Brief Report: Group Sex and Methamphetamine Use Fuel an Explosive Epidemic of Hepatitis C Among HIV-Infected Men Who Have Sex With Men in Bangkok, Thailand

Prevalence of hepatitis B and C infections among HIV-positive men who have sex with men: A systematic review and meta-analysis

Background

Human immunodeficiency virus (HIV) infection is highly prevalent and often coexists with other infectious diseases, especially Hepatitis B virus (HBV) and Hepatitis C virus (HCV). Men who have sex with men (MSM) represent a vulnerable population in terms of HIV infection. We aimed to determine the prevalence of HCV, HBV among HIV-infected MSM.

Methods

This systematic review and meta-analysis searched PubMed, Cochrane, Scopus, Web of Science, and ProQuest up-to 2023/04/22. All studies reporting the prevalence of HBV or HCV infection in MSM PLHIV were included. Meta-analysis used random effect model for synthesis and I 2 along with prediction interval for heterogeneity. Subgroup analysis based on continent and meta-regression for study size, average age and year of publication were used to explore heterogeneity. Modified Newcastle-Ottawa Scale was used to evaluate the quality of studies according to the protocol (PROSPERO: CRD42023428764).

Results

Fifty-six of 5948 studies are included. In 53 studies with 3,07,589 participants, a pooled prevalence of 7% (95% confidence interval [CI]: 5-10) was found for HCV among MSM PLHIV, while a 9% (95% CI: 4-18) prevalence was found for HBV infection from five studies which included 5641 MSM PLHIV. Asia reported the lowest pooled prevalence at 5.84% (95% CI: 2.98-11.13) for HCV while Europe reported the highest pooled prevalence at 7.76% (95% CI: 4.35-13.45). Baujat plot and influence diagnostic identified contributors to influence and between-study heterogeneity. Sensitivity analyses omitting these studies result in considerably more precise estimates. Another sensitivity analysis as leave-one-out meta-analysis did not change any pooled estimate significantly.

Conclusion

There is a significant burden of HCV and HBV among MSM PLHIV worldwide, with varying prevalence rates. Future studies should focus on these multimorbidity clusters and investigate factors influencing disease burden, long-term outcomes, optimal testing strategies, and tailored interventions.

Neuropsychiatric and Laboratory Outcomes of Hepatitis C Treatment in an Early-Treated HIV Cohort in Thailand

Background

Hepatitis C virus (HCV) coinfection may further compromise immunological and cognitive function in people with HIV (PWH). This study compared laboratory and neuropsychiatric measures across the periods of HCV seroconversion and direct-acting antiviral (DAA) therapy with sustained virologic response (SVR) among PWH who initiated antiretroviral therapy (ART) during acute HIV infection (AHI) and acquired HCV after 24 weeks of ART.

Methods

Participants from the RV254 AHI cohort underwent paired laboratory and neuropsychiatric assessments during regular follow-up. The former included measurements of CD4 + and CD8 + T-cell counts, HIV RNA, liver enzymes, and lipid profiles. The latter included the Patient Health Questionnaire-9 (PHQ-9), Distress Thermometer (DT), and a 4-test cognitive battery that evaluated psychomotor speed, executive function, fine motor speed and dexterity. The raw scores in the battery were standardized and averaged to create an overall performance (NPZ-4) score. Parameters of HCV-coinfected participants were compared across HCV seroconversion and DAA treatment groups.

Results

Between 2009 and 2022, 79 of 703 RV254 participants acquired HCV after ≥ 24 weeks of ART; 53 received DAA, and 50 (94%) achieved SVR. All participants were Thai males (median age: 30 years); 34 (68%) denied past intravenous drug use, and 41 (82%) had a history of other sexually transmitted infections during follow-up. Following SVR, aspartate transferase (AST) and alanine transaminase (ALT) decreased (p < 0.001), while total cholesterol, low-density lipoprotein, and triglycerides increased (p < 0.01). The median CD4+/CD8 + ratio increased from 0.91 to 0.97 (p = 0.012). NPZ-4 improved from 0.75 to 0.91 (p = 0.004). The median DT score increased from 1.7 to 2.7 (p = 0.045), but the PHQ-9 score remained unchanged.

