Sexual transmission of hepatitis C virus among gay and bisexual men: a systematic review

Incidence and prevalence of hepatitis C and B infections among men who have sex with men and transgender women enrolled in a United States HIV vaccine trial

BACKGROUND

Rising hepatitis C and B virus (HCV and HBV) rates have been reported in men who have sex with men (MSM) and transgender women (TGW). This study characterizes HCV and HBV infections longitudinally among 2,496 MSM/TGW aged 18-50 years and at risk for HIV acquisition enrolled in an HIV-1 vaccine trial in 18 U.S. cities between 2009-2013.

METHODS

Participants completed behavioral surveys, HIV testing, and blood collection over 24 months. Of the 2,397 participants who consented for future testing, 1,792 (74.8%) had available paired stored blood samples at baseline and a later timepoint (Month 24 [N = 999]; if unavailable, M12 [N = 775] or M15 [N = 18]).

RESULTS

Among 1,792 participants, 98.1% were MSM, 0.8% were TGW, and the median age was 30 years (IQR 24, 40). Participants reported a median number of 3 male sex partners (IQR 1,5) within the past 3 months. Condomless insertive anal sex was reported by 55.8% and condomless receptive anal sex by 46.7%. 1.3% reported injection drug use. During follow-up, 1.4% reported pre-exposure prophylaxis (PrEP) use. At baseline 11/1792 (0.61%) participants had HCV infection (HCV AB positive, RNA detectable), with all having persistent detectable RNA and chronic HCV infection at follow-up. Phylogenetic analysis showed no clusters of HCV infection. 8 participants had HCV AB positive, RNA undetectable at baseline and follow-up, representing past HCV infection with clearance; only 2 acquired HCV, which cleared over 12-24 months. At baseline, 2 participants (2/1792 = 0.11%) had positive HBsAg, indicating chronic HBV infection. Over 12-24 months, 4 (4/1790, 0.22%) developed HBsAg positivity; these participants had HBcAB positivity at baseline, thereby likely representing reactivation. There were no new HBV infections during follow-up.

CONCLUSION

Among 1,792 men who have sex with men and transgender women aged 18-50 years and at risk for HIV acquisition enrolled in a U.S. HIV-1 vaccine trial, incident hepatitis C infection rates were extremely low, with no cases of incident hepatitis B infection. These rates of incident HCV infection and HBSAg positivity are lower than previously reported among MSM/TGW.

Contemporary Insights into Hepatitis C Virus: A Comprehensive Review

Hepatitis C virus (HCV) remains a significant global health challenge. Approximately 50 million people were living with chronic hepatitis C based on the World Health Organization as of 2024, contributing extensively to global morbidity and mortality. The advent and approval of several direct-acting antiviral (DAA) regimens significantly improved HCV treatment, offering potentially high rates of cure for chronic hepatitis C. However, the promising aim of eventual HCV eradication remains challenging. Key challenges include the variability in DAA access across different regions, slightly variable response rates to DAAs across diverse patient populations and HCV genotypes/subtypes, and the emergence of resistance-associated substitutions (RASs), potentially conferring resistance to DAAs. Therefore, periodic reassessment of current HCV knowledge is needed. An up-to-date review on HCV is also necessitated based on the observed shifts in HCV epidemiological trends, continuous development and approval of therapeutic strategies, and changes in public health policies. Thus, the current comprehensive review aimed to integrate the latest knowledge on the epidemiology, pathophysiology, diagnostic approaches, treatment options and preventive strategies for HCV, with a particular focus on the current challenges associated with RASs and ongoing efforts in vaccine development. This review sought to provide healthcare professionals, researchers, and policymakers with the necessary insights to address the HCV burden more effectively. We aimed to highlight the progress made in managing and preventing HCV infection and to highlight the persistent barriers challenging the prevention of HCV infection. The overarching goal was to align with global health objectives towards reducing the burden of chronic hepatitis, aiming for its eventual elimination as a public health threat by 2030.

Sexual Orientation, Mental Illness, and Substance Use Disorders Among Criminal Legal System-Involved Individuals

OBJECTIVE

The purpose of this study was to examine the prevalence of mental illness, substance use disorders, and access to treatment among individuals from sexual minority groups who have been involved with the criminal legal system.

METHODS

This study used data from 195,239 heterosexual adults and 14,995 sexual minority adults ages ≥18 years surveyed in the 2015-2019 National Survey on Drug Use and Health. The authors compared mental illness, substance use disorders, and access to treatment between sexual minority and heterosexual adults by using multivariable logistic regression models and controlling for sociodemographic characteristics.

RESULTS

Approximately 9% of legal system-involved adults identified as belonging to a sexual minority group. Among legally involved individuals, sexual minority individuals were more likely than heterosexual individuals to have a serious mental illness, suicidal ideation, or depressive thoughts and to use inhalants, hallucinogens, alcohol, marijuana, or cocaine. Legally involved sexual minority individuals were also more likely than their heterosexual counterparts to receive treatment for mental illness or substance use disorders. The increased probability of receiving treatment for mental illness and substance use among sexual minority individuals was also observed when comparing sexual minority and heterosexual adults not involved with the criminal legal system.

CONCLUSIONS

This study adds new population-based research to a limited body of evidence on the health disparities and mental health needs of legally involved sexual minority populations. More research and programmatic and policy interventions are needed to better support legally involved sexual minority groups in order to achieve mental health equity for this vulnerable population.

Diagnostic Performance of the HCV Core Antigen Test To Identify Hepatitis C in HIV-Infected Patients: a Systematic Review and Meta-Analysis

The standard algorithm for diagnosing hepatitis C virus (HCV) infection has two steps, an HCV antibody test for screening and a nucleic acid amplification test (NAAT) for confirmation. However, the HCV core antigen (HCVcAg) detection assay is an alternative for one-step diagnosis. We aimed to evaluate the diagnostic performance of the Abbott ARCHITECT HCV Ag assay to detect active hepatitis C in serum/plasma in people living with HIV/AIDS (PLWHA), through a systematic review and meta-analysis. PubMed, EMBASE, Scopus, Web of Science, and the Cochrane Library were searched until 20 September 2022 (PROSPERO, CRD42022348351). We included studies evaluating Abbott ARCHITECT HCV Ag assay (index assay) versus NAATs (reference test) in PLWHA coinfected with HCV who did not receive antiviral treatment for HCV. Meta-analysis was performed with the MIDAS module using Stata and random-effects models. The QUADAS-2 tool evaluated the risk of bias. The bivariate analysis was conducted on 11 studies with 2,407 samples. Pooled sensitivity was 0.95 (95% CI = 0.92 to 0.97), specificity 0.97 (95% CI = 0.93 to 0.99), positive likelihood ratio 37.76 (95% CI = 12.84 to 111.02), and negative likelihood ratio 0.06 (95% CI = 0.04 to 0.09). The area under the curve was 0.97 (95% CI = 0.20 to 1.00). For low prevalence (≤5%), the posttest probability that an individual with a positive test was a true positive ranged from 4% to 67%, whereas, at high prevalence (≥10%), the posttest probability was between 81% and 87%, indicating that a confirmatory test should be necessary, particularly with prevalence values of ≤1%. Regardless of prevalence, the probability that an individual with a negative test was a false negative was close to zero, indicating that the individual was not infected with HCV. In conclusion, the accuracy of the Abbott ARCHITECT HCV Ag assay was very good for HCV screening in serum/plasma samples from PLWHA. The clinical utility to confirm HCV infection was acceptable in high-prevalence settings (≥10%) but poor in low-prevalence settings (≤1%). Furthermore, it was excellent in excluding active HCV infection.

