New Bug on the Block

Rise in gay hepatitis C cases fueled by injecting drugs, rough butt-play

David, 46, a gay New York City flight attendant diagnosed with HIV in 1997, first started doing crystal meth in 1993. It wasn’t until 1999, though, that he injected it—and not until late 2004 that he shared a needle with a fellow user.

“I was really high and thought it was some sort of bonding experience,” he recalled.

But early the next year, his doctor gave him some upsetting news—he was newly infected with hepatitis C.

“I cried and cried,” said David.

His doctor wanted him to start hep C treatment right away, owing to data showing that people who start treatment early have good chances of clearing the virus from their system. But the treatment is challenging and often causes or worsens depression, so because David was still struggling with addiction, he and his doctor missed that opportunity.

David is just one of the growing number of gay men in New York City, virtually all of them already diagnosed with HIV, to learn that they have also recently acquired hepatitis C—a virus that, until recently, has not loomed large in the city’s gay world.

Some have contracted the liver-ravaging virus by sharing syringes or other items used to inject drugs—mainly crystal meth—others by engaging in unprotected anal intercourse, fisting, or other rough butt-play that can tear the soft lining of the rectum and cause bleeding. This is especially possible when crystal or other drugs anesthetize users to pain that would usually be a sign to stop or slow down such activities.

For many of these men, who have sometimes spent years adapting to HIV, learning they have another life-threatening infectious disease can be overwhelming. Many such men have had hepatitis A or B, both common to gay men and preventable with vaccines, but few know much about hep C beyond its traditional association with injection-drug users, up to 90 percent of whom acquire the virus.

Now it seems that different kinds of unprotected anal sex can be added to that list of hep C risk factors

“This is the new gay sexually transmitted disease,” said Douglas Dieterich, M.D., who sees patients “co-infected” with HIV and hep C at Mount Sinai School of Medicine in New York City. Dieterich said he’s seen “a ton” of new hep C cases in HIV-positive gay men in recent years, all of them linked to unprotected anal sex, often accompanied by crystal-meth use.

Like HIV, hep C is passed through blood and semen, but unlike HIV, it does not die quickly when exposed to air, making it easier to get by sharing items like sex toys and injection equipment. It sometimes clears the system naturally without treatment, but this is rare in people who also have HIV.

Untreated, hep C generally progresses slowly, often not causing real liver damage for decades, if ever, but the virus progresses much faster in those who also have HIV.

Unlike HIV treatment, hepatitis C treatment is short-term and can sometimes cure the disease. However, chances of this are rarer in people who also have HIV unless they start hep C treatment early in their infection. Otherwise, a patient will have to carefully monitor hep C’s damage to his liver in the years to come. The best current method for this is a liver biopsy, which can be painful.

At the LGBT-serving Callen-Lorde Community Health Center in Chelsea, hepatitis C has gone from being virtually nonexistent two years ago to affecting four to eight percent of the patient base today, according to executive director Jay Laudato. “It’s really making headway into the community,” he said, noting that Callen-Lorde has begun screening all incoming HIV-positive patients for hepatitis C.

Gal Mayer, M.D., Callen-Lorde’s medical director, calls the number of cases so far “the tip of the iceberg. There’s probably a lot of transmission going on as we speak,” he said.

Some of the hep C cases surfacing at Callen-Lorde and elsewhere are years old, but many are so-called “acute” infections that have happened in recent weeks or months. Many private New York City HIV doctors say that patients who have regularly tested negative for hepatitis C are now testing positive. The new infections are usually linked to some combination of injecting or using crystal meth and unprotected rough anal sex, say doctors.

“I have one patient who I believe got hep C the first time he shared a needle using crystal,” says Paul Bellman, M.D., an HIV doctor in Greenwich Village whose practice consists primarily of gay men. This is in line with studies finding that hep C is often transmitted within someone’s first year of injecting drugs.

The seeming uptick in new hep C infections in gay HIV-positive New Yorkers is echoed in a recent spate of studies from Europe and Australia. In one of those studies, conducted at London’s Royal Free Hospital, fisting, group sex, and non-injection drug use of all sorts were found to be hep C risk factors.

