Photo Credit: Dr_Microbe
Identifying best practices that will prevent HCV transmission in MSM with HIV is needed to reduce HCV reinfection rates in this patient population.
MSM with HIV are at high risk for HCV reinfection, according to findings from a study conducted over nearly 20 years in New York City that was published in Clinical Infectious Diseases.
Of the 304 MSM with HIV who cleared HCV between 2000 and 2018, the median age at clearance was 45. Overall, 18% of participants identified as Black and 21% as Hispanic.
The HCV genotype was 1a in 237 (80%) of patients. Over 898 person-years, 42 reinfections occurred, for a reinfection rate of 4.7 (95% CI, 3.4-6.3) per 100 person-years.
From risk factor behaviors documented in 1,245 post-clearance visits in 226 (74%) patients, receipt of semen into the rectum during condomless receptive anal intercourse (HR, 9.7; 95% CI, 3.3-28.3; P<0.001), but not methamphetamine use, was associated with HCV reinfection. According to the study results, reinfections continued to occur for 11 or more years after clearance.
Three experts who were not involved in the study discussed its importance with Physician’s Weekly (PW).
PW: Why was this study important to conduct?
Jessie Torgersen, MD, MHS, MSCE: Few studies have comprehensively evaluated the risk for HCV reinfection. This study provides a better understanding of rates of HCV reinfection associated with sexual transmission, notably the magnitude of reinfection risk associated with receipt of semen in the rectum.
Christine Horvat Davey, PhD, BSPS, RN: This study is valuable as it addresses the epidemiology of HCV reinfection among MSM in New York City, with results potentially being generalizable to the greater population of MSM with HIV. This study provides contrary evidence regarding HCV transmission and emphasizes the inadequacy of current prevention strategies for efficiently managing HCV transmission in this population.
What are the most important takeaways?
Dr. Horvat Davey: The results are surprising in that they challenge the previous view that sexualized methamphetamine use is a direct risk factor for HCV reinfection. Instead, this study identified sexualized methamphetamine use as an indicator for high-risk sexual groups rather than as a direct mediator of reinfection.
Dr. Torgersen: While the high rate of HCV reinfection was similar to that reported in the MOSAIC cohort from the Netherlands, the finding that HCV reinfection rates were not decreasing despite FDA approval of direct-acting antivirals was startling. Taken together, these findings demonstrate that the availability of highly effective treatment alone will be insufficient to eliminate HCV due in part to continued barriers to care.
Are any strengths or limitations worth noting?
Dr. Penaloza-MacMaster: Behavioral reporting biases are possible. Self-reported data on risk behaviors might be inaccurate due to stigma or memory lapses.
Dr. Torgersen: A noteworthy strength is the large number of diverse patients in this study with the necessary longitudinal care to identify HCV reinfections.
What novel interventions show promise?
Dr. Horvat Davey: Clinicians should provide specific HCV transmission and prevention education to patients who belong to high-risk sexual groups. As we currently have no effective pre-exposure prophylaxis (PrEP) for HCV, more comprehensive interventions are needed, including behavioral counseling.
Dr. Torgersen: The authors point out that MSM with HIV and untreated HCV have been less engaged in care. Mobile clinics and HCV test-and-treat models of care are novel strategies that show promise by increasing access to screening and minimizing delays in initiating HCV treatment.
Armed with these findings, providers can more effectively counsel their patients on the risk for HCV reinfection and provide strategies to reduce their risk. Increasing the awareness of the potential for sexual transmission of HCV in MSM with HIV will also allow for routine serial reinfection screening and rapid treatment initiation when reinfection is identified.
Pablo Penaloza-MacMaster, PhD: Clinicians should prioritize behavioral interventions for individuals engaging in high-risk activities such as condomless receptive anal intercourse. Additionally, removing insurance restrictions on treatment could reduce transmission by enabling earlier intervention.
What further research might you recommend?
Dr. Penaloza-MacMaster: It is important to determine if these “reinfections” are actually viral rebound events. A similar issue, cryptic viral infection, is observed in HIV cure studies, where viral loads may stay undetectable for months after bone marrow reconstitution, only to rebound later, indicating possible incomplete viral eradication despite the initial undetectable status.
Dr. Torgersen: Which best practices will effectively prevent HCV transmission in MSM with HIV remains unclear, and optimal preventative strategies need to be defined. Further research aimed at understanding the dynamics of sexual networks may lead to new interventions to improve HCV testing and treatment in people who may not access traditional care delivery models.
Is there anything else you’d like to mention?
Dr. Penaloza-MacMaster: Insurance companies impose multiple restrictions on prescribing direct-acting antiviral treatments. These limitations cause significant delays in treatment initiation and contribute to increased transmissions. Eliminating the barriers patients face with insurance companies is recommended to facilitate quicker access to therapy.
Dr. Torgersen: Continued screening for HCV reinfection is important for people with ongoing risk factors for HCV exposure. Routine sexual health discussions are key to comprehensive care delivery and timely retreatment.
Dr. Horvat Davey: Clinicians must be informed that HCV reinfection risk remains high in MSM with HIV. Regular screening, patient education, and prevention should be considered critical for the care of this patient population.