Understanding the Changing Landscape of Health Disparities in Chronic Liver Diseases and Liver Cancer

Liver disease and liver cancer disparities in the U.S. are reflective of complex multiple determinants of health. This review describes the disproportionate burden of liver disease and liver cancer among racial, ethnic, sexual, and gender minority, rural, low socioeconomic status (SES) populations, and place-based contexts. The contributions of traditional and lifestyle-related risk factors (e.g., alcohol consumption, evitable toxin exposure, nutrition quality) and comorbid conditions (e.g., viral hepatitis, obesity, type II diabetes) to disparities is also explored. Biopsychosocial mechanisms defining the physiological consequences of inequities underlying these health disparities, including inflammation, allostatic load, genetics, epigenetics, and social epigenomics are described. Guided by the National Institute on Minority Health and Health Disparities (NIMHD) framework, integrative research of unexplored social and biological mechanisms of health disparities, appropriate methods and measures for early screening, diagnosis, assessment, and strategies for timely treatment and maintaining multidisciplinary care should be actively pursued. We review emerging research on adverse social determinants of liver health, such as structural racism, discrimination, stigma, SES, rising care-related costs, food insecurity, healthcare access, health literacy, and environmental exposures to pollutants. Limited research on protective factors of liver health is also described. Research from effective, multilevel, community-based interventions indicate a need for further intervention efforts that target both risk and protective factors to address health disparities. Policy-level impacts are also needed to reduce disparities. These insights are important, as the social contexts and inequities that influence determinants of liver disease/cancer have been worsened by the coronavirus disease-2019 pandemic and are forecasted to amplify disparities.

Treatment outcomes and costs of a simplified antiretroviral treatment strategy for hepatitis C among Hepatitis C Virus and Human Immuno deficiency Virus co-infected patients in Ukraine

Background and Aim

To demonstrate the use of a standard dose of ledipasvir (LDV) and sofosbuvir (SOF), with or without ribavirin, to treat hepatitis C and hepatitis C/HIV co-infection in Ukraine.

Methods

Eligible HCV viraemic adults from two clinics in Kyiv were treated with LDV/SOF with or without weight-based ribavirin for 12 weeks. Clinical assessments were performed at screening and at week 24, and as needed; treatment was dispensed every 4 weeks. The primary outcome was sustained virologic response (SVR) 12 weeks after treatment, with analysis by intention to treat. Cost per patient was estimated in USD (2018) over the 24-week period.

Results

Of 868 patients included in the study and initiated on therapy, 482 (55.5%) were co-infected with HIV. The common genotypes were 1 (74.1%) and 3 (22%). Overall, SVR was achieved in 831 of the 868 patients (95.7%). SVR in patients with hepatitis C alone and hepatitis C/HIV co-infection was 98.4% and 93.6%, respectively. Adverse events were infrequent and usually mild. Using generic medication, cost per patient was estimated at US$680.

Conclusion

A standard dose of LDV and SOF, with ribavirin as per protocol, resulted in good outcomes for patients with both hepatitis C alone and co-infected with hepatitis C/HIV. Program costs in Ukraine were modest using generic medication.

Development and Validation of a Risk Prediction Tool to Identify People at Greater Risk of Having Hepatitis C among Drug Users

BACKGROUND

People who use drugs (PWUD) are among those with the highest risk for hepatitis C virus (HCV) infection. Highly effective direct-acting antiviral agents offer an opportunity to eliminate HCV. A simple tool for the prediction of HCV infection risk in PWUD is urgently needed. This study aimed to develop and validate a risk prediction tool to identify people at greater risk of having hepatitis C among PWUD that is applicable in resource-limited settings.

METHODS

We extracted data from national HIV/AIDS sentinel surveillance in PWUD (Zhejiang Province, 2016-2021) and developed and validated a risk score to improve HCV testing in PWUD. This risk score consists of seven risk factors identified using multivariable logistic regression modeling (2016-2020, exploratory group). We validated this score using surveillance data for 2021 (validation group). The accuracy of the model was determined using C-statistics.

RESULTS

We identified seven risk factors, including sex, age, marital status, educational attainment, and the use of heroin, morphine, and methamphetamine. In the exploratory group, the positive rates of detecting the HCV antibody in the low-risk (0-9 points), intermediate-risk (10-16 points), and high-risk (≥17 points) groups were 6.72%, 17.24%, and 38.02%, respectively (P_trend < 0.001). In the validation group, the positive rates in the low-, medium-, and high-risk groups were 4.46%, 12.23%, and 38.99%, respectively (P_trend < 0.001).

CONCLUSIONS

We developed and validated a drug-specific risk prediction tool for identifying PWUD at increased risk of HCV infection. This tool can complement and integrate the screening strategy for the purpose of early diagnosis and treatment.

Risk factors for HCV transmission in HIV-positive men who have sex with men in México

Purpose

In the last two decades transmission of hepatitis C virus (HCV) in HIV positive men who have sex with men (MSM) has been reported globally. Chemsex and specific sexual practices have been identified as risk factors. Our study aimed to identify risk factors for HCV transmission in MSM living with HIV attending in Mexico.

Methods

We conducted a case-control study from April to December 2019 at the Hospital de Infectología “La Raza” National Medical Center, in Mexico City. A case was defined as an HIV-infected MSM with positive HCV-antibody test. For each case, 3 controls were included, defined as HIV infected MSM with negative HCV-antibody test. A self-questionnaire covering sexual practices and other risk factors for HCV transmission was applied. Bivariate analysis was performed to obtain odds ratio (OR) using Chi-square test. Independent risk factors were identified in a subsequent analysis performing a logistic regression model.

Results

A total of 324 patients participated in the study, 81 cases and 243 controls. Median age was 30.5 years (IQR: 18–52) and 28.8 years (IQR: 21–45) in the case and control group, respectively. Most prevalent HCV genotype was 1a (79%). In the logistic regression model, sharing straw during cocaine inhalation (OR: 9.03; 95% CI; 1.35–13.52; P = 0.003), sharing sex toys (OR: 17.53, 95% CI; 6.85–44.86; P = 0.002), and ethyl chloride use for chemsex (OR: 2.26; 95% CI; 1.29–5.56; P = 0.037) were significant risk factors for HCV infection.

Conclusion

This study identifies risk factors for HCV transmission in Mexico in HIV positive MSM in congruence with the findings of many studies performed worldwide. This is the first study that indicates a possible association between ethyl chloride use in chemsex and HCV infection. Assessment of local populations for risk factors for HCV transmission may help to develop specifically targeted behavioral interventions to reduce HCV transmission.

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.

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.

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.

HIV Prevention Trials Network 078: High Prevalence of Hepatitis C Virus Antibodies Among Urban US Men Who Have Sex With Men, Independent of Human Immunodeficiency Virus Status

BACKGROUND

Sexual transmission of hepatitis C virus (HCV) is uncommon, yet documented among men who have sex with men (MSM), primarily among those with human immunodeficiency virus (HIV).

METHODS

In the HIV Prevention Trials Network 078 study (HPTN 078), which assessed an integrated strategy to achieve HIV viral suppression, 1305 MSM were screened across 4 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

Among the 1287 (99%) of the MSM with HCV antibody results, the median age was 41, 69% were black, 85% had a high school education 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 (interquartile range, 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 = .12) and was higher in those receiving substance use counseling (36%) than in those who had not (15%) (P ≤ .01). Substance use counseling (odds ratio, 2.51; 95% confidence interval, 1.80-3.51) and unstable housing (2.16; 1.40-3.33) were associated with HCV antibody positivity.

CONCLUSIONS

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 implementation of preexposure prophylaxis expands and condom use declines, routine HCV counseling and screening among MSM are important.