Conclusion

HCV coinfection is common in this group of high-risk PWH, highlighting the need for regular screening, early diagnosis, and treatment. There was a modest improvement in the CD4+/CD8 + T-cell ratio and cognitive performance after DAA therapy in patients who achieved SVR. Future studies should examine potential neuropsychiatric impacts during early HCV infection as well as the longer-term neuropsychiatric outcomes after DAA treatment with SVR.

High PrEP uptake, adherence, persistence and effectiveness outcomes among young Thai men and transgender women who sell sex in Bangkok and Pattaya, Thailand: findings from the open-label combination HIV prevention effectiveness (COPE) study

Background

Daily oral pre-exposure prophylaxis (PrEP) is effective in preventing HIV infection, but no study has evaluated combination prevention interventions with PrEP for transgender women (TGW) and men who have sex with men (MSM) who sell sex.

Methods

The Combination Prevention Effectiveness (COPE) study was a community-based, non-randomized implementation study in Bangkok and Pattaya, Thailand. Participants were HIV-negative MSM and TGW aged 18-26 years who reported exchanging sex with men in the prior 12 months and who met 2014 U.S. Public Health Service PrEP eligibility criteria. The intervention included quarterly HIV testing, semiannual testing for sexually transmitted infections, provision of condoms with lubricant, and the opportunity to initiate or end daily oral PrEP use at any time during study participation. Participants taking PrEP received monthly adherence counseling and short message service reminders. The primary outcome was HIV incidence rate ratio (IRR) on PrEP vs. not on PrEP. Secondary outcomes were PrEP initiation, PrEP use at 12 months, and PrEP adherence.

Findings

From October 2017 to August 2019, 846 participants were enrolled: 531 (62.8%) immediately initiated PrEP; 104 (12.3%) subsequently initiated PrEP, and 211 (24.9%) never initiated PrEP. Among those initiating PrEP within 30 days of enrollment; 85.9% were on PrEP at the 12-months. When taking PrEP, participants reported adherent PrEP use at 94.2% of quarterly assessments. Ten HIV seroconversions occurred without PrEP use (incidence rate [IR] = 3.42 per 100 person-years [PY]; 95% CI = 1.64-6.30), while zero cases occurred with PrEP use (IR = 0.0 per 100PY; 95% CI = 0.0-0.62), with IRR = 0.0 (95% CI = 0.0-0.22; p < 0.001).

Interpretation

Young Thai MSM and TGW who exchange sex can have high PrEP uptake, persistence and adherence, and low HIV incidence when offered in supportive community-based settings.

Funding

U.S. National Institute of Allergy and Infectious Diseases; Centers for Disease Control and Prevention.

Chemsex and chemsex associated substance use among men who have sex with men in Asia: A systematic review and meta-analysis

BACKGROUND

The prevalence of chemsex has been reported by multiple systematic reviews among men who have sex with men (MSM) focussing predominantly on the Global North. An Asian perspective with meta-analytical evidence is missing. This meta-analysis summarised the prevalence of substance use associated with chemsex, and chemsex activity among MSM and MSM sub-populations in Asia, as well as the likelihood for chemsex among MSM living with or without HIV.

METHODS

We utilized PubMed, Web of Science and medRxiv to search for literature describing chemsex and its associated substance use among MSM and MSM sub-populations in Asia from January 1, 2010 to November 1, 2021 to conduct three meta-analyses with both frequentist and Bayesian approaches.

