HCV Infection in HIV-Positive MSM

In HIV-positive men who have sex with men, HCV acquisition is not uncommon and is often due to sexual exposure.
Sexual transmission of hepatitis C virus (HCV) has been thought to be relatively inefficient. Furthermore, in cases of HIV/HCV coinfection, HCV infection has been thought to typically precede HIV infection. However, these views were challenged after outbreaks of acute HCV infection were documented among HIV-positive men who have sex with men (MSM). Now, two studies show that new HCV infections in HIV-positive MSM often seem to be acquired through sexual contact.
Taylor and colleagues determined the incidence of HCV infection in a U.S.-based cohort of HIV-positive men who had participated in various clinical trials. Of 1830 men who were initially HCV-negative, 36 subsequently seroconverted, for an overall incidence rate of 0.51 cases per 100 person-years. Seroconverters were predominantly white and often college-educated, with a mean age of 46; notably, three quarters reported no injection-drug use (IDU), implying possible sexual acquisition of HCV.
Matthews and colleagues described 163 individuals in Australia with acute HCV infection (31% HIV-positive; 72% men). Eighteen percent of the study participants likely acquired their HCV infection through sexual exposure, and most of these were HIV-positive MSM. Phylogenetic analysis of HCV sequences suggested that infections among HIV-positive MSM often originate from a potential common source — and that transmission of HCV to HIV-positive individuals occurs within social networks in which IDU and sexual risk behaviors coexist.
Comment: HCV testing in HIV-positive patients has historically been recommended only at the time of HIV diagnosis. However, the recognition that HIV-positive MSM are at risk for acquiring HCV infection has led the European AIDS Treatment Network (NEAT) to now recommend annual HCV antibody testing in high-risk HIV-positive individuals — and HCV RNA testing if acute infection is suspected. U.S. guidelines are likely to follow suit. An important reason for identifying patients with newly acquired HCV infection is the relatively high efficacy of early versus later treatment — a topic nicely summarized in the new NEAT guidelines.
— Rajesh T. Gandhi, MD
Published in Journal Watch HIV/AIDS Clinical Care February 28, 2011

Citation(s):

Tayor LE et al. Incident hepatitis C virus infection among US HIV-infected men enrolled in clinical trials. Clin Infect Dis 2011 Jan 31; [e-pub ahead of print]. (http://dx.doi.org/10.1093/cid/ciq201)

Matthews GV et al. Patterns and characteristics of hepatitis C transmission clusters among HIV-positive and HIV-negative individuals in the Australian Trial in Acute Hepatitis C. Clin Infect Dis 2011 Jan 31; [e-pub ahead of print]. (http://dx.doi.org/10.1093/cid/ciq200)

The European AIDS Treatment Network (NEAT) Acute Hepatitis C Infection Consensus Panel. Acute hepatitis C in HIV-infected individuals: Recommendations from the European AIDS Treatment Network (NEAT) consensus conference. AIDS 2011 Feb 20; 25:399.

Putting PrEP into Practice

A young man who repeatedly engages in high-risk sexual activity with other men requests pre-exposure prophylaxis to prevent HIV infection. Do you oblige?

A 29-year-old man goes to the emergency department (ED) to request post-exposure prophylaxis (PEP) to prevent HIV infection. He has just returned from a week-long vacation, during which he had unprotected oral and receptive anal intercourse with several men whose HIV status he does not know. His last HIV test was 6 months prior to this ED visit, and the result was negative. He reports no medical problems and is not taking any medications. He receives a 28-day course of tenofovir/FTC + lopinavir/ritonavir PEP.
Four days later, the patient has a follow-up visit with his primary care provider (PCP), who is aware that he has received at least three similar courses of PEP during the previous 4 years. His HIV antibody test has again returned negative. He says he is aware of when he is going to put himself at high risk for HIV infection (usually during vacations and particular weekends) and would like a supply of tenofovir/FTC to take during these periods; however, he does not want to take the drugs continuously.
If you were the PCP, what additional history would you obtain? Would you try to change the patient's high-risk behavior? If so, what specifically would you say to him? Would you recommend tenofovir/FTC pre-exposure prophylaxis (PrEP) for him? If so, would it be continuous or intermittent? How frequently would you monitor for HIV, other sexually transmitted infections, and tenofovir/FTC toxicity? If you would not prescribe PrEP, what is your reasoning?
Published in Journal Watch HIV/AIDS Clinical Care February 28, 2011