A Tale of Two Viruses: Immunological Insights Into HCV/HIV Coinfection

Nearly 2.3 million individuals worldwide are coinfected with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Odds of HCV infection are six times higher in people living with HIV (PLWH) compared to their HIV-negative counterparts, with the highest prevalence among people who inject drugs (PWID) and men who have sex with men (MSM). HIV coinfection has a detrimental impact on the natural history of HCV, including higher rates of HCV persistence following acute infection, higher viral loads, and accelerated progression of liver fibrosis and development of end-stage liver disease compared to HCV monoinfection. Similarly, it has been reported that HCV coinfection impacts HIV disease progression in PLWH receiving anti-retroviral therapies (ART) where HCV coinfection negatively affects the homeostasis of CD4⁺ T cell counts and facilitates HIV replication and viral reservoir persistence. While ART does not cure HIV, direct acting antivirals (DAA) can now achieve HCV cure in nearly 95% of coinfected individuals. However, little is known about how HCV cure and the subsequent resolution of liver inflammation influence systemic immune activation, immune reconstitution and the latent HIV reservoir. In this review, we will summarize the current knowledge regarding the pathogenesis of HIV/HCV coinfection, the effects of HCV coinfection on HIV disease progression in the context of ART, the impact of HIV on HCV-associated liver morbidity, and the consequences of DAA-mediated HCV cure on immune reconstitution and HIV reservoir persistence in coinfected patients.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11–14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Acute hepatitis C virus infection and direct-acting antiviral drugs: Perfect combination to eliminate the epidemic?

Early diagnosis and treatment of incident cases of hepatitis C virus (HCV) infection is fundamental to eliminate HCV in HIV-positive patients. From January 2016 to December 2019, we attended 40 episodes of acute HCV infection (AHC) in 35 subjects (9 reinfections) who were coinfected with HIV. The patients were treated with direct-acting antiviral agents (DAAs) in seven hospitals in Andalusia, Spain. All were men who have sex with men (MSM), mean age was 42.9 (±8.3) years and median time of HIV infection was 46.6 months (IQR: 20.4-67.2). All received antiretroviral therapy and had undetectable HIV viral load (except 2 with 65 and 68 copies/mL); median CD4 count was 632 cells/mm³ (IQR: 553-896). Over half (74.3%) also had another concomitant sexually transmitted infection, syphilis (48.6%) being the most common. AHC was asymptomatic in 32 cases (80%). Genotypeic distribution was G1a 65%, G4 32.5% and G1b 3%. Median time to DAA was 6 weeks (IQR: 4.3-18.3) and median baseline HCV RNA was 6.1 Log (IQR: 5.6-6.5). DAA regimens were SOF/LDV (19 episodes), SOF/VEL (14), ELB/GZV (5) and GLP/PIB (2). All presented sustained viral response and none discontinued due to adverse effects. In conclusion, early treatment with DAA in AHC patients proved effective and safe. It could be an excellent strategy to eliminate HCV infection in HIV-coinfected MSM.

Current treatment for hepatitis C virus/human immunodeficiency virus coinfection in adults

Hepatitis C virus (HCV)/human immunodeficiency virus (HIV) coinfection is a major problem among HIV-infected patients, resulting in increased morbidity and mortality rates due to the acceleration of liver fibrosis progression by HIV, leading to liver cirrhosis and hepatocellular carcinoma. Although the efficacy of direct-acting antiviral therapy in patients with HIV/HCV coinfection and HCV monoinfection are similar in terms of sustained virologic response rate, there are some additional complications that arise in the treatment of patients with HIV/HCV coinfection, including drug-drug interactions and HCV reinfection due to the high risk behavior of these patients. This review will summarize the current management of HIV/HCV coinfection.

Elimination of hepatitis C among HIV-positive population in Asia: old and new challenges

Hepatitis C virus (HCV) prevalence is high among people living with HIV co-infected with HCV, people who inject drugs, men who have sex with men and inmates in correctional settings. The barriers to eliminate HCV among these key populations include diagnosis challenges, lack of awareness, discrimination and stigmatization. In addition, scaling up of HCV treatment has been a challenge in Asia–Pacific with the lack of national policies, targets and unavailability of appropriate direct-acting antivirals regimens. In order to achieve HCV micro elimination within these high-risk populations, novel strategies to improve the cascade of care from diagnosis to treatment with direct-acting antivirals, complemented by behavioral change interventions, harm reduction services for people who inject drugs, civil society led advocacy and policies from the government, will be necessary.

Allocating treatment resources for hepatitis C in the UK: a constrained optimization modelling approach

Background and objective: Although the treatment of chronic hepatitis C (CHC) has significantly evolved with the introduction of direct-acting antivirals, the treatment uptake rates have been low especially among marginalized groups in the UK, such as people who inject drug (PWID) and men who have sex with men (MSM). Cutting health inequality is a major focus of healthcare agencies. This study aims to identify the optimal allocation of treatment budget for chronic hepatitis CHC among populations and treatments in the UK so that liver-related mortality in patients with CHC is minimized, given the constraint of treatment budget and equity issue. Methods: A constrained optimization modelling of resource allocation for the treatment of CHC was developed in Excel from the perspective of the UK National Health System over a lifetime horizon. The model was designated with the objective function of minimizing liver-related deaths by varying the decision variables, representing the number of patients receiving each treatment (elbasvir-grazoprevir, ombitasvir-paritaprevir-ritonavir-dasabuvir, sofosbuvir-ledipasvir, and pegylated interferon-ribavirin) in each population (the general population, PWID, and MSM). Two main constraints were formulated including treatment budget and the issue of equity. The model was populated with UK local data applying linear programming and underwent internal and external validation. Scenario analyses were performed to assess the robustness of model results. Results: Within the constraints of no additional funding over original spending in status quo and the consideration of the issue of equity among populations, the optimal allocation from the constrained optimization modelling (treating 13,122 PWID, 160 MSM, and 904 general patients with ombitasvir-paritaprevir-ritonavir-dasabuvir) was found to treat 2,430 more patients (relative change: 20.7%) and avert 78 liver-related deaths (relative change: 0.3%) compared with the current allocation. The number of patients receiving treatment increased 4,928 (relative change: 60.1%) among PWID and 42 (relative change: 35.8%) among MSM. Conclusion: The current allocation of treatment budget for CHC is not optimal in the UK. More patients would be treated, and more liver-related deaths would be avoided using a new allocation from a constrained optimization modelling without incurring additional spending and considering the issue of equity.

Hepatitis C virus infection in HIV-infected men in Singapore, 2006-2018: incidence and associated factors

Background The epidemiology of hepatitis C virus (HCV) infection in people living with HIV has been evolving, with increasing evidence of permucosal (sexual) transmission identified predominantly in HIV-positive men who have sex with men (MSM). The aim of this study was to estimate the incidence rate and elucidate epidemiological factors associated with HCV infection among HIV-infected men in Singapore from 2006 to 2018.

METHODS

A retrospective cohort study was conducted using a clinical database maintained by the Clinical HIV Program at the National Centre for Infectious Diseases, Singapore. Factors associated with incident HCV infections were identified using Cox proportional hazards regression analyses.

RESULTS

Among 1348 HIV-infected male patients who were HCV seronegative at baseline, 64 (4.7%) subsequently tested positive for HCV, giving an incidence of 0.88 per 100 person-years of follow-up (PYFU) (95% confidence interval (CI) 0.69-1.13). The incidence rate of HCV seroconversion increased from 0.33 (95% CI 0.12-0.71) per 100 PYFU in 2010-2012 to 1.93 (95% CI 1.36-2.67) in 2016-2018. Independent factors associated with incident HCV infection were younger age groups at HIV diagnosis versus ≥45 years, HIV acquisition via MSM or via both sexual contact and intravenous drug use versus heterosexual transmission, HIV diagnosis in later periods versus 2006-2009, and recent syphilis acquisition.

CONCLUSIONS

An increasing trend of incident HCV infection was seen in HIV-infected men, particularly for MSM. Preventive and behavioural interventions should be targeted at HIV-infected individuals engaged in high-risk sexual behaviour.

