How One Country Reduced HCV in MSM With HIV to Less Than 1%

Heather Boerner

November 03, 2021

Rates of hepatitis C virus (HCV) infections fell to 0.6% among gay and bisexual men living with HIV after a systematic HCV elimination campaign, showing that micro-elimination campaigns paired with continued testing and treatment is effective in addressing the HCV epidemic, said Katharina Kusejko, PhD, head of the data center of the Swiss HIV Cohort Study at the University of Zurich, in Zurich, Switzerland.

But there are still gaps that clinicians need to address.

"For me, there are two key take-aways for clinicians: We found a lot of chronic infections," she told Medscape Medical News at the European AIDS Clinical Society (EACS) 2021 Annual Meeting. "On the other hand, we still have new infections in Switzerland, and we don't understand where these infections happen," she said.

She said that better targeting of gay and bisexual men for HCV screening and treatment before they acquire HIV could prevent dual infections with HCV and HIV. Such dual infections were seen in 5 of the 9 new HCV cases in the study. Another key is to devote energy to working with men engaged in sexualized drug use, or men for whom HCV is not their primary concern. Chronic HCV infections accounted for most of the 28 cases of HCV in the study.

Like US officials, the World Health Organization has set a goal of substantially eliminating HCV by 2030. It calls for a 90% reduction in HCV transmissions and a 65% reduction in HCV mortality by the end of the decade. The study Kusejko presented was a follow-up to a micro-elimination program aimed at identifying and treating HCV infections in gay and bisexual men living with HIV. Data show that among these men, rates of HCV infection increased 18-fold between 2002 and 2011. That program, called the Swiss HCVree Trial, began in 2015 with screening. Direct-acting antivirals were offered to people who tested positive. By the time the HCVree trial ended in 2017, the HCV rate had dropped from 177 cases among 3715 men to just 36 cases among 3107 men. The rate of chronic HCV infections also dropped, from 4.8% before 2016 to 0.8% after 2017.

In Kusejko's study, researchers analyzed banked blood samples from 4641 men who were participants in the Swiss HIV Cohort Study. A portion of those men participated in the HCVree trial, but data also included men who joined the Swiss HIV Cohort Study after the HCVree trial began, as well as men who'd refused HCV treatment the first time.

On rescreening, there were just 28 cases of replicating HCV — that is, HCV that could be transmitted. Nine were new transmissions, two were reinfections, and 17 were chronic HCV cases. That's an incidence rate of 0.6% — a more than threefold drop in new cases since the HCVree trial began, Kusejko said.

"That's a good message, right?" she said. "The hepatitis C epidemic seems to be under control in this study population."

But that's not the whole story, she said. Five of the nine new diagnoses were made at about the time the men were diagnosed with HIV, suggesting that targeting HCV screening and treatment in primary care and prevention efforts could be successful, she told Medscape Medical News.

"We should really extend our screening programs," she said. "The major message is thinking about the inclusion of HIV-negative [gay and bisexual men] with high-risk sexual behavior and working closer with PrEP [preexposure prophylaxis] studies."

Integrating HCV testing into HIV testing could lead to earlier treatment of HCV and potentially prevent transmission via sex or the sharing of injection drug equipment. Additionally, adding HCV testing to screening protocols in primary care could identify people who might benefit from HIV prevention pills, she said.

It is also key to address the needs of the men who continue to be chronically infected with HCV despite being offered and sometimes receiving treatment. Of the 28 cases of HCV, 17 were among people with chronic HVC infections; one patient first tested positive in 1995.

"Difficult to treat also means difficult to convince to take treatment — or actually to convince the physician to offer them treatment," she said. "Sometimes they might have more problematic things to solve first."

That could be a source of new transmissions, she said. Addressing the needs of people hesitant to receive HCV treatment or who have competing priorities will require more research. For instance, she said that the growth of so-called chemsex — that is, drug use, often of methamphetamine or other stimulants, to heighten the sexual experience — could play a role in HCV acquisition.

"Even if the person doesn't appear to be a drug addict as one would picture, they may be part of sex parties where methamphetamine is used with needle sharing," she said. "That should put an alert to the clinician to make an additional hepatitis C test."

For David Malebranche, MD, who practices internal medicine in Atlanta, Georgia, the findings show the potential of micro-elimination. But given his experience working with men living with HIV that was diagnosed with HCV — men who were denied treatment because of lack of insurance or who tested positive but were never informed of their status — he said the United States has a long way to go to get to where Switzerland is now.

According to the US Preventive Services Task Force, which recommended HCV screening in 2020, HCV testing rates in the United States vary from just 0.8% in people born between 1945 and 1965 to 17.3% among patients at community health clinics. More universal systems, such as the US Department of Veterans Affairs, have higher testing rates.

Malebranche recalled a man who showed up to his exam visit with such acute HCV that the nurse sent him to the emergency department. The emergency department stabilized the patient's condition but then sent him home with instructions to follow up with Malebranche's office. The man didn't have health insurance. When the man did return to Malebranche's office, they sent him to the local public hospital. It took a full month for Malebranche and the team to arrange all the lab work required in order for the man to qualify for free treatment under the manufacturer's drug treatment program.

"This may be a good idea for a research study that people can do — you can replicate whatever they did here and then bring it to the United States," said Malebranche, who recalled having patients who tested positive for HCV while seeing another practitioner and had never been informed or treated. "Right now, we're not even doing antibody screening, which is a lot cheaper [than the RNA screening they did in this study]."

Kusejko reported no relevant financial relationships. Malebranche has consulted and advised for ViiV Healthcare.

European AIDS Clinical Society (EACS) 2021 Annual Meeting: Presented October 29, 2021.

Heather Boerner is a science journalist based in Pittsburgh, Pennsylvania. Her book, Positively Negative: Love, Pregnancy, and Science's Surprising Victory Over HIV, was published in 2014.

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