Researchers documented a small number of cases of sexually acquired hepatitis C virus infection among men who have sex with men, or MSM, taking pre-exposure prophylaxis, or PrEP, for HIV prevention. The cases underscore a need for HCV prevention efforts and enhanced HCV surveillance among MSM who use PrEP, they said.
“In the decade before the FDA approval of emtricitabine/tenofovir for PrEP in 2012, sexual acquisition of HCV infection was rare in HIV-uninfected MSM compared to HIV-infected men,” the researchers, from institutions in San Francisco and New York, wrote in the Journal of Infectious Diseases. “However, since the FDA approval and the increasing prescription of PrEP in our regions, we have now documented 15 sexually acquired HCV infections among 14 HIV-uninfected MSM after their initiation of PrEP.”
The report included 14 HIV-uninfected MSM using PrEP with suspected sexually acquired HCV infection who were referred to Mount Sinai Medical Center in New York or the University of California, San Francisco. The men were tested for HCV infection or HCV re-infection between 2013 and 2018. One of the men became re-infected.
The researchers used patient reports or electronic medical records to determine behavioral changes after PrEP initiation, risk factors for HCV acquisition, time on PrEP, laboratory data at the time of HCV diagnosis and HCV treatment outcomes.
The 14 men had a median age at time of primary HCV infection of 35 years and had been taking PrEP for a median of 12 months before receiving their primary HCV diagnoses. Half the men reported an increase in behaviors that could possibly result in exposure to HCV after they started PrEP. These included decreased condom use and an increased number of sexual partners.
Of the 15 infections, 13 (87%) were asymptomatic, having been diagnosed during routine laboratory screening, the researchers reported. In 10 infections (67%), the men reported recreational drug use in the prior 6 months — mostly of crystal methamphetamine — including five reports of injection use of crystal methamphetamine. All the men in the study reported engaging in receptive anal intercourse, and most (80%) reported at least 10 sexual partners during the 3 months before HCV diagnosis.
According to the authors, the limitations of the study included that they were unable to determine the incidence rate of HCV infection in MSM using PrEP in the study regions because they did not know the number of MSM using PrEP in referral networks.
“While most of the PrEP clinics involved in our case series performed routine follow-up ALT or HCV testing, this practice was not uniform,” they wrote. “As quarterly HIV testing is recommended during PrEP prescribing and elevated ALT is more sensitive than HCV Ab during acute infection, we strongly encourage incorporating ALT testing to this quarterly panel to facilitate earlier HCV diagnoses.
“Finally, we support the [American Association for the Study of Liver Diseases/Infectious Diseases Society of America] guidelines to perform HCV Ab at least annually for all MSM using PrEP who report multiple sex partners to prevent what might otherwise become an undetected expansion of sexually transmitted HCV infection into HIV-uninfected MSM.”
They said “CDC guidelines for monitoring during PrEP should include regular ALT and HCV testing.” – by Bruce Thiel
Disclosures: Please see the study for all authors’ relevant financial disclosures.