Hepatitis A outbreak in HIV-infected MSM and in PrEP-using MSM despite a high level of immunity, Lyon, France, January to June 2017

Sexual and preventive behaviors associated with HAV, HBV, and HPV vaccine hesitancy among men who have sex with men in France

Vaccination coverage against hepatitis A virus (HAV), hepatitis B virus (HBV), and human papillomaviruses (HPV) is insufficient among men who have sex with men (MSM), partly because of their high prevalence of vaccine hesitancy (VH) specific to these vaccines. This study aimed to investigate determinants of specific VH in MSM, focusing on characteristics of their sexual activity, propensity to use prevention tools and medical care, disclosure of sexual orientation to health care professionals (HCPs), and perceived stigmatization. A cross-sectional electronic survey (February - August 2022) collected perceptions of HBV, HAV, and HPV, and of their respective vaccines among 3,730 French MSM and enabled the construction of a specific VH variable. Using agglomerative hierarchical cluster analysis, we constructed a typology of MSM sexual and prevention practices. We identified three MSM clusters (low- (C1, 24%), moderate- (C2, 41%), and high- (C3, 35%) "sexual activity/medical engagement") that showed an increasing gradient in the use of medical prevention with regular medical care and exposure to high-risk sexual practices. A multiple ordinal logistic regression showed that overall specific VH was higher in the C1 cluster and in men who had not informed their physician of their sexual orientation. This typology could usefully help to adapt vaccination communication strategies for MSM prevention program according to patients' profiles. HCPs should be encouraged and trained to ask men about their sexual practices and to provide appropriate vaccination recommendations nonjudgmentally.

Factors associated with hepatitis A susceptibility among men who have sex with men using HIV pre-exposure prophylaxis in Northeastern Brazil: A cross-sectional study

Hepatitis A virus (HAV) infection has disproportionately affected more men who have sex with men (MSM), occurring in outbreaks, despite being vaccine-preventable. We determined the prevalence and factors associated with HAV susceptibility among cisgender MSM on HIV pre-exposure prophylaxis (PrEP) in Northeastern Brazil. From September 30, 2021 to June 19, 2023, 282 cisgender MSM receiving HIV PrEP were enrolled into this cross-sectional study. Sociodemographic and clinical information were collected. Blood samples were collected for screening of sexually transmitted infections (STIs) and serum samples were tested for IgM and total anti-HAV antibodies. Non-reactive results for total anti-HAV antibodies were found in 106 of 282 (37.6%) participants. Factors associated with HAV susceptibility included age <30 years (prevalence ratio [PR]: 2.02; 95% confidence interval [95% CI]: 1.61-2.53), having health insurance (PR: 1.39; 95% CI: 1.19-1.64), sex only with cisgender men (PR: 1.52; 95% CI: 1.23-1.89), non-steady partner (PR: 1.20; 95% CI: 1.01-1.43) and no lifetime history of STIs (PR: 1.25; 95% CI: 1.03-1.53). Identifying clinical correlates of HAV susceptibility in key populations is a fundamental step towards development of public policy focused on prevention, especially following the recent hepatitis A outbreak in Brazil.

Prevalence and incidence of HEV among men using HIV pre-exposure prophylaxis: A sub-study of the ANRS IPERGAY trial

BACKGROUND

Men who have sex with men (MSM) have an increased risk of infection by pathogens transmitted by the oro-fecal route. Here, we investigated the seroprevalence and incidence of hepatitis E virus (HEV) infection in 416 MSM included in the ANRS IPERGAY PrEP trial.

RESULTS

Among the 62 (14.9% (95% CI: [11.6%-18.7%]) seropositive for HEV at inclusion, the only factor associated with testing seropositive for HEV was older age. Geographical origin, use of recreational drugs, number of sexual partners, status for HAV and bacterial sexually transmitted infection (STI) at inclusion were not associated. Among the 342 HEV-seronegative patients with available samples, 9 seroconverted after a median of follow-up of 2.1 years (IQR (interquartile range): [1.6; 3.0]).

CONCLUSION

Overall, the HEV incidence was 1.19% per 100 person-years [95% CI: 0.54%; 2.26%]. Sexual transmission does not seem to be a major route of HEV infection in MSM, unlike HAV.