RESULTS

We identified 219 studies and included 23 in the meta-analysis. Based on the frequentist models, methamphetamine was the default substance associated with chemsex among MSM in Asia (prevalence = 0.16, 95 %CI:0.09-0.22), followed by GHB/GBL (prevalence = 0.15, 95 %CI:0.03-0.27) and ketamine (prevalence = 0.08, 95 %CI:0.04-0.12), but hardly any cocaine (prevalence = 0.01, 95 %CI:0.00-0.03). Compared to a general MSM population (prevalence = 0.19, 95 %CI:0.15-0.23), MSM engaging in transactional sex showed a higher prevalence of chemsex (MSM sex work clients [prevalence = 0.28, 95 %CI:0.11-0.45]; MSM sex worker [prevalence = 0.28, 95 %CI:0.17-0.26]). MSM living with HIV also showed higher odds of chemsex activity (OR = 3.35, 95 %CI:1.57-7.10), compared to MSM living without HIV. Both meta-analytic models converged, indicating robust evidence.

CONCLUSIONS

Our meta-analyses showed that chemsex is not uncommon among MSM, and MSM engaging in transactional sex in Asia. We confirmed that MSM living with HIV have a higher likelihood of engaging in chemsex, too. Chemsex prevention and management strategies in Asia should be adjusted accordingly.

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.

Factors associated with testing for HIV and other sexually transmitted infections in men who have sex with men and transgender women in Bangkok, Thailand

Background

Routine screening for HIV and other sexually transmitted infections (STIs) facilitates early diagnosis and treatment, thereby preventing morbidity and onward transmission. We estimated the prevalence of prior HIV/STI testing among men who have sex with men (MSM) and transgender women (TGW) in Bangkok, Thailand, and identified factors associated with prior testing.

Methods

Cross-sectional analyses were performed using data collected at enrollment into an HIV incidence cohort. From April to October 2017, MSM and TGW were enrolled if they were aged 18–35 years, reported anal intercourse with a male or TGW partner, and reported behavioral vulnerability to HIV. Participants answered questions about demographics, sexual behaviors, and lifetime HIV/STI testing history. Multivariable robust Poisson regression was used to estimate risk ratios (RRs) and 95% confidence intervals (CIs) for factors potentially associated with prior testing.

Results

Among 1,014 participants, 348 (34.3%) were TGW and the median age was 21.6 (interquartile range 20.0-24.8) years. Prior testing for HIV was reported by 421 (41.5%) and for other STIs by 268 (26.4%). HIV testing was more common among participants aged ≥ 22 years (RR 1.37 [95% CI 1.13–1.67]), with college education as compared to secondary or less (RR 1.37 [95% CI 1.08–1.72]), and who met male sexual partners online (RR 1.52 [95% CI 1.24–1.85]), but lower among participants attracted to both men and women as compared to men only (RR 0.64 [95% CI 0.51–0.81]) and who met male sexual partners in bars (RR 0.83 [95% CI 0.72–0.97]). Similar associations were observed with prior testing for other STIs, including increased testing among participants with college education (RR 1.52 [95% CI 1.11–2.09]) and who met male sexual partners online (RR 1.73 [95% CI 1.30–2.31]), but lower among participants attracted to both men and women (RR 0.70 [95% CI 0.51–0.96]) and who met male sexual partners in bars (RR 0.67 [95% CI 0.54–0.83]).

Conclusions

Despite behavioral vulnerability, prior testing for HIV and other STIs was uncommon. Online engagement strategies may be effectively reaching Thai MSM and TGW who meet sexual partners online, but new interventions are needed to encourage testing among younger, less educated, and bisexual MSM and TGW.

Prevalence and the associated factors of hepatitis B and hepatitis C viral infections among HIV-positive individuals in same-day antiretroviral therapy initiation program in Bangkok, Thailand

Background

Viral hepatitis is highly prevalent among people with HIV (PWH) and can lead to chronic liver complications. Thailand started universal hepatitis B vaccination at birth in 1992 and achieved over 95% coverage in 1999. We explored the prevalence of hepatitis B and C viral infections and the associated factors among PWH from same-day antiretroviral therapy (SDART) service at the Thai Red Cross Anonymous Clinic, Bangkok, Thailand.