Slam Practice: A Review of the Literature

BACKGROUND

Slamming has been developing since 2011 as a new international phenomenon, mostly among men who have sex with men (MSM). It consists of intravenous drug injection before or during planned sexual activity to sustain, enhance, disinhibit, or facilitate the experience. We aimed to synthesize the available published evidence through a systematic literature review in order to precisely describe this phenomenon and to better characterize the population engaging in this practice and its specific motives.

METHODS

A systematic review of the available literature was conducted to identify all relevant publications using PubMed, Psyc-INFO, the Cochrane Library, and ScienceDirect. To complete the review, we followed the recommendations of the "Preferred Reporting Items for Systematic Reviews and Meta-Analyses" method. We limited the search to studies published between January 2008 and May 2020.

RESULTS

Our search identified 530 publications, of which 27 were included in the final data synthesis. One study focused on heterosexual and homosexual subpopulations, and all other studies focused on MSM-specific samples. Among MSM, slam prevalence was extremely variable, ranging from 2 to 91%; regarding other sexually active subjects, prevalence ranged from 7 to 14%. The prevalence of HIV-positive subjects varied widely across studies, ranging from 0.6 to 100%. We found less data about hepatitis C virus serostatus, ranging from 3 to 100%. Methamphetamine and mephedrone were the 2 most used drugs.

DISCUSSION/CONCLUSION

The data we found in international literature were very heterogeneous and from poorly reproducible studies. The definition of slamming in the international literature is not always clear, which limits the completeness of the collected data. This topic has been open to studies only recently; however, health professionals must be trained in the management of this practice, considering its risks in the short and medium terms and its addictive potential. We provided and discussed recommendations and potential future directions.

Current and future strategies for the treatment of chronic hepatitis C

Chronic hepatitis C infection is a major cause of liver disease and hepatocellular carcinoma worldwide. While hepatitis C has been treated for decades with some success, the introduction of direct acting antiviral agents has revolutionized the treatment of hepatitis C with finite, highly effective, well-tolerated therapy and there are few populations that cannot be successfully treated now or are complicated to manage. The World Health Organization has released elimination targets in an effort to eliminate viral hepatitis and reduce dramatically the morbidity and mortality caused by both viral hepatitis. While hepatitis C is straightforward to treat, it remains problematic to eliminate on a global scale. Diagnosis of hepatitis C remains the major gap in the cascade of care and numerous screening strategies will be required to reduce this gap. While historically, treatment of hepatitis C has been centralized, decentralized approaches will be required to diagnose, evaluate, and link to care the large population of individuals worldwide with hepatitis C across low-, middle-, and high-income countries. With the introduction of multiple pangenotypic treatment options and reduced cost for these therapies, assessment and treatment for those with hepatitis C has been simplified and made more accessible worldwide. There are multiple populations for whom care models are being developed and refined, including those when inject drugs, those who are incarcerated, those who present with sexually transmitted disease including the men who have sex with men population, amongst many others. While a vaccine for hepatitis C remains elusive these efforts continue. Multiple successful elimination efforts have been reported.

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

BACKGROUND

WHO has set targets for hepatitis C virus (HCV) elimination by 2030. We did a global systematic review of HCV prevalence and incidence in men who have sex with men (MSM) to provide updated estimates that can guide community education and public health policy.

METHODS

We did a systematic review and meta-analysis of studies published and listed on MEDLINE or Embase between Jan 1, 2000, and Oct 31, 2019, including conference proceedings. Studies were eligible if they reported measures of HCV prevalence or HCV incidence (or both) among MSM. Studies that relied on participants' self-reported HCV status with no laboratory confirmation were excluded. Pooled HCV estimates in MSM were stratified by HIV status and by injecting drug use, then by WHO region and by income level. Random-effects meta-analysis was done to account for between-study heterogeneity and examined using the I² statistic. Pooled HCV prevalence was also compared with HCV estimates in the general population and presented as prevalence ratios (PRs). In HIV-negative MSM, incidence estimates were stratified by use of HIV pre-exposure prophylaxis (PrEP). The systematic review was registered with PROSPERO, number CRD42020156262.

FINDINGS

Of 1221 publications identified, 194 were deemed to be eligible and included in the systematic review and meta-analysis. Overall, the pooled HCV prevalence in MSM was 3·4% (95% CI 2·8-4·0; I²=98·0%) and was highest in Africa (5·8%, 2·5-10·4) and South-East Asia (5·0%, 0·0-16·6). Globally, HCV prevalence was 1·5% (1·0-2·1) in HIV-negative MSM and 6·3% (5·3-7·5) in HIV-positive MSM. Compared with the general population, HCV prevalence was slightly higher in HIV-negative MSM (PR 1·58, 95% CI 1·14-2·01) and markedly higher (6·22, 5·14-7·29) in HIV-positive MSM. Pooled HCV prevalence was substantially higher in MSM who had ever injected drugs (30·2%, 22·0-39·0) or currently injected drugs (45·6%, 21·6-70·7) than in those who never injected drugs (2·7%, 2·0-3·6). In HIV-negative MSM, the pooled HCV incidence was 0·12 per 1000 person-years (95% CI 0·00-0·72) in individuals not on PrEP and 14·80 per 1000 person-years (9·65-20·95) in individuals on PrEP. HCV incidence in HIV-positive MSM was 8·46 per 1000 person-years (6·78-10·32).

INTERPRETATION

HIV-positive MSM are at substantially increased risk of HCV. Overall, HIV-negative MSM had a slightly higher prevalence of HCV than the general population but had a lower prevalence than HIV-positive MSM. High HCV incidence in more recent PrEP studies suggests that as PrEP use increases, greater HCV transmission might occur. HCV burden in MSM varies considerably by region, which is likely to be associated with variation in the prevalence of injecting drug use and HIV.

FUNDING

World Health Organization.

Trends in hepatitis C virus seroprevalence and associated risk factors among men who have sex with men in Montréal: results from three cross-sectional studies (2005, 2009, 2018)

Objectives

To eliminate the hepatitis C virus (HCV) by 2030, Canada must adopt a microelimination approach targeting priority populations, including gay, bisexual and other men who have sex with men (MSM). Accurately describing HCV prevalence and risk factors locally is essential to design appropriate prevention and treatment interventions. We aimed to estimate temporal trends in HCV seroprevalence between 2005 and 2018 among Montréal MSM, and to identify socioeconomic, behavioural and biological factors associated with HCV exposure among this population.

Methods

We used data from three cross-sectional surveys conducted among Montréal MSM in 2005 (n=1795), 2009 (n=1258) and 2018 (n=1086). To ensure comparability of seroprevalence estimates across time, we standardised the 2005 and 2009 time-location samples to the 2018 respondent-driven sample. Time trends overall and stratified by HIV status, history of injection drug use (IDU) and age were examined. Modified Poisson regression analyses with generalised estimating equations were used to identify factors associated with HCV seropositivity pooling all surveys.

Results

Standardised HCV seroprevalence among all MSM remained stable from 7% (95% CI 3% to 10%) in 2005, to 8% (95% CI 1% to 9%) in 2009 and 8% (95% CI 4% to 11%) in 2018. This apparent stability hides diverging temporal trends in seroprevalence between age groups, with a decrease among MSM <30 years old and an increase among MSM aged ≥45 years old. Lifetime IDU was the strongest predictor of HCV seropositivity, and no association was found between HCV seroprevalence and sexual risk factors studied (condomless anal sex with men of serodiscordant/unknown HIV status, number of sexual partners, group sex).

Conclusions

HCV seroprevalence remained stable among Montréal MSM between 2005 and 2018. Unlike other settings where HCV infection was strongly associated with sexual risk factors among MSM, IDU was the pre-eminent risk factor for HCV seropositivity. Understanding the intersection of IDU contexts, practices and populations is essential to prevent HCV transmission among MSM.