Poor increase on HAV vaccination coverage among people living with HIV after an immunization-based intervention

OBJECTIVES

To assess HAV serologic and vaccination status among people who live with HIV (PLWH), and to evaluate the impact of a vaccination-based strategy on HAV-negative patients in Seville, Spain.

METHODS

Study with two time-overlapping phases: (i) cross-sectional study of HAV immunity prevalence among PLWH followed at a Spanish hospital between August 2019 and March 2020. (ii) Patients seronegative for HAV, reliably unvaccinated were included in a before-and-after quasi-experimental study, with an intervention focused on HAV vaccination according to national recommendations in force.

RESULTS

Six hundred and fifty-six patients were included, of which 111 [17%, 95% confidence interval (95% CI) 14-20%] were seronegative for HAV. Of these, 48 [43% (95% CI, 34-53%)] individuals were MSM. The absence of HAV immunity was attributed in 69 [62% (95% CI, 52-71%)] patients to non-referral to vaccination, followed by lack of achievement of a correct vaccination scheme [n=26; 23% (95% CI, 16-32%)]. After the program implementation, 96 [15% (95% CI, 12-18%)] individuals were seronegative (17% vs. 15%, p=0.256), of whom 42 [41% (95% CI, 32-51%)] were MSM. The absence of immunity after the intervention was mainly attributed to: adherence failure in 23 [24.0% (95% CI, 15.8-33.7%)] patients, on-course immunization scheme in 34 [33% (95% CI, 24-43%)] individuals and pending appointment at the vaccine delivery unit in 20 [20.8% (95% CI, 13.2-30.3%)] patients.

CONCLUSIONS

A sizeable proportion of PLWH remains susceptible for HAV infection in future outbreaks. A program based on referral to the vaccine delivery unit yields poor results, largely due to program adherence failures. New strategies are needed to increase HAV vaccination coverage.

Hepatitis A occurrence and outbreaks in Europe over the past two decades: A systematic review

Hepatitis A (HA) is a vaccine-preventable liver disease with >170 million new cases occurring yearly. In recent outbreaks in the USA, hospitalization and case-fatality ratios were >60% and ~1%, respectively. In Europe, endemicity persists and outbreaks continue to occur. We performed a systematic literature review to understand the changes in HA occurrence in Europe over the past two decades. PubMed and Embase were systematically searched for peer-reviewed articles published between 1 January 2001 and 14 April 2021 using terms covering HA, 11 selected European countries, outbreaks, outcomes and HA virus circulation. Here, we focus on HA occurrence and outbreaks in the five countries with the largest population and the most comprehensive vaccination recommendations: France, Germany, Italy, Spain and the UK; 118 reports included data for these five European countries. Notification rates (≤9.7/100,000 population) and percentages of men among cases (≤83.0%) peaked in 2017. The number of person-to-person-transmitted cases and outbreaks decreased in children but increased in other risk groups, such as men who have sex with men (MSM). Sexually transmitted outbreaks in MSM clustered around 2017. Travel-related outbreaks were few; the proportion of travel-related cases decreased during the past two decades, while the number of domestic cases increased. Despite the existing risk-based vaccination recommendations, HA transmission shifted in proportions from travelers and children to other risk groups, such as MSM and older age groups. Because a substantial proportion of the European population is susceptible to HA, adherence to existing recommendations should be monitored more closely, and enhanced vaccination strategies should be considered.

Hepatitis A Outbreak in Men Who Have Sex with Men Using Pre-Exposure Prophylaxis and People Living with HIV in Croatia, January to October 2022

The hepatitis A virus (HAV) is a highly hepatotropic virus transmitted mainly via the fecal-oral route. The purpose of this study is to describe a prolonged HAV outbreak in HIV-infected men who have sex with men (MSM) and pre-exposure prophylaxis (PrEP) users in Croatia in 2022. Croatia has a centralized system of HIV care and the PrEP service is only available at the University Hospital for Infectious Diseases (UHID), Zagreb. We reviewed all MSM living with HIV and MSM PrEP users at UHID and identified those diagnosed with HAV between January and October 2022. During this period, a total of 1036 MSM living with HIV and 361 PrEP users were followed, and 45 (4.4%) and 32 (8.9%) were diagnosed with HAV, respectively. Most cases were diagnosed in mid-February. A total of 70.1% (726/1036) MSM living with HIV and 82.3% (297/361) PrEP users were susceptible to HAV. Sequencing information was available for 34 persons; in all cases the HAV subtype IA was found. Our findings indicate that both MSM living with HIV and HIV-uninfected PrEP users are vulnerable to HAV infection and might be a potential source for a more widespread HAV epidemic.

