Data emerging from the US and Europe shows that more HIV-negative gay and bisexual men are contracting hepatitis C than in the past, and New York-based health experts say PrEP’s role in preventing the spread of HIV could be altering what had been a longstanding link between the two infections.
Hepatitis C, for which there is no vaccine, is more known in general for being transmitted via needle-sharing and contaminated blood, but it can also be sexually transmitted and its historical ties to gay and bisexual men have typically been largely limited to HIV-positive men. Recent studies, however, are reflecting a shift in that pattern, including one presented at the 25th Annual Conference of the British HIV Association showing that 40 percent of gay and bisexual men who became infected with hepatitis C at three British clinics were HIV-negative. Eighty-one percent of those men were on PrEP, which is a drug taken daily to prevent its user from contracting HIV.
Those numbers echoed findings in separate studies out of the Netherlands and France, while the intersection of PrEP, HIV, and hepatitis C was also similarly explored in a US-based report in the Journal of Infectious Diseases.
The American report evaluated 14 men who had sex with men — some at New York’s Mount Sinai Medical Center and others at the University of California, San Francisco — who were on PrEP and became infected with hepatitis C but remained HIV-negative. Among those men, half reported an increase in behaviors that could have put them at risk of acquiring hepatitis C, including decreased condom usage and injection drug use.
Alicia Stivala, who is a nurse practitioner at New York City’s Callen-Lorde Community Health Center and was one of the authors of that study, told Gay City News on April 11 that Callen-Lorde’s health clinic in the last 12 months has seen two cases of hepatitis C among HIV-negative gay men on PrEP. She was unable to immediately confirm how that statistic compared to previous years.
The study noted that, previously, the rareness of hepatitis C infections among gay men who were HIV-negative was partly due to the tendency of men to have sex with men of the same HIV status and/ or to use condoms. But the emergence of PrEP has changed that dynamic.
“More HIV-positive and negative men are mixing and having condom-less sex because they’re able to and not worry about HIV” in the PrEP era, she said, while adding that an increase in the transmission of HCV between these groups is “definitely something we’re concerned about.”
In light of the increase in sex between positive and negative men, Stivala stressed that data regarding hepatitis among HIV-positive men should serve as a warning regarding the importance of protection against non-HIV sexually-transmitted diseases. She said there has been a “cluster of new infections” of hepatitis C among gay men in Manhattan who have HIV.
“I think that could translate into more infections in HIV-negative men, including in the crystal meth community,” she said.
The spread of other sexually transmitted infections among gay and bisexual men on PrEP was also studied in a report published in the Journal of the American Medical Association on April 9. The study of 2,981 men on PrEP over two years found an increase in sexually transmitted infections.
Further complicating the dual effort to address both HIV and hepatitis C are barriers to access to affordable medications. There is a campaign to remove the patent that has kept PrEP out of reach for many of those who need it the most, while Gilead, which holds that patent, recently embarked on a plan to introduce generic versions of hepatitis C treatment in the US.
“Both the HIV and HCV epidemics share the burden of having limited access to groundbreaking medications simply due to patents,” said Clifton Garmon, who serves as the chief of staff at VOCAL-NY, a grassroots organization geared toward helping low-income folks with HIV/ AIDS, hepatitis C, and other health issues that also campaigns for reform of drug, incarceration, and homelessness policies. “Maintaining patents on life-changing medications like HCV treatments and PrEP only perpetuates decades-long epidemics. This approach is completely counterproductive to roles that government and pharmaceuticals are supposed to play.”
New York Governor Andrew Cuomo last year announced the nation’s first statewide campaign to eliminate hepatitis C by expanding funding for hepatitis C prevention, testing, and treatment programs while urging pharmaceutical manufacturers to slash prices on medications. He also called for increased focus on the opioid epidemic because of the way hepatitis C can be transmitted via the sharing of injection equipment.
Stivala believes the campaign to address hepatitis C needs to include a coordinated effort to encourage HIV-negative gay and bisexual men as well as transgender women to get screened for hepatitis C. She also said that anyone, regardless of gender or sexual orientation, who has receptive unprotected anal sex should be tested.
Others who should be screened, she said, include those who use crystal meth or are injection drug users, have a history of sexually transmitted infections such as gonorrhea, or have ulcerations to the anal area.
According to Mayo Clinic, hepatitis C often presents no symptoms, but can be accompanied by bleeding, fatigue, and weight loss, among other issues, and can lead to liver damage.