Transmission of hepatitis C virus in HIV-positive and PrEP-using MSM in England

We sought to characterize risk factors and patterns of HCV transmission amongst men who have sex with men (MSM). MSM with recently acquired HCV (AHCV) were prospectively recruited ('clinic cohort') between January and September 2017. Clinical data and risk behaviours were identified and blood obtained for HCV whole genome sequencing. Phylogenetic analyses were performed, using sequences from this cohort and two other AHCV cohorts, to identify transmission clusters. Sixteen (40.0%) men in the clinic cohort were HIV-negative MSM. HIV-negative MSM were younger than HIV-positive MSM; most (81.3%) had taken HIV PrEP in the preceding year. Eighteen men (45.0%) reported injection drug use; most (34, 85.0%) reported noninjection drug use in the last year. Most in both groups reported condomless anal sex, fisting and sex in a group environment. Few (7, 17.5%) men thought partners may have had HCV. There were 52 sequences in the HCV genotype 1a phylogeny, 18 from the clinic cohort and 34 from other AHCV cohorts; 47 (90.4%) clustered with ≥1 other sequence. There were 7 clusters of 2-27 sequences; 6 clusters contained HIV-negative and HIV-positive MSM and 1 cluster only HIV-positive MSM. Four of these clusters were part of larger clusters first described in 2007. PrEP-using MSM are at risk of HCV, sharing similar risk factors to HIV-positive MSM. Phylogenetics highlights that PrEP-using and HIV-positive MSM are involved in the same HCV transmission networks. Few men demonstrated HCV awareness and risk reduction strategies should be expanded.

Management of hepatitis B and hepatitis C coinfection: an expert review

INTRODUCTION

Hepatitis B virus (HBV) and hepatitis C virus (HCV) infections share common routes of transmission. HBV/HCV coinfection can lead to interactions affecting mechanisms of infection and therapy.

AREAS COVERED

In the review, we present epidemiology of HBV/HCV coinfection and current therapeutic options for both viruses. The possibility of drug-drug interactions during the treatment of coinfected patients is discussed. However, the major part of the review is dedicated to interactions between viruses and risk of HBV reactivation during HCV treatment with direct-acting antivirals (DAA). Finally, we analyze available international and national guidelines for the management of HBV reactivations related to DAA administration.

EXPERT OPINION

The most important international societies' guidelines include comments on HBV/HCV coinfection, but due to their inconsistency we present a proposal of management for HBV/HCV coinfected patients focusing mostly on HBV reactivation in patients treated for HCV. We provide some advice that should be considered in future guidelines for the management of HBV/HCV coinfection.

Prevalence of Sexually Transmitted Infections and Human Immunodeficiency Virus in Transgender Persons: A Systematic Review

Purpose: Despite reportedly high rates of human immunodeficiency virus (HIV) and other sexually transmitted infections (STIs) among transgender people, laboratory-proven prevalence of these infections in this population has not been systematically reviewed. We performed a systematic review and meta-analysis of the medical literature involving laboratory-proven HIV and STI diagnoses among transgender people.

Methods: A systematic review of the English literature regarding laboratory-proven HIV and/or STI testing in transgender populations within the last 50 years was performed. Preliminary meta-analyses assessing the prevalence of HIV and STIs among both transgender men and transgender women were performed. Given the heterogeneity of included studies, these analyses were difficult to interpret and not included in our results.

Results: Our literature review identified 25 studies, representing 11 countries. All of these studies included transgender women, with 9 (36%) including data on transgender men. HIV was the most commonly studied STI, with prevalence ranging from 0% to 49.6% in transgender women and 0% to 8.3% in transgender men. For syphilis, gonorrhea, and chlamydia, respectively, prevalence ranged from 1.4% to 50.4%, 2.1% to 19.1%, and 2.7% to 24.7% in transgender women and from 0% to 4.2%, 0% to 10.5%, and 1.2% to 11.1% in transgender men. Site-specific testing practices for gonorrhea and chlamydia were variable. No studies reported prevalence data on trichomoniasis.

Conclusion: The literature describing STIs and transgender people primarily focuses on transgender women and HIV. Data involving HIV and STIs among transgender men are lacking. These findings highlight opportunities for the future study of epidemiology of HIV/STIs in transgender men and the relevance of STIs in transgender people.

Are we on the precipice of a new epidemic? Risk for hepatitis C among HIV-negative men-, trans women-, and trans men- who have sex with men in the United States

Emerging data from Europe have documented increases in diagnoses of acute hepatitis C virus (HCV) infection among HIV-negative men who have sex with men. We investigated risk factors for HCV and their correlates in the Together 5000 study, a U.S. national cohort study of HIV-negative men (n = 6089), transgender women (n = 40), and transgender men (n = 42) who have sex with men. We used bivariate and multivariable analyses to determine demographic and behavioral factors associated with high risk for acute HCV infection (using the HCV-MOSAIC risk indicator with a score ≥ 2.0). Mean HCV risk score was 1.38 (SD = 1.09) and 27.3% of participants had HCV risk scores ≥ 2.0. In multivariable modeling, being cisgender male (vs. not) was associated with having a lower HCV-MOSAIC risk score. Meanwhile, being white, having been incarcerated, prior use of HIV pre- or post-exposure prophylaxis, having ever been tested for HIV, and recent methamphetamine use were associated with high risk for HCV. More than one-in-four participants exceeded the threshold score for HCV risk. Those with high HCV-MOSAIC risk scores were more likely to have been in settings where they could be tested for acute HCV (i.e., HIV testing, PrEP care, PEP care, incarceration), suggesting opportunities to engage them in HCV screening, prevention, and treatment.

Knowledge, attitudes and practices related to hepatitis C among gay and bisexual men in the era of direct-acting antivirals: implications for treatment and prevention

Increases in hepatitis C (HCV) infections among gay and bisexual men have recently been reported in a number of countries, with sexual transmission being the primary route of infection. Given that in countries such as Australia most gay and bisexual men living with HIV are already engaged in clinical care - as are an increasing number of HIV-negative men - there is potential for reducing onward HCV transmission through proactive testing and treatment. This study explored knowledge, attitudes and practices related to HCV among 194 gay and bisexual men collected through an online survey in Australia. Overall, respondents had high levels of HCV knowledge; however, only 76% knew about the availability of new treatments for HCV. Men's knowledge of their own HCV testing history was uncertain, with one in six unaware if they had ever been tested. Among men who reported recent drug injecting, one-third had been injected by someone else, and two-thirds had injected someone else, indicating a subculture of cross-administering within sexualised drug-use networks. We argue that the robust sexual, socio-cultural and clinical infrastructure that has been developed by - and for - gay and bisexual men around HIV care and prevention creates the potential for reducing HCV in this group.

Injecting drug use during sex (known as "slamming") among men who have sex with men: Results from a time-location sampling survey conducted in five cities, France

BACKGROUND

In the last decade, European cities saw the development of "slamming," a practice related to chemsex that combines three elements: a sexual context, psychostimulant drug use, and injection practices. Epidemiological data on this practice is still sparse and media attention might have unintentionally distorted the size of this phenomenon. Therefore, we aimed to estimate the prevalence of men practicing slam and to identify factors associated with this practice.

METHODS

We used data from the Prevagay 2015 bio-behavioral survey to estimate the prevalence of slamming practices. A time-location sampling was performed among gay-labeled venues in five French cites. Behavioral information was recorded using a self-administered questionnaire. The HIV and HCV serostatus were investigated using ELISA tests on dried blood spots. The factors associated with slamming were assessed using a multiple logistic regression. We applied a weighting mechanism to enhance the generalizability of the estimates.

RESULTS

Among the 2646 men who have sex with men (MSM) included in our study, 3.1% reported slamming at least once during their lifetime (95% confidence interval (CI) = 2.2-4.3) and 1.6% (95% CI = 1-2.3) said they participated in a slamming session in the last 12 months. In the multivariate analysis, both HCV and HIV biological status were strongly associated with practicing "slam" in the last 12 months (OR = 13.37 (95% CI = 3.26-54.81) and 4.73 (95% CI = 1.58-14.44), respectively). Furthermore, a ten-point decrease in mental health scores was linked with the practice with an OR of 1.37 (95% CI = 1.08-1.73), indicating poorer mental health.