Establishment of Outbreak Thresholds for Hepatitis A in South Africa Using Laboratory Surveillance, 2017–2020

As South Africa transitions from endemic to intermediate endemicity, hepatitis A surveillance needs strengthening to monitor trends in disease incidence and to identify outbreaks. We used passive laboratory-based surveillance data from the National Health Laboratory Services to calculate national hepatitis A incidence and to establish thresholds for outbreaks. Incidence was calculated by age and geographic location. The static threshold used two or three standard deviations (SDs) above the mean hepatitis A incidence in 2017–2019, and a cumulative summation (CuSum2) threshold used three SDs above the mean of the preceding seven months. These thresholds were applied to hepatitis A data for 2020. From 2017 to 2020, the mean incidence of hepatitis A IgM was 4.06/100,000 and ranged from 4.23 to 4.85/100,000 per year. Hepatitis A incidence was highest in the Western Cape province (WCP) (7.00–10.92/100,000 per year). The highest incidence was in the 1–9-year-olds. The incidence of hepatitis A in 2020 exceeded the static threshold in two districts of the WCP: Cape Winelands in January and Overberg district in August. The provincial incidence did not exceed the static and CuSum2 thresholds. District-level analysis using either threshold was sensitive enough to monitor trends and to alert district health authorities, allowing early outbreak responses.

Hepatitis A: Epidemiology, High-Risk Groups, Prevention and Research on Antiviral Treatment

The hepatitis A virus (HAV) is a leading cause of acute viral hepatitis worldwide. It is transmitted mainly by direct contact with patients who have been infected or by ingesting contaminated water or food. The virus is endemic in low-income countries where sanitary and sociodemographic conditions are poor. Paradoxically, improving sanitary conditions in these countries, which reduces the incidence of HAV infections, can lead to more severe disease in susceptible adults. The populations of developed countries are highly susceptible to HAV, and large outbreaks can occur when the virus is spread by globalization and by increased travel and movement of foodstuffs. Most of these outbreaks occur among high-risk groups: travellers, men who have sex with men, people who use substances, and people facing homelessness. Hepatitis A infections can be prevented by vaccination; safe and effective vaccines have been available for decades. Several countries have successfully introduced universal mass vaccination for children, but high-risk groups in high-income countries remain insufficiently protected. The development of HAV antivirals may be important to control HAV outbreaks in developed countries where a universal vaccination programme is not recommended.

An Outbreak of Hepatitis A among Young Adult Men in Cyprus

Background: Outbreaks of acute hepatitis A (AHA) have recently been reported in Europe among men who have sex with men (MSM). The aim of this work was to evaluate, for the first time, trends in the reported cases of AHA in Cyprus over the last seven years. Methods: We retrospectively studied all people reported with AHA in Cyprus between January 2013 and December 2019. Demographic data, type of transmission, vaccination status for HAV, laboratory and clinical data were analyzed. Results: The asnalysis involved 33 AHA cases (age 32.7 ± 17.4 years, 78.8% males). An increase in AHA reports was observed between July 2017 and June 2018 when more than a third (n = 13) of the cases of the period 2013–2019 were reported. The reporting rate of AHA doubled from 0.52 cases per 100,000 population (before July 2017) to 1.12 cases per 100,000 population (July 2017–June 2018). The male/female (M/F) ratio increased from one in 2013 to eight in 2018. Conclusion: An increase in AHA reports occurred in Cyprus between July 2017 and June 2018. Many cases with AHA in that period were MSM. Enhanced surveillance and timely public health interventions, like vaccination and awareness promotion, are important for preventing future outbreaks.

Hepatitis A outbreak among MSM in Berlin due to low vaccination coverage: Epidemiology, management, and successful interventions

OBJECTIVES

To describe the characteristics of a large hepatitis A virus (HAV) outbreak among men who have sex with men (MSM) in Berlin and to assess the impact of measures implemented.

