Another study, has demonstrated the realities of sexual transmission of hepatitis C among HIV+ gay men. This time it is the CEASE study based on 175 HIV/hep C co-infected men in Australia. The study is ongoing, but preliminary results were presented recently at the annual Conference on Retroviruses and Opportunistic Infections in Boston.
Researchers found that hep C transmission occurred most often between casual sex partners. Much of the transmission was through sharing injecting equipment, although 33% was sexual transmission. The high risk sexual activities implicated are fisting, sex toy sharing and group sex.
74% of these guys reported condomless anal sex. Those who contracted hep C through sex were 13.6 times more likely to be acutely infected than those infected through other means. Those with casual male partners were four times more likely to have acute infection. Given the history of HIV you might ask “How could this be happening?” I think the reason this is happening is that we are still not talking about sexual transmission of hep C. And we are still not providing clear information on avoiding sexually transmitted hep C to people at risk.
For years people have been advised that hep C is not sexually transmitted. The results of a 10-year prospective follow-up study by Vandelli et al. show that there is a lack of evidence of sexual transmission of hepatitis C among monogamous couples. They evaluated 895 monogamous heterosexual couples who did not use condoms and concluded that condoms were not required for individuals in monogamous partnerships with people with hep C. Numerous other studies have validated this finding.
Condoms have been tremendously effective in preventing the spread of HIV among gay men and between heterosexual couples. But they are only part of the story. Over time we also have developed complex conversations and strategies for negotiated safety to protect against HIV transmission. Sero-sorting and strategic positioning are strategies that require frank and open conversations including discussion of HIV status. But where is the conversation about sexual transmission of hepatitis C? Where are the strategies for people to engage in the sex they want but not end up with hepatitis C?
With the recent recognition of Treatment as Prevention and PrEP as effective prevention strategies, it could be argued that the days of condoms as a front line strategy for HIV prevention are numbered. It is also likely that the wearing of condoms is not the most effective strategy to protect against sexual transmission of hep C among gay men, particularly when it is known that the concentration of hep C is semen is typically 10,000 times lower than in blood Bradshaw, D et al.
The CEASE study shows that knowledge regarding behaviours associated with hep C transmission was variable; 83% and 73% correctly identified needle sharing and sharing other drug paraphernalia as high risk, whereas fisting, sex toys and group sex were identified as risk factors by only 51%, 46% and 52%. Only 69% were aware of the potential for hep C reinfection. 74% ‘always’ or ‘sometimes’ disclosed their HIV status, while only 41% disclosed their hep C status.
Sexual behaviour is clearly associated with recently acquired hep C in HIV/hep C co-infected gay men. We need much more discussion and openness to counter the limited knowledge around sexual transmission risks and the low level of hep C status disclosure. Surely we can develop our own risk reduction strategies and language to discuss this if the information is provided for us to do so.
The views expressed above are mine alone and not necessarily those of my employer