthly screening among HIV-diagnosed MSM. Improved case-finding strategies included screening alongside HIV testing in HIV-negative MSM not using PrEP (PrEP non-users); 12/6/3-monthly screening in PrEP users; and 6-monthly screening in HIV-diagnosed MSM, with the cost-effectiveness being compared incrementally. Costs (GBP) and quality-adjusted life years (QALYs) were assessed to estimate the mean incremental cost-effectiveness ratio (ICER) with a time horizon to 2050, compared to a willingness-to-pay threshold of £20,000/QALY. From the baseline, the most incrementally cost-effective strategy is to firstly undertake: (1) 12-monthly HCV screening of PrEP users (gaining 6715 QALYs with ICER £1760/QALY), followed by (2) HCV screening among PrEP non-users alongside HIV testing (gaining 7048 QALYs with ICER £4972/QALY). Compared to the baseline, this combined strategy would cost £46.9 (95%CrI £25.3-£66.9) million and achieve the HCV elimination target in 100% of model runs. Additional screening incurs ICERs >£20,000/QALY compared to this combined strategy. In conclusion, HCV elimination can be achieved cost-effectively among UK MSM. Policymakers should consider scaling-up HCV screening in HIV-negative MSM, especially PrEP users, for achieving this target.