CONCLUSION

Even though slamming seems to involve a relatively small proportion of MSM, the vulnerability of this sub-group is high enough to justify setting up harm reduction measures and specific care. Training health professionals and creating services combining sexual health and drug dependence could be an effective response.

The Elimination of Hepatitis C as a Public Health Threat

Hepatitis C virus is a global public health threat, affecting 71 million people worldwide. Increasing recognition of the impact of this epidemic and recent advances in biomedical and technical approaches to hepatitis C prevention and cure have provided impetus for the World Health Organization (WHO) to call for global elimination of hepatitis C as a public health threat by 2030. This work reviews the feasibility of hepatitis C elimination and pathways to overcome existing and potential future barriers to elimination. Drawing on cost-effectiveness modeling and providing examples of successful implementation efforts across the globe, we highlight the resources and strategies needed to achieve hepatitis C elimination. A timely, multipronged response is required if the 2030 WHO elimination targets are to be achieved. Importantly, achieving hepatitis C elimination will also benefit the community well beyond 2030.

Estimation of the impact of changing drug-use trend on HIV, hepatitis C and syphilis epidemics among people who use synthetic drug-only, polydrug and heroin-only during 2005-2035 in China: modelling study

OBJECTIVE

The rapid expansion of the recreational drug market becomes a global health concern. It is worrying that the bacterial and viral infection epidemics linking to drug use may worsen accordingly. This study aimed to estimate the impacts of changing trend and behaviours of using heroin only, synthetic drug (SD) only and polydrug (using SD and heroin concurrently) on HIV, hepatitis C virus (HCV) and syphilis epidemics among people who use drugs in China by 2035.

METHODS

We constructed a compartmental model to estimate HIV, HCV and syphilis epidemics in the dynamic drug-use trend by three scenarios: SD-only use, heroin-only use and polydrug use based on Monte Carlo simulations. The parameters for the model were collected from a comprehensive literature search.

RESULTS

Our model estimated that polydrug use led to the highest HIV and HCV prevalence among three drug-use patterns. The prevalences were projected to increase from 10.9% (95% CI 10.2% to 11.5%) and 61.7% (95% CI 59.4% to 62.5%) in 2005 to 19.0% (95% CI 17.3% to 20.7%) and 69.1% (95% CI 67.3% to 69.5%), respectively, in 2035 among people using polydrug. Similarly, HIV and HCV prevalence in the SD-only group were projected to increase from 0.4% (95% CI 0.3% to 0.4%) and 19.5% (95% CI 19.4% to 21.7%) to 1.8% (95% CI 1.4 to 2.1%) and 33.7% (95% CI 33.2% to 34.9%) in 2005-2035. Conversely, HIV prevalence in the heroin-only group was projected to decrease from 8.0% (95% CI 7.6% to 8.1%) to 2.2% (95% CI 2.0% to 2.3%) in 2005-2035. Syphilis prevalence was estimated to remain unchanged in all population groups within this time frame. It was projected that the proportion of HIV transmitted by sexual transmission will increase compared with unsafe injection transmission in all people who use drugs from 2005 to 2035.

CONCLUSION

Our modelling suggests that polydrug use is projected to lead to the highest HIV and HCV disease burden by 2035, and the proportion of HIV transmitted by sexual transmission will increase. Current HIV intervention among people using heroin seems effective according to our estimation.

Hepatitis C Virus Epidemiology and the Impact of Interferon-Free Hepatitis C Virus Therapy

The public health impact of hepatitis C virus (HCV) infection has been realized only recently. Globally, 71 million people are living with HCV chronic infection. HCV prevalence is higher in some regions and countries, as well as in some subpopulations such as people who inject drugs, prisoners, or people living with HIV. In 2017, an estimated 580,000 people died from HCV, largely because of long-term complications of the disease. The advent of direct-acting antivirals (DAAs), which are highly effective in treating the infection and are well tolerated, led the World Health Organization (WHO) in 2016 to call for the elimination of HCV by 2030, which would be possible by meeting the numerical targets laid down by the organization. However, at present, only 12 countries are on track. Overall, only 20% of people with HCV have been diagnosed and only 7% of people diagnosed have initiated treatment, with major differences among countries. Underdiagnoses, a general lack of awareness, poor surveillance, and the prices of diagnostics and treatment remain major barriers to achieving the elimination goals. Comprehensive strategies, which include innovative models of care and the removal of reimbursement restrictions for treatment, are needed to overcome these public health and health system obstacles.

HIV Prevention Research on Men Who Have Sex With Men: A Scoping Review of Systematic Reviews, 1988-2017

In the United States, men who have sex with men (MSM) are disproportionately affected by HIV. To identify research gaps and inform HIV prevention for MSM, we conducted a scoping review of systematic reviews using CDC's Prevention Research Synthesis database. Eligibility criteria comprised English-language systematic reviews focused on HIV prevention for MSM, published during 1988-2017, and included at least one U.S. primary study. We coded data type, subpopulations, topics, and key findings. To assess study quality, we used the Assessment of Multiple Systematic Reviews (AMSTAR). Among 129 relevant systematic reviews, study quality was high or moderate for 63%. Most common topics were sexual behavior and disease vulnerability. The most frequently mentioned MSM subgroups were HIV-positive, Black or African American, and young. Research gaps include Hispanic/Latino MSM, pre-exposure prophylaxis (PrEP), treatment as prevention, social determinants of health, health disparities, syndemics, and protective factors for sexual health.

Scaling up screening and treatment for elimination of hepatitis C among men who have sex with men in the era of HIV pre-exposure prophylaxis

BACKGROUND

Routine HIV pre-exposure prophylaxis (PrEP) and HIV care appointments provide opportunities for screening men who have sex with men (MSM) for hepatitis C virus infection (HCV). However, levels of screening required for achieving the WHO elimination target of reducing HCV incidence by 90% by 2030 among all MSM are unknown.

METHODS

An HCV/HIV transmission model was calibrated to UK prevalence of HIV among MSM (4·7%) and chronic HCV infection among HIV-positive MSM (9·9%) and HIV-negative MSM (1.2%). Assuming 12·5% coverage of PrEP among HIV-negative MSM, we evaluated the relative reduction in overall HCV incidence by 2030 (compared to 2018 levels) of HCV screening every 12/6-months (alongside completing direct acting antiviral treatment within 6-months of diagnosis) in PrEP users and/or HIV-diagnosed MSM. We estimated the additional screening required among HIV-negative non-PrEP users to reduce overall incidence by 90% by 2030. The effect of 50% reduction in condom use among PrEP users (risk compensation) was estimated.

RESULTS

Screening and treating PrEP users for HCV every 12 or 6-months decreases HCV incidence by 67·3% (uncertainty range 52·7-79·2%) or 70·2% (57·1-80·8%), respectively, increasing to 75·4% (59·0-88·6%) or 78·8% (63·9-90·4%) if HIV-diagnosed MSM are also screened at same frequencies. Risk compensation reduces these latter projections by <10%. To reduce HCV incidence by 90% by 2030 without risk compensation, HIV-negative non-PrEP users require screening every 5·6 (3·8-9·2) years if MSM on PrEP and HIV-diagnosed MSM are screened every 6-months, shortening to 4·4 (3·1-6·6) years with risk compensation. For 25·0% PrEP coverage, the HCV elimination target can be reached without screening HIV-negative MSM not on PrEP, irrespective of risk compensation.

INTERPRETATION

At low PrEP coverage, increased screening of all MSM is required to achieve the WHO HCV-elimination targets for MSM in the UK, whereas at higher PrEP coverage this is possible through just screening HIV-diagnosed MSM and PrEP users.

