Hepatitis C is becoming more concentrated in gay and bisexual men with HIV in France as direct-acting antiviral treatment cures the infection in other people with HIV while hepatitis C transmission between gay and bisexual men increases, French epidemiologists report in the journal Clinical Infectious Diseases.
But Dr Laurent Cotte and colleagues involved in the Dat’AIDS cohort say that elimination of hepatitis C among people with HIV and hepatitis C co-infection is feasible if acute infections with hepatitis C can be prevented, or detected and treated early.
The prevalence of hepatitis C is high among people with HIV in most European countries and elimination of hepatitis C in co-infected people will be essential to achieve global targets for hepatitis C elimination by 2030. France has declared that people with HIV and hepatitis C are a priority group for hepatitis C elimination.
To check progress on hepatitis C elimination in France, the Dat’AIDS cohort investigators reviewed hepatitis C diagnoses and treatment in people with HIV between 2012 and 2018.
The Dat’AIDS cohort covers around 25% of people with HIV in care in France (57,339 participants). At the last follow-up visit, 39% of the cohort had acquired HIV through sex between men, 43% through sex between men and women and 8% through injecting drug use. Over two-thirds (68%) were male, 8% were currently injecting drugs, and 32% had previously injected drugs or were currently receiving opioid substitution therapy (including 26% of gay and bisexual men).
Between 2012 and 2018, just under 16% of the cohort had at least one positive hepatitis C antibody test. Of these, 1302 infections were new diagnoses that took place after 2012, including 574 cases of primary or acute hepatitis C infection and 189 cases of reinfection.
Hepatitis C prevalence in the cohort fell from 15.4% in 2012 to 13.5% in 2018 after the introduction of direct-acting antiviral treatment. The uptake of treatment increased sharply in 2014 after sofosbuvir-based regimens became available for people with advanced fibrosis in France, and again in 2015 after the approval of sofosbuvir/ledipasvir (Harvoni) and other combination products.
Each year, the proportion of people with chronic hepatitis C infection who were treated increased, so that in 2018, 61% of people with detectable hepatitis C virus started direct-acting antiviral treatment. By 2018, only 21% of people who had tested positive for hepatitis C were viraemic, and based on treatment uptake during 2018, the researchers estimate that the proportion of those ever testing positive who remained viraemic in 2019 fell further, to just below 9%.
An increasing proportion of those with detectable hepatitis C virus were people who had been recently infected or reinfected. In 2018, 26% of all viraemic patients in care had been recently infected and 13% of all hepatitis C treatments took place during acute infection. However, although 100 people in the cohort were diagnosed with acute infection or reinfection in 2018, only 44 treatments were started in acute infection, showing that more work is needed to ensure rapid diagnosis and treatment initiation.
Hepatitis C prevalence remained stable or decreased among all groups apart from gay and bisexual men, where prevalence almost doubled from 1.9% to 3.5% between 2012 and 2018. Although the incidence of recent first hepatitis C infections fell among the entire cohort, it rose among gay and bisexual men with HIV from 0.36 per 100 person-years to 1.25 per 100 person-years between 2012 and 2018.
The investigators note that whereas active drug use declined among people exposed to HIV through injecting drug use, so that by 2018 less than 10% of this group were actively using drugs, more than 40% of gay and bisexual men reported active drug use (although the investigators cannot say what proportion were sharing injecting equipment). Increases in condomless sex and international sexual mixing are also important contributors to the rise in infections among gay and bisexual men, say the investigators. Unless recent infections can be diagnosed promptly and treated, the rate of new infections and reinfections among gay and bisexual men will make it difficult to eliminate hepatitis among people with HIV in France.
Overall progress towards the World Health Organization’s hepatitis C elimination goals was good in all respects except reduction of new chronic infections. The target of diagnosing 90% of chronic infections was met by 2018 (95%), as was the target for treatment of 80% of chronic infections (88%) and a 65% reduction in deaths (no deaths due to hepatitis C in 2018, representing a 100% reduction). The target for reducing new chronic infections by 90% was not met: new infections in France fell by 35% between 2012 and 2018.
Cotte L et al. Microelimination or not? The changing epidemiology of HIV-HCV coinfection in France 2012-2018. Clinical Infectious Diseases, published online 5 January 2021.