The rate of new hepatitis C (HCV) infections is increasing among men who have sex with men (MSM). The prevalence of hepatitis C is highest in MSM who are HIV positive. Although injection drug use may account for some of HCV’s prevalence in HIV-positive MSMs, the latest evidence points to sexual transmission of hep C.

Recent data found evidence of hepatitis C in rectal fluid samples. Despite the absence of visible blood, HCV was detected in 20 out of 43 specimens of rectal fluid obtained from HCV/HIV-positive MSM. Those whose blood tests showed higher viral loads were both more likely to shed HCV into the rectum and to shed it at higher levels. In short, sexual transmission via body fluid or other abrasions may lead to rectal transmission of hep C in HIV-infected MSM.

Looking at HCV prevalence overall, the incidence among MSM is highest in those who have any of the following risk factors:

  • HIV positive
  • Drug use
  • Engaging in unprotected anal-receptive sex
  • Fisting (the practice of inserting the hand into the rectum or vagina)
  • Sex with multiple partners

Hep C Testing

The CDC recommends HCV screening for all HIV-positive persons. Hepatitis C screening has not been clearly established for HIV-negative MSM. However, HCV screening is recommended for those who have other risk factors or elevated liver enzymes.

Note that the rate of HCV-antibody formation may be longer in HCV/HIV-coinfected MSM. Among all people who are exposed to hep C, about half will form antibodies in 5 to 10 weeks following exposure. Antibody formation may take an average of 10 to 13 weeks to be detectable in HCV/HIV-coinfected MSM. There have been reports of some HIV-infected individuals for whom HCV antibody didn’t show up for more than three years. One extreme case reported an HIV-positive man who had positive HCV viral load results but no positive HCV-antibody results for seven years. Because of this, some researchers recommend HCV viral load testing rather than relying solely on antibody testing for HIV-infected MSM.

HCV Reinfection

Compared to others with hep C, HCV/HIV co-infected MSM are at greatest risk for HCV re-infection. This is true regardless of whether HCV was cleared by a strong immune response during the initial months of infection or cured with treatment. In short, having had hepatitis C once does not make you “immune” to getting hepatitis C again.

The best way to avoid re-infection is to reduce risky behaviors that can result in exposure to the hepatitis C virus.

Last Reviewed: March 5, 2019