Sexually transmitted hepatitis C infection: the evolving epidemic in HIV-positive and HIV-negative MSM

PURPOSE OF REVIEW

The scale-up of direct-acting antiviral (DAA) therapy and introduction of preexposure prophylaxis (PrEP) has changed the epidemiology of sexually acquired hepatitis C virus (HCV) amongst HIV-positive and HIV-negative MSM.

RECENT FINDINGS

Sexually acquired HCV continues to occur predominantly amongst HIV-positive MSM. Despite an increased uptake of DAA therapy the incidence of acute HCV has not declined consistently amongst HIV-positive MSM, likely a result of high infection and reinfection rates. Increasing cases of sexually acquired HCV have been reported amongst HIV-negative MSM accessing PrEP. Despite a lower prevalence of HCV at baseline, HIV-negative MSM accessing PrEP have an equally high overall incidence of HCV compared with HIV-positive MSM during follow-up. Behavioural factors (high-risk sexual behaviours and sexualized drug use) appear to be driving this HCV epidemic amongst MSM and effective behavioural interventions and early identification of reinfections are essential to control the HCV epidemic amongst MSM.

SUMMARY

An improved understanding of the epidemiology of sexually acquired HCV will allow implementation of more effective public health interventions to control the transmission of HCV amongst HIV-positive and HIV-negative MSM.

Cathinone Use Disorder in the Context of Slam Practice: New Pharmacological and Clinical Challenges

BACKGROUND

"Slam" has emerged since 2008 as a new international phenomenon among men who have sex with men (MSM); it consists of the intravenous injection of drugs before or during planned sexual activity. The practice of slam is associated with the use of psychostimulants, including synthetic cathinones.

METHODS

All spontaneous notifications (Nots) of slam practice reported between January 2012 and October 2019 at the Nantes addictovigilance center in France were collected and analyzed. The purpose of this work was to analyze cases of slam to characterize cathinone use disorder according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) and to further our knowledge of slam practice based on data on drug use, risk taking and harmful consequences.

RESULTS

We collected 39 slam Nots. The severity of cathinone use disorder was mild, moderate and severe for 18%, 12%, and 58% of the patients, respectively. "Much time spent using cathinone" was the diagnostic criterion most often cited (82%).

CONCLUSIONS

To the best of our knowledge, our study is the first to evaluate the presence of a cathinone use disorder. Cathinone use disorder seems particularly important in this population of users, and negative consequences of slam practice appear quickly.

Sexual behaviour as a risk factor for hepatitis C virus infection among people who inject drugs in Montreal, Canada

Hepatitis C virus (HCV) acquisition remains high in key risk environments including injection drug use and sex between men. However, few studies examine the independent contribution of sexual behaviour to HCV acquisition among people who inject drugs (PWID). We estimated HCV incidence and examined sexual behaviour as a time-varying predictor of HCV acquisition in a prospective cohort study of PWID in Montreal (2004-2017). Initially, HCV-negative participants completed behavioural questionnaires and HCV antibody testing (6 months until 2011, 3 months thereafter). A time-updating exposure variable (no sex, opposite-sex partner only, ≥1 same-sex partner) was generated for the previous 6/3 months. Time to HCV seroconversion was examined using Cox regression analysis, adjusted for age, unstable housing and incarceration (both past 3 months), and daily, heroin, cocaine and prescription opioid injecting (all past month). Among 440 PWID (baseline: median age 33 years, 18.9% female, 1.4% HIV-positive), 156 participants seroconverted during follow-up (overall incidence rate: 11.9/100 person-years [PY]). Incidence was lowest in the no sex group (8.70 and 2.91 cases/100 PY in males and females, respectively) and highest in the ≥1 same-sex partner group (24.14 and 21.97 cases/100 PY in males and females, respectively). Among males, HCV risk was 47% lower in those reporting no sex compared to ≥1 same-sex partner (adjusted hazard ratio: 0.53, 95% confidence interval: 0.28, 0.99). In this cohort of PWID, reporting recent same-sex partners was associated with greater risk of HCV acquisition among males, necessitating targeted harm reduction strategies that consider the complex interplay of sexual and injecting risk behaviours.

Hepatitis C

Hepatitis C is a global health problem, and an estimated 71·1 million individuals are chronically infected with hepatitis C virus (HCV). The global incidence of HCV was 23·7 cases per 100 000 population (95% uncertainty interval 21·3-28·7) in 2015, with an estimated 1·75 million new HCV infections diagnosed in 2015. Globally, the most common infections are with HCV genotypes 1 (44% of cases), 3 (25% of cases), and 4 (15% of cases). HCV transmission is most commonly associated with direct percutaneous exposure to blood, via blood transfusions, health-care-related injections, and injecting drug use. Key high-risk populations include people who inject drugs, men who have sex with men, and prisoners. Approximately 10-20% of individuals who are chronically infected with HCV develop complications, such as cirrhosis, liver failure, and hepatocellular carcinoma over a period of 20-30 years. Direct-acting antiviral therapy is now curative, but it is estimated that only 20% of individuals with hepatitis C know their diagnosis, and only 15% of those with known hepatitis C have been treated. Increased diagnosis and linkage to care through universal access to affordable point-of-care diagnostics and pangenotypic direct-acting antiviral therapy is essential to achieve the WHO 2030 elimination targets.

Sexually transmitted hepatitis C virus infections: current trends, and recent advances in understanding the spread in men who have sex with men

INTRODUCTION

Hepatitis C virus (HCV) is a major public health threat. Although the recent availability of highly effective directly acting antivirals created optimism towards HCV elimination, there is ongoing transmission of HCV in men who have sex with men (MSM). We here report current epidemiological trends and synthesise evidence on behavioural, network, cellular and molecular host factors associated with sexual transmission of HCV, in particular the role of HIV-1 co-infection. We discuss prevention opportunities focusing on the potential of HCV treatment.

METHODS

We searched MEDLINE, fact sheets from health professional bodies and conference abstracts using appropriate keywords to identify and select relevant reports.

RESULTS AND DISCUSSION

Recent studies strongly suggest that HCV is transmitted via sexual contact in HIV-positive MSM and more recently in HIV-negative MSM eligible for or on pre-exposure prophylaxis. The reinfection risk following clearance is about 10 times the risk of primary infection. International connectedness of MSM transmission networks might contribute to ongoing reinfection. Some of these networks might overlap with networks of people who inject drugs. Although, the precise mechanisms facilitating sexual transmission remain unclear, damage to the mucosal barrier in the rectum could increase susceptibility. Mucosal dendritic cell subsets could increase HCV susceptibility by retaining HCV and transmitting the virus to other cells, allowing egress into blood and liver. Early identification of new HCV infections is important to prevent onward transmission, but early diagnosis of acute HCV infection and prompt treatment is hampered by the slow rate of HCV antibody seroconversion, which in rare cases may take more than a year. Novel tests such as testing for HCV core antigen might facilitate early diagnosis.

CONCLUSIONS

High-risk sexual behaviour, network characteristics, co-infection with sexually transmitted infections like HIV-1 and other concomitant bacterial and viral sexually transmitted infections are important factors that lead to HCV spread. Targeted and combined prevention efforts including effective behavioural interventions and scale-up of HCV testing and treatment are required to halt HCV transmission in MSM.

Hepatitis C prevalence among men who have sex with men in Central Brazil

To assess the prevalence of hepatitis C virus infection among men who have sex with men (MSM) in Central Brazil, a cross-sectional study was conducted in the City of Goiânia, Central Brazil, using Respondent-Driven Sampling (RDS). All serum samples were tested for anti-HCV and also for alanine aminotransferase (ALT). Anti-HCV positive samples and/or those with elevated ALT were tested for HCV RNA and genotyped. Of the 522 participants, four were found to be anti-HCV positive, and one was also HCV RNA positive (active HCV infection). Elevated ALT was found in 14 individuals. Of these, one showed evidence of acute HCV infection (HCV RNA positive and anti-HCV negative). Therefore, five MSM were positive for either anti-HCV and/or HCV RNA, giving a crude overall HCV prevalence of 1.0%; 1.3% (95% CI: 0.3-5.5) after being weighted by RDSAT. All five individuals reported high-risk sexual behaviors, including two who showed evidence of active HCV infection (genotype 1, subtypes 1a and 1b). Although the study population reported high-risk sexual practices, HCV infection was not more frequent in MSM than in the general Brazilian population.

