Acute HCV infections observed among HIV-negative gay men in London

Hepatitis C virus (HCV) infections are occurring among HIV-negative gay men in London, investigators report in the Journal of Viral Hepatitis. Researchers at the Chelsea and Westminster Hospital identified 44 cases of acute HCV infection among HIV-negative gay and other men who have sex with men (MSM) between January 2010 and May 2014. Almost all the men reported unprotected anal sex, and drug use during sex was also common

“We have identified a cohort of HIV-negative MSM with acute hepatitis C,” write the authors. “Accurate history taking, documentation of drug use and risk prevention strategies are crucial in this population. Larger, prospective data are needed to further clarify the incidence and prevalence of hepatitis C in MSM without HIV infection.”

There is an HCV epidemic among HIV-positive gay men in London and many other cities in western Europe and north America. These infections appear to be due to a combination of sexual risk factors (unprotected anal sex, fisting, co-infection with ulcerative sexually transmitted infections) and drug use behaviours (injecting and snorting).

There have been isolated case reports of acute HCV infections in HIV-negative MSM. However, little is known about the extent of HCV transmissions in this population.

Investigators therefore conducted a retrospective analysis of the records of HIV-negative MSM attending a large sexual health clinic in London. Their aim was to identify cases of acute HCV infection.

A total of 44 cases were identified. Just over a third (34%) of individuals had had a previous negative HCV screen within the previous twelve months. Significant elevations in ALT – a key marker of liver function – were detected in a quarter of cases.

The men had a median age of 37 years and two-thirds were white British/Irish.

Sexual risk taking was highly prevalent. Almost all the participants (93%) reported unprotected anal sex, with 88% reporting both insertive and receptive unprotected anal sex. A quarter of participants told the investigators that they’d engaged in fisting

Overall, half of individuals reported drug use of any kind, with 36% reporting nasal use and 21% reporting injecting. Approximately a third said they’d had unprotected sex under the influence of recreational drugs.

Individuals were asked about the HCV and HIV infections status of their sexual partners. Just under a third said they’d had sex with an HIV-mono-infected partner; 14% reported sex with a man with HIV/HCV co-infection.

A concurrent sexually transmitted infection was diagnosed in 30% of participants. Use of HIV post-exposure prophylaxis (PEP) was reported by 18% of men and 5% were taking HIV pre-exposure prophylaxis (PrEP). None of the participants acquired HIV.

Median HCV load at the time of acute HCV diagnosis was 5.47 log¹⁰ iu/ml. Most of the participants had HCV genotype-1 infection.

Spontaneous HCV clearance was observed in 34% of individuals and eleven individuals received HCV therapy with ten achieving sustained clearance of the virus.

Only 15% of HIV-negative gay men attending sexual health services in a typical month (November 2013) were screened for HCV.

“We have highlighted a low rate of HCV screening for at risk MSM, concerning for un-diagnosed HCV infection and onward transmission,” conclude the authors. “HIV-negative MSM remain at risk of HCV infection, sharing similar risk behaviours as HIV-positive MSM. HCV testing should be part of routine sexual health screening in those with risk factors, particularly in environments with high HCV prevalence.”