METHODS

Cases of laboratory-confirmed, symptomatic HAV infection notified in Berlin, Germany between August 2016 and February 2018 were analysed using routine and enhanced surveillance data including genotyping results. Several studies involving different groups of participants were conducted to further investigate the outbreak, including surveys on knowledge and practices of HAV vaccination among physicians and vaccination coverage and determinants of vaccination status among MSM. The measures implemented were categorized by target group in a Gantt chart. To assess their impact, health insurance data on HAV vaccination uptake were analysed, comparing Berlin and other federal states.

RESULTS

During the outbreak period, a total of 222 cases were reported (of which 91 were sequence-confirmed), with a peak in case numbers in January 2017. Physicians were aware of the existing vaccination recommendations, but vaccination coverage among 756 MSM was low, with 32.7% being completely vaccinated and 17.3% being incompletely vaccinated before 2017. HAV vaccination before 2017 was associated with being born in Germany (odds ratio 2.36) and HIV-positive (odds ratio 1.80). HAV monovalent vaccination uptake increased by 164% from 2016 to 2017 among males in Berlin, compared to 7% in other federal states.

CONCLUSIONS

Multiple measures targeting the MSM community, physicians, and public health to increase HAV vaccination uptake were successfully implemented. To prevent future HAV outbreaks, we recommend monitoring vaccination coverage among MSM, promoting awareness of existing recommendations among physicians, and ensuring access for foreign-born and young MSM.

Acute Hepatitis A Outbreak Among Men Who Have Sex With Men in Krakow, Poland; February 2017-February 2018

Since February 2017 in Poland, an increasing number of acute hepatitis A (AHA) cases have been reported; a noteworthy increase to 3,072 cases of AHA in 2017 compared to 35 cases in 2016 was reported by the National Institute of Public Health (NIPH). The aim of this study was to evaluate the demographic features, clinical manifestations, laboratory results, and sexually transmitted coinfections. All cases of AHA diagnosed between February 2017 and February 2018 at the University Hospital in Krakow were analyzed. A total of 119 cases of hepatitis A virus (HAV) were reported; 105 (88%) were males and 14 (12%) were females, with a mean age 31 years (range 19–62). In 84 patients (71%), the HAV was transmitted by oral–anal sexual contact between men. Six women were infected by close house contact with men infected with HAV. The route of transmission was not identified for 29 cases, and 88 patients (74%) required hospitalization. Among the cases, the following coinfections were already diagnosed: HIV 36 patients (30%), chronic hepatitis C virus (HCV) 4 patients (3%), and chronic hepatitis B virus (HBV) 2 patients (1.5%). During AHA diagnosis, some new sexually transmitted infections (STIs) were detected; syphilis eight patients (6.7%), HIV/syphilis seven patients (6%), HIV//HCV/syphilis one patient, and acute retroviral syndrome/Shigella flexneri one patient. Overall, AHA outbreak in Poland in 2017 affected primarily men who have sex with men (MSM) and was connected with oral–anal sexual contacts, and the majority of patients did not have HAV vaccination. These results show a clear need for routinely offering HAV vaccination to at-risk populations and that awareness among health-care workers about HAV sexual transmission may help introduce prevention methods.

A description of a hepatitis A outbreak in men who have sex with men and public health measures implemented in Seine-Maritime department, Normandy, France, 2017

BACKGROUND

In 2016-2017, a European-wide circulation of genotype IA hepatitis A virus was responsible for hepatitis A outbreaks in men who have sex with men (MSM). This study aimed to describe the outbreak investigation in Seine-Maritime department (France) and the control measures implemented accordingly.

METHODS

Outbreak description used data from mandatory reporting and enhanced surveillance of male cases. Confirmed case was genotype IA isolated, possible cases had no reported genotype information. Targeted control measures included communication on sexual practices at risk of hepatitis A transmission and two vaccination campaigns in April 2017 and January 2018. Characteristics of cases and vaccinees were described. We reported the best communication channel for relaying outbreak information and control measures based on the monitoring of social network activities and feedback from vaccinees.

RESULTS

During the outbreak period (December 2016 to December 2017), a total of 48 confirmed outbreak cases and 30 possible outbreak cases were notified. Among them, 69 were male (88%). Two epidemic waves were observed. Cases encountered their partners through gay-dating apps (54%) and in one specific sauna (62%). In response to the outbreak, two vaccination campaigns were deployed. A total of 156 MSM were vaccinated, of whom 56 in a truck parked beside the sauna. Most of the vaccinees had been informed about the campaign through dating apps (44%). Community-based organizations involved in sexual health promotion and other gay social media were very proactive in sharing information about the outbreak and promoting the vaccination campaign through their social media account and also on site (gay venues). Vaccinees reported the same sexual practices at risk of hepatitis A transmission as cases.