2020, sexually transmissible infections and HIV in gay, bisexual and other men who have sex with men

This editorial accompanies a series of papers dealing with this watershed period for HIV and sexually transmissible infections (STI) infections in gay, bisexual and other men who have sex with men (GBM). We are delighted to share with you the views of some international opinion leaders on what the future may hold and what challenges lie ahead. In this issue of the Journal, authors describe current HIV and STI incidence among GBM and predict the future.

Switch to dolutegravir is well tolerated in Thais with HIV infection

INTRODUCTION

Dolutegravir (DTG) is recommended as part of first-line antiretroviral therapy (ART) for people living with HIV(PLHIV). We sought to determine the rate of adverse events (AEs) and discontinuations among Thais treated during acute HIV infection (AHI) and switched to DTG-based regimens.

METHODS

Thai participants in the SEARCH010/RV254 cohort who initiated ART during AHI and switched to DTG for at least 48 weeks were prospectively observed and included in the analysis. Rates and characteristics of DTG-related AEs and discontinuations were described.

RESULTS

A total of 313 Thai participants were included in the analysis. The median age was 29 years, 96% were male, 64% had a Bachelor's degree or higher and 16% had a body mass index (BMI) <18.5 kg/m2 . Participants were on ART for a median of 124 weeks before switching to DTG. The median (IQR) body weight increased from 63 (56 to 70) kg before to 65 (58 to 73) kg (p < 0.0001) after 48 weeks of DTG. Forty-nine (16%) developed DTG-related AEs, corresponding to an incidence of 16.6 per 100 person-years. Neuropsychiatric symptoms were most frequently encountered (n = 25, 8%), followed by laboratory abnormalities (n = 16, 5%). Six (2%) discontinued DTG, corresponding to an incidence of 2.4 per 100 person-years. All discontinuations were due to increased liver enzymes in the presence of hepatitis C virus coinfection. In the multivariate analysis, incident hepatitis C virus infection was the only risk factor for discontinuing DTG (hazard ratio 59.4, 95% CI 8.5 to 297.9, p < 0.0001). Neither low BMI nor concurrent abacavir therapy was associated with discontinuation.

CONCLUSIONS

DTG was well tolerated with few discontinuations in this cohort of young men. Incident hepatitis C virus infection was a driver of liver-related AEs leading to discontinuations. In populations at risk, regular testing for hepatitis C virus during ART is recommended to anticipate possible AEs, guide management and improve safety.

High rates of unprotected anal sex and use of generic direct-acting antivirals in a cohort of MSM with acute HCV infection

The role of condomless anal intercourse (CAI) as a driver for the epidemic of hepatitis C in MSM is still debated. Timely access to direct-acting antivirals (DAA) could represent an essential strategy to tackle this. Case notes of MSM diagnosed with acute hepatitis C (AHC) between July 2016 and June 2017 in a sexual health clinic in London were included. Behavioural data on sexual practices and STI monitoring in the 6 months prior to AHC diagnosis were collected. DAA routes of access and timing from AHC diagnosis to start of treatment were analysed. A total of 60 individuals were enrolled (median age 39 years, IQR = 33-46, 62% HIV co-infected, 72% genotype 1a). CAI was reported by 97%, drug use prior to or during sex by 73%; 46% was diagnosed with a rectal STI and 29% with syphilis. About 37% did not report any HCV risk factors other than condomless anal sex. About 36% had a new rectal STI in the 6 months following AHC. About 82% accessed DAA treatment and median time from AHC to DAA start was 278 days for those following the NHS standard of care route, 132 days for those accessing DAA via participation in trials and 114 for those who had self-sourced DAA online (P < 0.0011). SVR12 was achieved in 100% of the patients who received DAA treatment.In conclusion, CAI is a significant risk factor for HCV acquisition in MSM, irrespective of their HIV status. Rapid and wider access to treatment with DAA could represent a powerful strategy to reduce onward transmission and risk of reinfection in MSM.

Epidemiology and prevention of sexually transmitted infections in men who have sex with men at risk of HIV

Since 2012, the increasingly widespread promotion and uptake of HIV treatment as prevention and pre-exposure prophylaxis in men who have sex with men has been associated with increased sexually transmitted infections (STIs). However, numbers of STI cases have been rising for more than 20 years and the introduction of biomedical HIV interventions cannot explain the majority of the rises in STIs. The increases appear to have occurred mostly because of gradual changes in behaviour over many years, coupled in some settings with more condomless anal intercourse, and as a result of the increased screening for previously undetected asymptomatic infections. If control of STIs is to be improved, then a far greater emphasis on increased use of existing effective STI control strategies will be required, in addition to the investigation of new interventions. Central to effective STI control is accessible clinical care and screening services, which are currently inadequate in most settings. Insufficient action carries a risk of increased STI epidemics, including of newly resistant organisms.

Hepatitis C virus infection in children: How do we prevent it and how do we treat it?

INTRODUCTION

Hepatitis C virus (HCV) infection is an important contributor to the worldwide burden of liver-related morbidity and mortality. Mother-to-child transmission of HCV ranges from 6 to 11% in different populations globally, but accurate estimates on the burden of pediatric HCV infection are limited because screening approaches are not consistent. Areas covered: The advent of new direct-acting antiviral agents that achieve very high rates of sustained virologic response (representing virologic cure) with short (i.e. 8-12 weeks) regimens has revolutionized the field of HCV treatment and led to the development of global elimination goals for HCV transmission and mortality. However, information on their safety during pregnancy and efficacy in preventing mother-to-child transmission is lacking. Currently, there are no approved treatment regimens with these antiviral agents for children younger than 12 years of age. Expert commentary: If these agents are shown to be safe during pregnancy and effective in preventing transmission to the infant, screening of pregnant women and antenatal treatment of those infected, could pave the way for eliminating pediatric HCV infection- particularly as these drugs become less costly and more accessible. Treatment of infected children when indicated, along with universal safe health care practices, can further pediatric HCV elimination.

The role of prevention strategies in achieving HCV elimination in Canada: what are the remaining challenges?

BACKGROUND

The worldwide economic, health, and social consequences of drug use disorders are devastating. Injection drug use is now a major factor contributing to hepatitis C virus (HCV) transmission globally, and it is an important public health concern.

METHODS

This article presents a narrative review of scientific evidence on public health strategies for HCV prevention among people who inject drugs (PWID) in Canada.

RESULTS

A combination of public health strategies including timely HCV detection and harm reduction (mostly needle and syringe programmes and opioid substitution therapy) have helped to reduce HCV transmission among PWID. The rising prevalence of pharmaceutical opioid and methamphetamine use and associated HCV risk in several Canadian settings has prompted further innovation in harm reduction, including supervised injection facilities and low-threshold opioid substitution therapies. Further significant decreases in HCV incidence and prevalence, and in corresponding disease burden, can only be accomplished by reducing transmission among high-risk persons and enhancing access to HCV treatment for those at the greatest risk of disease progression or viral transmission. Highly effective and tolerable direct-acting antiviral therapies have transformed the landscape for HCV-infected patients and are a valuable addition to the prevention toolkit. Curing HCV-infected persons, and thus eliminating new infections, is now a real possibility.

CONCLUSIONS

Prevention strategies have not yet ended HCV transmission, and sharing of injecting equipment among PWID continues to challenge the World Health Organization goal of eliminating HCV as a global public health threat by 2030. Future needs for research, intervention implementation, and uptake in Canada are discussed.