Methods

We collected baseline characteristics from PWH enrolled in the SDART service between July 2017 and November 2019. Multivariable logistic regression was performed to determine factors associated with positive hepatitis B surface antigen (HBsAg) and hepatitis C antibody (anti-HCV).

Results

A total of 4011 newly diagnosed PWH who had HBsAg or anti-HCV results at baseline: 2941 men who have sex with men (MSM; 73.3%), 851 heterosexuals (21.2%), 215 transgender women (TGW; 5.4%), and 4 transgender men (0.1%). Median age was 27 years. Overall seroprevalence of HBsAg and anti-HCV were 6.0 and 4.1%, respectively. Subgroup prevalence were 6.2 and 4.7% among MSM, 4.6 and 2.4% among heterosexuals, and 9.3 and 3.7% among TGW, respectively. Factors associated with HBsAg positivity were being MSM, TGW, born before 1992, CD4 count < 200 cells/mm³, and alanine aminotransferase ≥ 62.5 U/L. Factors associated with anti-HCV positivity were being MSM, age > 30 years, alanine aminotransferase ≥ 62.5 U/L, creatinine clearance < 60 ml/min, and syphilis infection.

Conclusions

Around 5–10% of newly diagnosed PWH in Bangkok had hepatitis B viral infection after 25 years of universal vaccination. Anti-HCV positivity was found in 4–5% of PWH who were MSM and TGW. As World Health Organization and Thailand national guidelines already support routine screening of hepatitis B and C viral infections in PWH and populations at increased risk of HIV including MSM and TGW, healthcare providers should reinforce this strategy and provide linkage to appropriate prevention and treatment interventions. Catch-up hepatitis B vaccination should be made available under national health coverage.

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/.

Factors associated with testing for HIV and hepatitis C among behaviorally vulnerable men in Germany: a cross-sectional analysis upon enrollment into an observational cohort

BACKGROUND

HIV and hepatitis C virus (HCV) have shared routes of transmission among men who have sex with men (MSM). Routine testing facilitates early diagnosis and treatment, thereby preventing morbidity and onward transmission. We evaluated factors associated with HIV and HCV testing in a behaviorally vulnerable cohort of predominantly MSM.

METHODS

From June 2018 through June 2019, the BRAHMS study enrolled adults at ten German outpatient clinics that serve gender and sexual minority populations. Participants completed behavioral questionnaires that captured prior experience with HIV and HCV testing. Multivariable robust Poisson regression was used to evaluate factors potentially associated with testing in the previous 6 months.

RESULTS

Among 1017 participants with median age 33 (interquartile range 28-39) years, 1001 (98.4%) reported any lifetime history of HIV testing and 787 (77.4%) reported any HCV testing, including 16 (1.6%) known to be living with HCV. Testing within the last 6 months was reported by 921 (90.6%) and 513 (50.4%) for HIV and HCV, respectively. Recent HIV testing was more common among participants with higher education level and recent HCV testing. Recent HCV testing was more common among participants with non-cisgender identity, lifetime history of illicit drug use, hepatitis B immunity or infection, and recent HIV testing.

CONCLUSION

Prior testing for HIV was common in this cohort, but interventions are needed to improve HCV risk stratification and access to testing. HIV testing infrastructure can be successfully leveraged to support HCV testing, but differentiated preventive care delivery is needed for some vulnerable populations.

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.

Expanding reimbursement of immediate treatment using direct acting antivirals to reduce hepatitis C incidence among HIV positive men who have sex with men in Bangkok, Thailand: A cost effectiveness modelling study

BACKGROUND

Increasing number of hepatitis C virus (HCV) infections among HIV positive men whohave sex with men (MSM) as in an acute HIV infection cohort study in Bangkok, reached an incidence of 45/1000 person-years in 2018. Direct-acting antivirals (DAAs), that cure HCV infection and thereby can prevent transmission, are expensive, their reimbursement being presently delayed to the chronic stages of liver fibrosis. The aim of this study was to determine the cost-effectiveness of immediate DAA treatment to reduce HCV transmission among HIV positive MSM in Bangkok.