CONCLUSIONS

In response to this massive hepatitis A outbreak that affected mostly MSM in Seine-Maritime department, vaccination campaign remained the cornerstone of prevention. Prevention officers from the community-based organization played a key role in vaccination promotion. Gay-dating apps and outdoor sessions of vaccination allowed to effectively reach MSM. Cost-effectiveness studies might analyze the interest of a continuous sexual health promotion including vaccination against hepatitis A in MSM through dating apps and social networks.

Hepatitis A outbreak in HIV-infected patients in Southeastern France: questions and responses?

During the 2017 European hepatitis A (HA) outbreak we assessed HA incidence in our cohort of 2300 HIV-infected patients, implemented preventive measures and evaluated practices and knowledge on sexually transmitted diseases (STD). HA incidence was assessed between 1 January 2017 and 31 December 2017 and included all symptomatic patients with virologically confirmed HA. Preventive measures consisted in identifying at risk and not immunised patients to propose them a free HAV vaccination, and an anonymous survey related to transmission routes of STD and to sexual behaviours. Twenty HA were diagnosed. All were homosexual men recently diagnosed with HIV and another STD. None were vaccinated against hepatitis A virus (HAV). Hospitalisation was required for 52%. We identified 250 patients at risk to acquire HAV and invited them to a free immunisation program. A total of 110 (44%) were vaccinated, of whom 74 responded to our survey. A majority of them (84%) reported recent active anal and oral sexuality with multiple (52%) male partners (81%), and ChemSex consumption (14%). Internet was the meeting link for 58%. Another STD history was found in 69%. One third of these individuals had no idea about STD transmission modes. This HA outbreak pointed the insufficient vaccine coverage against HAV and knowledge on STD, which may be improved by Internet.

A new pattern in hepatitis A virus infection in an urban population

INTRODUCTION

hepatitis A virus (HAV) infection is a common cause of acute hepatitis worldwide. Since the generalization of vaccination, its incidence had markedly declined. Nevertheless, several HAV-outbreaks have been described in the last decade, mainly related to contaminated alimentary products. In recent years, a new pattern of acute HAV infection has been described with changes in the demographic profile of the infected population, which is more common in healthy young men.

PATIENTS AND METHODS

a retrospective case series study was performed to evaluate this possible change in the pattern of HAV infection. The case series included all patients with a diagnosis of HAV acute infection in our hospital between January 2005 and May 2017.

RESULTS

a total of 196 cases were diagnosed which were comprised of two probable outbreaks: one starting in November 2008 of 26 cases and one starting in 2016 with 69 cases at the time of data collection. The two outbreak populations were comparable. While the sporadic cases group was predominantly formed by pediatric and third-age patients with a slight male tendency, the outbreak related cases showed a clear predominance for young males (proportion of males: 63.2% vs 85.3%, p < 0.001). A possible chronological relationship with the national gay festivity celebrated in Madrid was observed. Outbreak related cases had higher bilirubin, alanine aminotransferase and longer APPT at diagnosis as well as a lower albumin concentration. The clinical relevance was minimal with a similar hospitalization rate and clinical outcome in both groups. There were no related deaths, acute liver failure or need for liver transplantation in our cohort.

CONCLUSION

these epidemiological findings emphasize the importance of implementing preventive measures as well as social awareness campaigns.

Hepatitis A virus infection in an HIV-positive man with previously confirmed immunity against hepatitis A virus

A Japanese man with human immunodeficiency virus (HIV) was detected 9 years ago to have a positive titer for hepatitis A virus (HAV) immunoglobulin (Ig) G, without a history of HAV infection or vaccination. His plasma HIV RNA was well-controlled on antiretroviral therapy for more than 6 years. He developed HAV infection with subsequent reduction of the HAV IgG titer. A decreasing HAV IgG in persons living with HIV might indicate the possibility of HAV reinfection and should prompt the consideration for additional vaccination.

