HIV update - 7th June 2017

Recent infection with hepatitis C

Infection with hepatitis C is becoming more common among gay and bisexual men who are living with HIV, especially in larger cities in the United Kingdom and Europe. Almost one in ten were co-infected in 2011 in the United Kingdom and the prevalence is even higher in some other European countries. The number of new infections remains high.

The hepatitis C virus (HCV) is transmitted in blood, semen and rectal fluid, and is much more infectious than HIV.

Recent hepatitis C infection (acute infection) may be cleared spontaneously, or can be cleared with a short course of treatment in most cases – if it is diagnosed within six months of infection. Early diagnosis and cure also prevent hepatitis C being passed on to others.

Current recommendations encourage antibody testing for HCV for gay and bisexual men every six months in Europe for men at high risk. An unexplained increase in liver enzymes should also trigger an HCV test, but not everyone recently infected with hepatitis C has an increase in liver enzymes.

Not all health care providers follow the guidelines for testing, and some people may benefit from more frequent testing. The British HIV Association recommends that HCV testing should take place whenever high-risk practices are reported, but both doctors and people living with HIV may be unaware of which sexual and drug-using practices place people at higher risk of catching hepatitis C.

Recent research in the Netherlands shows that six questions can identify HIV-positive gay men who are at higher risk of having acute (recent) hepatitis C infection and who would benefit from further testing.

The six questions in the risk score concern self-reported behaviours:

• Condomless receptive anal intercourse in the past six months (score 1.1)
• Sharing of sex toys in the past six months (score 1.2)
• Fisting without gloves in the past six months (score 0.9)
• Injecting drug use in the past 12 months (score 1.4)
• Sharing of straws to snort drugs in the past 12 months (score 1.0)
• An ulcerative sexually transmitted infection in the past 12 months (e.g. syphilis) (score 1.4)

All of these practices have been linked to hepatitis C infection in gay and bisexual men in recent studies.

A man scoring a total of 2.0 or more would be recommended to be tested for acute hepatitis C. The researchers found that at least 73% of men with a risk score of 2 or above turned out to have a recent hepatitis C infection when they tested the scoring system using data from the Netherlands, Belgium and England on hepatitis C infections in gay and bisexual men living with HIV.

The researchers say that the risk scoring system should not be used as the only way of identifying men who need a hepatitis C test, but the scoring system could prove useful outside clinic systems as a way of encouraging men to seek hepatitis C testing and look at behaviours that might put them at risk of acquiring hepatitis C.

For more information on hepatitis C transmission read NAM's leaflet 'How hepatitis C is passed on'.

Anal cancer

HIV-positive gay and other men who have sex with men (MSM) have a high prevalence of anal infection with cancer-associated strains of human papillomavirus (HPV). Persistent infection can lead to the development of HGAIN, a precursor to anal cancer.

A review of published studies in 2012 estimated that between 8 and 15% of MSM living with HIV developed HGAIN each year, and 3 to 6% of MSM without HIV. The reviewers calculated that 1 in 377 men with HIV diagnosed with HGAIN would go on to develop anal cancer each year, and 1 in 4196 men without HIV.

Early diagnosis and prompt treatment of pre-cancerous lesions is therefore important. However, there is some evidence that even after successful therapy, a proportion of men experience recurrence of HGAIN.

Spanish researchers have now looked at how frequently pre-cancerous lesions appear again in men successfully treated, and which methods are best for spotting recurrence.

They found that 39 out of 100 men successfully treated with electrocautery – a surgical technique in which lesions are destroyed by burning with an electrical probe – subsequently experienced recurrence. The probability of recurrence was estimated at 54% after two years.

Men in the study were more likely to experience a recurrence if they had a low CD4 count (below 200), or hepatitis C, or a previous large lesion.

High-resolution anoscopy (a procedure that involves examining the anal canal with a microscope) was sufficient to detect all cases of recurrence. The researchers say that after HGAIN treatment, people should be monitored regularly for recurrence.

For more information on anal cancer, read NAM's factsheet.

Meningococcal disease (meningitis)

Meningococcal disease is a rare but serious bacterial infection caused by Neisseria meningitidis. The bacteria can be transmitted in saliva, through kissing or sexual contact, or through close and prolonged household contact.

The typical symptoms of infection are the sudden onset of fever, rash, severe headache and stiff neck, often accompanied by sensitivity to light, confusion and nausea. Meningococcal disease is a life-threatening condition that can cause brain damage, kidney damage or septicaemia (blood poisoning) leading to loss of limbs.

The Global Meningococcal Initiative has recommended that all people living with HIV should be vaccinated against meningococcal disease. The Global Meningococcal Initiative is an international scientific expert panel; its review of the scientific literature and recommendations for action were published last week in the Journal of Infection. The panel highlighted the need for national vaccination programmes to include people living with HIV in sub-Saharan Africa where the prevalence of meningococcal disease is high, and also drew attention to recent outbreaks among men who have sex with men (MSM).

Meningococcal disease is most common in infants and in young adults, but has also been reported in MSM of varying ages. 

Clusters of the infection were reported in 2016 and 2017 among MSM in New York City, Los Angeles and Chicago. Many of the affected MSM were HIV-positive.

A small outbreak of meningococcal disease among MSM was reported in Germany, Belgium and France in 2013. French public health authorities subsequently recommended that all MSM over the age of 25 should be vaccinated, as should anyone else attending gay social venues.

Current United Kingdom guidance, published by the British HIV Association in 2015, is that people living with HIV should be offered vaccination against meningococcal disease according to the same criteria as the rest of the population. Although infant vaccination against type C meningococcus began in 1999 in the United Kingdom, not all are covered and university entrants are currently being offered vaccination due to the risk of transmission on campus.

People under 25 who are not yet vaccinated, and people with asplenia or complement component deficiency (a lack of proteins involved in early responses to infections) should be vaccinated, the guidelines recommend.

Those at risk of exposure through travel or recent contacts should also be vaccinated. Travellers to cities or countries where a current outbreak is reported (see above) or where meningococcal disease is common (e.g. central Africa) should discuss vaccination with their clinic. People vaccinated previously should discuss with their clinic whether they need a booster dose, and everyone with HIV vaccinated for the first time should receive two doses two months apart to ensure protection.