A spokesperson for the New York City Department of Health and Mental Hygiene said the trend had not yet come on their radar.

Doctors say they believe the hep C cases are appearing almost only in HIV-positive men not because such men are more biologically vulnerable but because they make up the majority of those injecting crystal meth or having unprotected anal sex.

And with many HIV-positive men choosing to have sex only with one another, a process called “sero-sorting,” there is an increased likelihood that they will transmit the virus among themselves. The blood level of hepatitis C is much higher in those with HIV than those without.

Doctors and advocates say that many gay men lack basic knowledge about hepatitis C and how to prevent it.

Antonio Urbina, MD, an HIV doctor with St. Vincent’s Medical Centers, said that a patient of his recently got hep C at a sex party where guys used separate needles and syringes to inject crystal meth but drew the drug from the same bowl of water.

The patient didn’t understand that hep C could reside not only in shared needles and syringes, said Urbina, but in all shared items used for injection, including the water and cotton bits used to dilute and then absorb the drug before it is drawn up into the syringe.

“There’s a real health illiteracy among gay men who are now starting to inject drugs,” said Urbina. “Because my patient was at a nice apartment in Chelsea and these guys ‘looked fine,’ he didn’t perceive there to be a risk.”

Plus, many men don’t know how to prevent the tearing and bleeding that rough ass-play can cause, making both bottoms and tops more vulnerable to hep C infection during anal intercourse.

In addition, “booty bumping”—getting high by inserting crystal meth into the rectum—may be playing a role in the anal transmission of both HIV and hep C, said Spencer Cox, executive director of the Medius Institute, a gay men’s health advocacy group. “We know that crystal meth is a very caustic chemical,” he said.

To close the knowledge gap, the Medius Institute and Callen-Lorde have teamed up to launch informational postcards they intend to distribute widely to sex clubs and other venues with large numbers of men who use crystal meth and/or engage in high-risk sex.

Cox plans to have go-go boys debut the cards at the outdoor gay S&M festival Folsom Street East on June 18. One card will give hep C basics, one will give tips for safer fisting and ass-play and the third will give tips for safer injecting.

Cox said the postcards have been designed with their target population in mind. “These are relatively upper-middle class guys,” he said. “They’d prefer to walk into a pharmacy and buy needles.”

To avoid the needle-sharing that leads to HIV and hep C, New York State allows pharmacies to sell syringes without a prescription.

“They are not going to be using a needle-exchange,” say Cox, referring to venues where injection-drug users can access clean needles for free.

HIV-positive people stand a good chance of curing—or “clearing”—hep C if they start treatment, usually consisting of the drugs pegylated interferon and ribavirin, early in their infection. But many people aren’t diagnosed that early. Even when they are, they are often not ready to plunge into a months-long treatment regimen that often comes with severe side effects including flu-like symptoms and depression.

Still, for sexually active gay men, especially HIV-positive ones, doctors stress the importance of routine hep C screening to detect the virus early. Dieterich said that of the 15 gay men he’s seen in recent years with new hep C infections, all of them have managed to clear the virus by promptly starting a six-month course of treatment.

“So far we’re batting 1,000,” he said. He also observed that side effects have seemed minimal in patients who started treatment early.

Bellman conceded that starting hep C treatment sometimes is not possible for patients struggling with drug addiction, especially because hep C treatment can trigger or worsen depression, which is common when withdrawing from meth or other drugs. But he noted that learning of having another virus on top of HIV often prompts patients to go into recovery from drugs.

One patient, he said, “was so freaked out” by the news that “he never wanted to use crystal again—and he started treatment.”

As for flight attendant David, he’s still struggling with the drug. And as for his hep C, his doctor said that his viral load is moderate and his liver functions are only slightly elevated. But he knows that, down the line, only a liver biopsy, which is often a painful procedure, likely can definitively assess whether he needs to start hep C treatment.

“I worry more about having hep C than HIV,” David said. “I guess it’s because it’s a newer disease for me and the treatment is really hard, whether it’s getting a liver biopsy or doing interferon. Those are things I don’t really want to have to deal with.”