Spillover of a hepatitis A outbreak among men who have sex with men (MSM) to the general population, the Netherlands, 2017

Since 2015, outbreaks of hepatitis A among men who have sex with men (MSM) have been reported worldwide. To examine the impact of these MSM outbreaks in the Netherlands, we combined notification and epidemiological data with sequence analysis. Our results show the hazards of outbreaks within risk-groups spilling over into the largely susceptible general population. One third of the outbreak-related hepatitis A virus genotypes were detected in non-MSM cases.

HIV and the liver

Among individuals with HIV infection, liver disease remains an important cause of morbidity and mortality, even with the availability of agents that cure hepatitis C infection and suppress hepatitis B replication. The causes of liver disease are multifaceted and continue to evolve as the population ages and new etiologies arise. Nonalcoholic fatty liver disease and nonalcoholic steatohepatitis and hepatitis viruses such as A, D, and E have emerged even as hepatitis C has receded. Newer antiretroviral agents may increase risk of weight gain and subsequent fatty infiltration, and prior use of nucleotide-based therapies may continue to impact liver health. Several barriers including economics, social stigma, and psychiatric disease impact identification of liver disease, as well as management and treatment interventions. Hepatocellular carcinoma is emerging as a more common and late-diagnosed complication in those with HIV infection and liver disease.

Antiretroviral Medications for the Prevention of HIV Infection: A Clinical Approach to Preexposure Prophylaxis, Postexposure Prophylaxis, and Treatment as Prevention

Preventing new human immunodeficiency virus (HIV) infections is essential to halting the global pandemic. HIV prevention strategies include integrating both nonpharmacologic (eg, safe sexual counseling, circumcision) and pharmacologic approaches. Several pharmacologic HIV prevention strategies are increasingly used globally and include postexposure prophylaxis, preexposure prophylaxis, and treatment as prevention. These prevention modalities have enormous clinical and public health appeal, as they effectively reduce HIV acquisition in individuals and also may lower HIV incidence in communities when integrated and implemented broadly. Efforts are now underway to scale HIV prevention programs using these techniques in both high- and low-resource settings.

Outbreak of hepatitis A linked to European outbreaks among men who have sex with men in Osaka, Japan, from March to July 2018

AIM

Ongoing hepatitis A outbreaks among men who have sex with men (MSM) have been reported worldwide, mainly in Europe, since 2016. In Japan, there has been an increase in the number of notified hepatitis A cases since January 2018, most of which were suspected to have been transmitted through homosexual contact. In this paper, we describe the current outbreak situation of hepatitis A among MSM.

METHODS

Between March and July 2018, 13 cases of hepatitis A were identified in our hospital. All cases were identified as MSM. Data on clinical and laboratory findings and therapies were collected from medical records. Serum or stool samples were obtained from 13 patients and subjected to sequence analysis.

RESULTS

Of all patients, 12 reported to have male-to-male homosexual contact within 7 weeks prior to symptom onset, and 6 visited sex-on-premises venues in the same area. Furthermore, 12 patients were infected with HIV and consequently received antiretroviral therapy with sustained viral suppression. Ten patients received pulsed methylprednisolone therapy. Plasma exchange was additionally carried out in one patient. All patients received inpatient hospital care and were discharged alive. Sequence information, which was available in all cases, showed that the hepatitis A virus strain was identical to the EuroPride strain (RIVM-HAV16-090).

CONCLUSIONS

Results of sequence analysis suggest that the ongoing hepatitis A outbreak among MSM in Japan is linked to the 2016 European outbreaks. A vaccination program is urgently required for high-risk populations to control this ongoing outbreak.

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.

The As and Bs of HIV and Hepatitis Co-Infection

Hepatitis A and B co-infection among people living with HIV are public health challenges that account for an increasing degree of morbidity and mortality. Understanding the changing epidemiology, clinical manifestations, and new approaches to treatment and prevention continues to be important in the care of people living with HIV. We conducted a review of the literature that included studies on hepatitis A and HIV co-infection and hepatitis B and HIV co-infection, focusing on epidemiology, clinical manifestations, treatment, and prevention. Important updates include the changing epidemiology of hepatitis A outbreaks among the homeless and individuals who use substances, and novel approaches to hepatitis B vaccination and hepatitis B cure strategies.

