Transmission of HCV Among Men who have sex with men (MSM ): Issues and Access Barriers

1. Transmission of HCV Among Men who have sex with men (MSM): Issues and Access Barriers Noah Metheny, Esq., MPH MSMGF, Director of Policy February 23,2014

2. Transmission of HCV in MSM • Transmission through blood-blood contact • Most transmission occurs from injection drug use • Growing evidence-base of sexual transmission of HCV among MSM living with HIV • Research highlights that MSM who engage in unprotected anal sex while experiencing skin tearing and/or genital ulcer disease (e.g. herpes lesions) are at greater risk for HCV. • Additional factors believed to increase risk of sexual transmission include unprotected anal sex, group sex, fisting, and cocaine/methamphetamine use

3. New data on MSM and HCV co-infection • Previously, sexual transmission of HCV was thought to be rare • However, new research shows that HIV co-infection with HIV may increase the risk of HCV transmission among MSM • Reports of outbreaks of sexually transmitted HCV among HIV+ MSM in Europe, US, and Australia

4. New (limited) data on MSM and HCV co-infection: USA • In New York City, Mount Sinai evaluated 74 HIV+ MSM who tested positive for HCV and reported no history of injecting drugs from 2005-1010(1) • In 2006, the Miriam Hospital Immunology Clinic in Providence, Rhode Island started testing all HIV+ patients for HCV. During the first six months, they found a 9% prevalence rate among the 150 HIV+ MSM patients it tested. (2)

5. New (limited) data on MSM and HCV co-infection: Europe • Dutch study increased change in HCV seroprevalence among HIV+ MSM from 1%-4% in 2000 to 21% in 2008 (3) • Overall European HCV prevalence is 6.6% among HIV+ MSM, with a prevalence of 7.2% in the UK (4) • Overall HCV prevalence among HIV- MSM remains low and comparable to that of the general population

6. US Guidelines • All MSM be vaccinated for HAV and HBV • All MSM screened and tested for chronic HBV on an annual basis at the very least • Testing for HCV is recommended only for MSM who engage in high-risk sex (e.g. unprotected anal sex with multiple partners) and/or MSM who are living with HIV  

7. Guidelines and recommendations • Generalized viral hepatitis programs vary greatly from country to country depending on resources available for addressing the disease • Guidelines specifically for viral hepatitis and MSM are not widely available, as few studies outside the Global North have been conducted on this issue

8. What needs to happen next… • Given that MSM are disproportionately affected by viral hepatitis and that the long-term health effects of HBV and HCV contribute to high morbidity and mortality among MSM, more efforts are needed to address hepatitis among MSM • Global advocates, donors, program managers, and policymakers can mobilize to support the following 5 priorities…

9. #1: Better access & coordination for screening/treatment • Screening and treatment for HCV should be included as part of the minimum service package for MSM • This may entail a stronger referral network across health facilities as well as a push for stronger screening and testing policies worldwide  

10. #2: Capacity building of health professionals in hepatitis • Health professionals working with MSM need to be provided training and education around viral hepatitis and co-morbidity of HIV • This is especially important given recent research highlighting that sexually transmission of HCV is not as uncommon as previously thought

11. #3: Mobilize MSM communities • MSM communities will require resources and capacity building to develop and mobilize innovative public health prevention models to educate their own communities about viral hepatitis and HIV co-infection

12. #4: Advocate for affordable HCV medications • Current costs for lifesaving medications to treat HCV are prohibitive and create extreme barriers to access, especially in low- and middle-income countries • Both MSM and non-MSM communities alike, as well as national governments and multilateral agencies such as the WHO, must push pharmaceutical companies to reduce their prices to an affordable-level

13. #5: Fill research gaps • We currently have far too little information or funding support regarding MSM and hepatitis and HIV/hepatitis co-infection • We both need to deepen and broaden the research agenda and increase our knowledge base to improve programs and policy

14. Conclusion • At a starting point to ensure that hepatitis/HIV co-infection is part of the global conversation about the wellness of gay men and other MSM • Despite disproportionate burden of disease on MSM and the deleterious health consequences of viral hepatitis, there is still relatively low awareness and understanding of the disease among both MSM communities and global health donors • In light of new funding streams to support comprehensive HIV prevention and treatment targeting gay men and other MSM, greater efforts are needed to support and integrate viral hepatitis into ongoing global HIV programming and policy efforts

15. References (1) Daniel Fierer, M.D., et al. Sexual Transmission of Hepatitis C Virus Among HIV-Infected Men Who Have Sex With Men—New York City, 2005-2010, MMWR, July 22, 2011, vol. 60, no. 28. (2) L.E. Taylor, M.D., et al. Acute Hepatitis C Virus in an HIV Clinic: A Screening Strategy, Risk Factors, and Perception of Risk, AIDS Patient Care and STDs, Volume 25, 2011. (3) Urbanis, Anouk, et al. Hepatitis C virus infections among HIV-infected men who have sex with men: an expanding epidemic. AIDS 2009 Vol 23 No 12, F1-7. (4) Daniel Bradshaw, et al. Sexually transmitted hepatitis C infection: the new epidemic in MSM? Current Opinion in Infectious Diseases: Feb 2013, Vol. 26, Issue 1, pp. 66-72.