Scientific and Medical Consultant
Former Adjunct Professor of Medicine
Division of Infectious Diseases
Johns Hopkins University School of Medicine
W. David Hardy, MD, has disclosed that he has received consulting fees from Gilead Sciences, Merck, and ViiV and funds for research support (paid to his former institution) from Amgen, Gilead Sciences, Janssen, Merck, and ViiV.
Historically, HCV was commonly thought to be transmitted almost exclusively by percutaneous exposure in people who inject drugs. Newer data have emerged illuminating a role for sexual transmission of HCV among men who have sex with men (MSM) living with HIV infection. When these cases were initially reported, it was hypothesized that sexual transmission of HCV was occurring in this setting because of HIV-induced immunodeficiency. However, more recent data reported during the current pre-exposure prophylaxis (PrEP) for HIV era have clearly established that sexual transmission of HCV is increasing among MSM without HIV infection, likely due to reduced condom use and other high-risk activities among persons receiving PrEP.
For practitioners providing care for MSM, how should these risks inform your practice? I would like to underscore 2 essential messages to answer that question: (1) Routine HCV screening of sexually active MSM is critical, and (2) early initiation of HCV treatment is key to prevent onward transmissions.
HCV Screening in MSM Receiving PrEP
Prescribers of PrEP need to know that despite PrEP‘s high efficacy in preventing HIV infection, the risk for acquiring other sexually transmitted infections (STIs) remains high. In fact, it is increasing. Moreover, it is critical that we acknowledge HCV as an STI among MSM and, therefore, include HCV testing as standard practice. MSM should be screened for HCV as part of the initial STI testing prior to PrEP and periodically while receiving PrEP, with the frequency of testing based on risk factors. Current CDC guidelines are unclear on the recommended frequency of “periodic” testing, and others do not yet explicitly classify HCV as an STI. The AASLD/IDSA recommendations to test for HCV at least annually and more frequently based on risk factors are the ones that I recommend we follow. My advice is to screen at least annually for persons with low risk factors, such as consistent condom use with anal sex and no sexualized or injection drug use. For individuals at higher risk (eg, condomless receptive anal intercourse, sharing of sex toys, unprotected fisting [without gloves], ulcerative STI, sexualized and/or injection drug use), I screen for HCV (and other STIs) every 3 months, which syncs with the CDC-recommended schedule of routine HIV testing for PrEP maintenance.
HCV Screening in MSM With HIV
Providers caring for MSM with HIV should also proactively screen for HCV infection. According to current guidance, these individuals should be tested for HCV at their initial provider visit and then at least annually based on risk behaviors. MSM living with HIV who report engaging in condomless sex or other sexual risk factors noted above and those who inject drugs should be screened more frequently.
HCV Treatment as Prevention
The importance of rapid ART initiation after HIV diagnosis is becoming a well-established paradigm for rapidly reducing viral load, which simultaneously improves individual health and reduces the risk of HIV transmission, also known as treatment as prevention (TasP). Prompt diagnosis and immediate treatment of incident HCV infections is equally important and arguably more profound, given the ability to cure this viral infection vs merely suppress viral replication. This TasP approach is critical for slowing the spread of HCV. Indeed, I anticipate that the AASLD/IDSA guidance will soon be updated to reflect a TasP strategy for HCV in MSM. Current guidance recommends at least a 3-month waiting period to allow for potential spontaneous clearance of the infection; however, this window of time poses a significant hazard for ongoing transmission, and the rate of spontaneous clearance is not high enough to support cost-effectiveness arguments).
What is your approach to managing HCV risk among MSM in your care? Answer the polling question and enter your thoughts in the Comments section below. For more in-depth discussion on HCV elimination among MSM, watch this CME/CE-certified interactive video featuring my colleagues Daniel S. Fierer, MD, Mark S. Sulkowski, MD, and I discussing this important issue.