Herd Immunity Likely Protected the Men Who Have Sex With Men in the Recent Hepatitis A Outbreak in San Diego, California

A high seroprevalence of hepatitis A virus (81%) among human immunodeficiency virus-negative high-risk men who have sex with men is likely why this community was largely spared from a recent hepatitis A virus outbreak in San Diego, California.

Acute hepatitis A virus infection in patients hospitalized at the Department of Infectious Diseases, Medical University of Lublin (Eastern Poland) in 2017 - a hospital-based retrospective study

The aim of our study was to analyze medical records of all adult patients with acute hepatitis A virus (HAV) infection who were hospitalized at the Department of Infectious Diseases, Medical University of Lublin, Poland in 2017. During the studied period acute HAV infection was confirmed in 33 patients. In the study group there were 30 men and 3 women. The mean time of hospitalization was 12 days. All patients recovered with no clinical sequelae.

Incidence of sexually transmitted infections in men who have sex with men and who are at substantial risk of HIV infection - A meta-analysis of data from trials and observational studies of HIV pre-exposure prophylaxis

Background

Men who have sex with men (MSM) and who engage in condomless anal intercourse with casual partners are at high risk of acquiring sexually transmitted infections (STIs), but reliable epidemiological data are scarce. Studies on HIV pre-exposure prophylaxis (PrEP) enrol MSM who indicate that they engage in behaviour that puts them at high risk of acquiring HIV. Because they also screen for STIs at regular intervals, these studies may serve as a valuable source to estimate incidence rates of STIs in this subpopulation of MSM.

Methods

We systematically searched for trials and observational studies of PrEP in MSM that reported data on the incidence of STIs during the study period. Incidence rates were calculated as events per 100 person-years (py) with 95% confidence intervals (CI). Data from individual studies were pooled building subgroups along study types and geography. We performed sensitivity analyses, including data only from studies that met pre-defined quality criteria.

Results

Twenty-four publications on 20 studies were included. The majority of studies reported that sexual behaviour and/or STI incidence remained stable or decreased during the study period. For syphilis, incidence rates ranged from 1.8/100py to 14.9/100py, the pooled estimate was 9.1/100py (95%-CI: 7.7–10.9). Incidence rates for gonorrhoea and chlamydia of any site ranged from 13.3/100py to 43.0/100py and 15.1/100py to 48.5/100py, respectively. Considering only studies that met the criteria for sensitivity analysis yielded pooled estimates of 39.6/100py (95%-CI: 32.9–47.6) and 41.8/100py (95%-CI: 33.9–51.5), respectively. The overall estimate for hepatitis C incidence was 1.3/100py (95%-CI: 1.0–1.8).

Conclusions

Despite partly heterogeneous results, the data depict high incidence rates of STIs among MSM who engage in higher-risk sexual behaviours such as condomless sex with casual partners. This subpopulation of MSM requires access to STI screening at close intervals. By offering access to structures that provide regular STI monitoring and prompt treatment, PrEP may not only decrease HIV incidence but also have beneficial effects in decreasing the burden of STIs.

Hepatitis A outbreak disproportionately affecting men who have sex with men (MSM) in the European Union and European Economic Area, June 2016 to May 2017

Between 1 June 2016 and 31 May 2017, 17 European Union (EU) and European Economic Area countries reported 4,096 cases associated with a multi-country hepatitis A (HA) outbreak. Molecular analysis identified three co-circulating hepatitis A virus (HAV) strains of genotype IA: VRD_521_2016, V16-25801 and RIVM-HAV16-090. We categorised cases as confirmed, probable or possible, according to the EU outbreak case definitions. Confirmed cases were infected with one of the three outbreak strains. We investigated case characteristics and strain-specific risk factors for transmission. A total of 1,400 (34%) cases were confirmed; VRD_521_2016 and RIVM-HAV16-090 accounted for 92% of these. Among confirmed cases with available epidemiological data, 92% (361/393) were unvaccinated, 43% (83/195) travelled to Spain during the incubation period and 84% (565/676) identified as men who have sex with men (MSM). Results depict an HA outbreak of multiple HAV strains, within a cross-European population, that was particularly driven by transmission between non-immune MSM engaging in high-risk sexual behaviour. The most effective preventive measure to curb this outbreak is HAV vaccination of MSM, supplemented by primary prevention campaigns that target the MSM population and promote protective sexual behaviour.