Sexual transmission of hepatitis C virus has been reported among HIV-positive gay men in Paris. The report is included in the June edition of Eurosurveillance Monthly. Investigators believe that transmission of hepatitis C virus “can occur through bleeding during unprotected anal intercourse and ‘hard’ practices which may be facilitated by mucosal lesions linked to sexually transmitted infections.”
The Paris report follows well-documented sexual transmissions of hepatitis C virus among HIV-positive gay men in London and the Netherlands, where unprotected anal sex, “hard” sexual practices such as fisting and a recent sexually transmitted infections were associated with infection with hepatitis C.
In mid-2004 two hospitals in Paris informed the French public health authorities of several cases of acute hepatitis C virus infection in HIV-positive gay men. None of the men had traditional risk factors for infection with hepatitis C virus, such as injecting drug use. A third Parisian hospital reported a number of cases of acute hepatitis C virus infection with concomitant syphilis in HIV-positive gay men.
Investigators conducted a retrospective review of medical records and designed a questionnaire to identify risk factors for recent infection with hepatitis C virus. They wished to determine how many cases of acute hepatitis C virus infections had been diagnosed in HIV-positive gay men in Paris since 2001. In addition, they wished to define the HIV infection characteristics of these patients (including CD4 cell count, viral load, use of highly active antiretroviral therapy [HAART] and duration of HIV infection), hepatitis C virus infection description (duration of infection, reason for hepatitis C virus testing, genotype, treatment and disease progression) and risk factors for acquisition of hepatitis C virus infection.
The anonymous questionnaire asked the men recently diagnosed with acute hepatitis C virus infection about their sexual practices (including “hardcore” practices such as fisting), the number of sexual partners, where these partners were met and about drug use.
A total of 29 cases of acute hepatitis C virus infection in HIV-positive gay men were identified. These cases were diagnosed evenly over the three years of the study. At the time hepatitis C virus infection was diagnosed, men had a median age of 40 years. The majority of men (24) were tested for hepatitis C virus infection because of abnormal liver function.
The majority of men (15, 52%) were infected with hepatitis C virus genotype 4. Genotype 1, was present in 22% of men, and 23% were infected with genotype 3.
None of the men had traditional risk factors for hepatitis C virus infection, such as injecting drug use.
A review of medical records indicated that sexual risk activities, which earlier studies in the United Kingdom and the Netherlands identified as involving a risk of sexual transmission of hepatitis C virus infection in HIV-positive gay men, were widespread. All 29 men reported unprotected anal sex. In addition, six men said that they had engaged in “harder” sexual practices, with two men saying that this had resulted in anal perforations.
A recent sexually transmitted infection was reported by twelve men (41%).
At the time acute hepatitis C virus infection was diagnosed, 76% of the men had asymptomatic HIV disease. Most of the men (86%) were taking HAART and none of the men had a CD4 cell count below 200 cells/mm3 with over half having a CD4 cell count above 500 cells/mm3. Viral load was undetectable in two-thirds of the men.
A total of eleven men completed the anonymous questionnaire about their sexual activities. All had had unprotected anal sex with casual partners in the six months before their diagnosis with acute hepatitis C virus infection. Eight men said that they had engaged in “harder” sex and five men reported fisting. All but one man reported a recent sexually transmitted infection and all the men said that they had met casual partners in sex clubs or via the internet. Recreational drug use was widespread. All eleven men said that they used poppers and five said that they had used ecstasy, ketamine, GHB, cocaine or LSD during sex. None of the men said that they had injected drugs. All but one of the men had had a recent sexually transmitted infection.
The investigators note that cohort studies in gay men have found a low incidence of hepatitis C virus infection suggesting that “hepatitis C is not easily spread by sex between men.” However, they suggest that sexual transmission between men “may be facilitated by HIV infection, which may promote viral receptivity in individuals sexually exposed to hepatitis C virus and enhance hepatitis C virus infectivity in genital secretions.”
It is speculated by the investigators that the “HIV-positive [gay] men who acquired hepatitis C virus may belong to a specific group of men who are engaged in sensation seeking and sexual experiments including ‘hard’ sex with high-risk sexual practices (multiple partners, no condom use for anal sex, fisting without protective gloves) which results in multiple sexually transmitted infections. In this group, psychoactive substance use may be used to facilitate ‘hard’ sexual practices by lowering inhibitions.”
Fisting, and other sexual activity which could involve bleeding (visible or not) are also identified by the investigators as risk factors for hepatitis C virus infection.
“The proportion of genotype 4 (52%) among this group was much greater than usually observed in France (11%)”, note the investigators, who believe that this could be cause “selected strains” of hepatitis C virus are being transmitted “in a social network of people with specific behaviours.”
Gambotti L et al. Acute hepatitis C infection in HIV-positive men who have sex with men in Paris, France, 2001 – 2004. Eurosurveillance Monthly 10:5, 2005.