Associate Clinical Professor
Division of Infectious Diseases
Department of Medicine
UC San Diego School of Medicine
La Jolla, California
Chief, Population Health
Director, Graduate Medical Education
Family Health Centers of San Diego
San Diego, California
Christian B. Ramers, MD, MPH, has disclosed that he has received consulting fees from AbbVie and Gilead Sciences; fees for non-CME/CE services from AbbVie, Gilead Sciences, Janssen Therapeutics, and Merck; and funds for research support from Gilead Sciences.
As we gradually attend to the multitude of individuals infected with HCV still awaiting diagnosis and treatment, it is important to remember that comprehensive care does not end with the SVR12 visit. Perhaps because I work in a primary care setting, I tend to see patients longitudinally and not just for a discrete 6-month interval. With long-term health and wellness as a framing principle, curing HCV is not the finish line but rather a starting point for a conversation about maintaining wellness, preventing progression of liver disease, addressing harmful drug and alcohol habits, and, of importance, preventing HCV reinfection.
Assessing Patient Risk for HCV Reinfection
Clinical trial and cohort data have provided limited estimates of the incidence of HCV reinfection by various modes of transmission. One of the surprising findings from these studies has been the wide variation in incidence of reinfection among cohorts with suspected sexual transmission of HCV (rates of 5-15/100 person-years). To be sure, one methodological consideration in these reports is the overlap in transmission potential among individuals who demonstrate both high-risk sexual practices and injection drug use as risk factors.
The “reinfection prevention” discussion with recently cured patients must come from a place of familiarity with the patient’s life situation and specific risk factors for reinfection. My patients typically fall into one of several categories:
If I have sufficiently appraised a patient’s history at the initial HCV visit, the suspected mode of transmission should already be documented in the medical record and can be a starting point for conversations regarding reinfection.
Avoiding HCV Reinfection in PWID
For PWID, counseling to prevent HCV reinfection must encompass the chronic nature of addiction, the local availability of medication-assisted treatment, harm reduction/syringe exchange services, and access to ongoing virologic HCV testing. Even when a patient has minimal liver fibrosis, if there are ongoing risk factors for HCV reinfection, I like to be the one seeing him or her annually to order the HCV RNA test; this avoids any potential confusion that may arise when a new provider unfamiliar with HCV care starts from scratch with an HCV antibody test.
In addition, the patient–provider bond, developed through the HCV treatment course and solidified with the news of SVR, facilitates proper engagement with sensitive issues. Discussing an individual’s drug use habits, down to the specificity of actual paraphernalia or injection practices, requires great care to avoid stigmatization, alienation, and judgment. I have found that coming from a place of harm reduction and compassion generally helps to engender honesty and frank discussions with my patients.
Avoiding HCV Reinfection in MSM
The “reinfection prevention” conversation is somewhat more complicated in the MSM population because less is known about the true incidence of sexual HCV transmission as noted above. However, MSM are disproportionately affected by sexually transmitted infections (STIs) such as syphilis and HIV, and available data show that HIV infection and low CD4+ cell counts increase the risk of HCV acquisition. Furthermore, the recent unprecedented increase in sexually transmitted disease incidence nationwide in the United States underscores the importance of general sexual health treatment and prevention services. Data from modeling studies suggest that achieving HCV elimination targets among HCV/HIV-coinfected MSM may be impossible without a combination of scaling up HCV treatment plus increased HCV testing and/or harm reduction interventions.
Because of recent buzz regarding HIV treatment as prevention, the concept of undetectable HIV-1 RNA equaling untransmissible virus, and the adoption of pre-exposure prophylaxis to prevent HIV infection, clinicians in HIV clinics tend to capture thorough sexual histories. Regarding the “reinfection prevention” discussion in the context of sexual HCV transmission, this level of comfort with discussing sexual practices remains key. Because certain sexual practices likely to cause mucosal trauma have been associated with an increased risk of sexual HCV transmission, it is incumbent on clinicians to discuss with recently cured patients how such sexual behaviors affect their reinfection risk. Although specific guidelines are lacking, and literature gaps persist, at the very least we should be promoting condom and lubricant use, awareness of HCV serostatus, and frequent HCV and STI testing among cured patients and their sexual partners. Recent results from the HCVree trial reported by Braun and colleagues at the 2017 European AIDS Conference may indicate a promising way forward for harm reduction approaches in this setting. The HCVree trial is evaluating HCV treatment with elbasvir/grazoprevir (with or without ribavirin) in combination with a behavioral intervention to reduce HCV reinfection risk among HCV/HIV-coinfected MSM. The study demonstrated a 99% SVR12 rate (121/122) as well as a high rate of acceptance of the behavioral intervention, which included 4 sessions using a combination of short videos, interactive tools, and motivational counseling. Among 68 patients who self-reported condomless sex, 75% participated in the risk counseling intervention. Further study is under way to assess the risk reduction efficacy.
In summary, the SVR12 visit should be not only a moment of celebration at the successful eradication of HCV infection but also an important opportunity to provide counseling on the very real risks of reinfection and the known modes of prevention, as well as a chance to plot a path forward for ongoing testing if a patient remains at risk. Finally, if reinfection does occur, despite our best efforts to prevent it, we must ensure access to ongoing care with retreatment if we are to realize the vision of HCV elimination. I encourage you to join this conversation by sharing your relevant thoughts and experiences in the comments box below.