METHODS

A deterministic transmission model was calibrated to the HCV epidemic among HIV positive MSM in Bangkok. We compared the current practice of starting DAAs at METAVIR stage F2 rather than at stage F1, or immediately after diagnosis, at stage F0. Cost-effectiveness was examined from a payer's perspective, using a 3% annual discounting rate.

RESULTS

Compared to the incidence in 2018, delaying DAA treatment to METAVIR stage F2 or F1, increases HCV incidence in 2030 to 63/1000 person-years and 56/1000 person-years, respectively. Conversely, immediate DAA treatment reduces the incidence to 26/1000 person-years. Compared to initiating treatment at stage F2, immediate treatment is cost saving within seven years and saves $17 million over 40 years. One-way sensitivity analysis showed that lower cost savings were achieved at a higher price of DAA treatment and at less frequent HCV screening.

CONCLUSION

Immediate DAA treatment is cost saving and increases health benefits by reducing HCV incidence among HIV-infected MSM.

Substance use treatment partially mitigates association between methamphetamine use and STI risk: findings from the NSDUH cohort

BACKGROUND

In recent years, both methamphetamine use and STIs have been on the rise in the USA. In this analysis, we sought to ascertain whether the risk of STIs and HIV among methamphetamine users was moderated on the basis of participation in substance use treatment programmes.

METHODS

Data came from the National Survey on Drug Use and Health, 2015-2019. Among adult participants, survey-weighted logistic regression analyses were used to assess the relationship between past year methamphetamine use and risk of HIV and STIs, stratified by methamphetamine treatment utilisation and adjusted for demographic and other risk factors.

RESULTS

Among participants in the analytic sample (n=210 392), 1862 (0.9%) reported past year methamphetamine use, 566 (0.3%) reported receiving treatment for its use, 5471 (2.6%) tested positive for any STI in the past year and 395 (0.2%) for HIV ever in their lifetime. Past year methamphetamine use was associated with increased risk of STIs among those who did not receive treatment (adjusted OR=3.628; 95% CI 2.75 to 4.92). Significant moderation was also present between past-year methamphetamine use, risk of STI, and substance use treatment.

CONCLUSION

In this analysis, we demonstrated a strong relationship between methamphetamine use and risk of STIs that differed based on receipt of substance use treatment. These findings suggested that integrated STI and substance use treatment programmes may yield substantial public health benefits.

Large transmission cluster of acute hepatitis C identified among HIV-positive men who have sex with men in Bangkok, Thailand

A rapidly emerging and highly concentrated hepatitis C virus (HCV) outbreak has recently been observed among both acute and chronic HIV-positive men who have sex with men (MSM) in Bangkok, Thailand. NS5B regions of the HCV genome were amplified using nested PCR and sequenced. Phylogenetic inference was constructed by Maximum Likelihood methods and clusters were identified with support and genetic distance thresholds of 85% and of 4.5%. Forty-eight (25 acute HIV and 23 chronic HIV) MSM with incident HCV infection were included in the analysis. HCV genotype (GT) was 85% GT 1a and 15% GT 3a or 3b. Median age at HCV diagnosis was 34 (interquartile range, 28-41) years. 83.3% (40/48) had history of syphilis infection and 36% (16/44) reported crystal methamphetamine use. Only 2 (4%) reported ever injecting drugs, both crystal methamphetamine. In the phylogenetic clustering analysis, 83% belonged to one of two clusters: one large (75%) and one small (8%) cluster. All clusters were GT 1a. MSM with acute HIV infection were more likely to be in a cluster (92%) than those with chronic infection (74%). HCV screening should be regularly performed for MSM in ART clinics, and offering direct-acting antiviral agents to all MSM with HCV infection might contain the HCV epidemic from expanding further.