Hepatitis C virus infections among HIV-infected men who have sex with men: an expanding epidemic

Characterization of People Living with HIV Who Inject Drugs in Mexico City: Importance for Transmission and Detection

People who inject drugs (PWID) face a heightened risk of acquiring/transmitting HIV, enhanced by stigma and limited health care access. In Mexico, studies on PWID have focused on the north of the country. This study aimed to delineate characteristics of PWID living with HIV in Mexico City, identify profiles based on the substance injected, and evaluate variables associated with forming transmission clusters. A cross-sectional study was conducted with data from 2019 to 2023. Participants completed a questionnaire on sociodemographic, clinical, and behavioral variables. Bivariate and multi-variate logistic regression analyses were made. Among PWID, 96.3% were male (n = 437), of which 90.1% were men who have sex with men, 1.5% were cisgender females (n = 7), and 2.2% were transgender females (n = 10). PWID were more likely to use drugs during sex (adjusted odds ratio [aOR] = 3.3, 95% confidence interval [CI]: 1.7-6.4, p < 0.001), have more sexually transmitted diseases (aOR = 1.7, 95% CI: 1.1-2.9, p = 0.035), and have less condom use (aOR = 0.5, 95% CI: 0.3-0.8, p = 0.002). The most frequently injected substance was crystal meth, and those who injected it were more likely to have syphilis (aOR = 2.9, 95% CI: 1.2-7.1, p = 0.021), use Grindr (aOR = 3.6, 95% CI: 1.5-8.9, p < 0.001), and engage in high-risk practices (aOR = 6.9, 95% CI: 2.1-22.7, p < 0.001) in the last 3 months. Those under 25 years (p = 0.002), recently infected (p < 0.001), and who practiced insertive anal sex (p < 0.001) were more likely to be part of a cluster. These findings, and the increasing use of crystal meth, underscore the critical need to implement targeted risk-reduction strategies for PWID living with HIV and to design interventions responsive to specific profiles associated with different substances, taking into account not only their risk practices but also protective behaviors such as HIV testing.

Association between non-injection drug use and hepatitis C infection among HIV-negative men who have sex with men

BACKGROUND

Prior research predominantly examined the association between HIV-positive men who have sex with men (MSM) or those using injection drugs and hepatitis C virus (HCV) infection. However, limited attention has been given to understanding the association among HIV-negative MSM who do not inject drugs. This gap leaves apportion of the population unexamined, potentially overlooking important factor that may contribute to the transmission and prevalence of HCV. This study aims to investigate the relationship between non-injection drug use and HCV infection in this population.

METHODS

In this cross-sectional study, we analyzed data on 118 MSM who reported use of non-injection drugs. The participants were recruited from two inner-city communities in Houston, TX, between 2004 and 2007 and were negative for both HIV and hepatitis B virus infection. Latent class analysis (LCA) was used to identify drug use latent classes. Multinomial logistic regression analysis was used to evaluate the association between drug use latent class and HCV infection.

RESULTS

Four distinct latent classes of drug use were identified: class 1, persons ≥ 42 years of age who used only crack cocaine; class 2, persons approximately 42 years of age who used > 2 drugs; class 3, persons < 42 years of age who used > 5 drugs; and class 4, persons ≥ 42 years of age who used > 6 drugs. Class 4 was significantly associated with HCV infection. The odds of HCV infection in members of class 4 was 17 times higher than in class 2 members (adjusted odds ratio [aOR] = 16.9, 95% confidence interval [CI]: 1.4-205.4) and almost 22 times higher than in class 3 members (aOR = 21.8, 95% CI: 1.5-322.8).

CONCLUSIONS

Among MSM with non-injection drug use, the subgroup of individuals who were ≥ 42 years of age and used multiple drugs (including heroin, speedball, methamphetamine, crack cocaine, and marijuana) had a high probability of HCV infection. Public health and education programs, as well as drug treatment and rehabilitation programs, should be developed for this high-risk subgroup of individuals to prevent HCV acquisition and transmission.

Phylogenetic Analysis of Hepatitis C Virus Infections in a Large Belgian Cohort Using Next-Generation Sequencing of Full-Length Genomes

The hepatitis C virus (HCV) epidemic in Western countries is primarily perpetuated by the sub-populations of men who have sex with men (MSM) and people who inject drugs (PWID). Understanding the dynamics of transmission in these communities is crucial for removing the remaining hurdles towards HCV elimination. We sequenced 269 annotated HCV plasma samples using probe enrichment and next-generation sequencing, obtaining 224 open reading frames of HCV (OR497849-OR498072). Maximum likelihood phylogenies were generated on the four most prevalent subtypes in this study (HCV1a, 1b, 3a, 4d) with a subsequent transmission cluster analysis. The highest rate of clustering was observed for HCV4d samples (13/17 (76.47%)). The second highest rate of clustering was observed in HCV1a samples (42/78 (53.85%)) with significant association with HIV-positive MSM. HCV1b and HCV3a had very low rates of clustering (2/83 (2.41%) and (0/29)). The spread of the prevalent subtype HCV1b appears to have been largely curtailed, and we demonstrate the onwards transmission of HCV1a and HCV4d in the HIV-positive MSM population across municipal borders. More systematic data collection and sequencing is needed to allow a better understanding of the HCV transmission among the community of PWID and overcome the remaining barriers for HCV elimination in Belgium.

Patterns and correlates of hepatitis C virus phylogenetic clustering among people living with HIV in Australia in the direct-acting antiviral era: A molecular epidemiology study among participants in the CEASE cohort

Background and Aims

In moving towards the elimination of hepatitis C virus (HCV) infection among people living with HIV, understanding HCV transmission patterns may provide insights to guide and evaluate interventions. In this study, we evaluated patterns of, and factors associated with HCV phylogenetic clustering among people living with HIV/HCV co-infection in Australia in the direct-acting antiviral era.

Methods

HCV RNA was extracted from dried blood spot (DBS) samples collected between 2014 and 2018 in the CEASE cohort study. The HCV Core-E2 region was amplified by a polymerase chain reaction and Sanger sequenced. Maximum likelihood phylogenetic trees (1000 bootstrap replicates) were used to identify patterns of clustering (3% genetic distance threshold). Mixed-effects logistic regression was used to determine correlates of phylogenetic clustering. Factors assessed were sexual risk behavior, education, injecting drug use, housing, employment, HIV viral load, age, sex, and sexuality.

Results

Phylogenetic trees were reconstructed for HCV subtype 1a (n = 139) and 3a (n = 63) sequences, with 29% (58/202) in a pair or cluster. Overall (n = 202), phylogenetic clustering was positively associated with younger age (under 40; adjusted odds ratio [aOR] 2.52, 95% confidence interval [CI] 1.20-5.29), and among gay and bisexual men (n = 168), was positively associated with younger age (aOR 2.61, 95% CI 1.10-6.19), higher education (aOR 2.58, 95% CI 1.09-6.13), and reporting high-risk sexual behavior (aOR 3.94, 95% CI 1.31-11.84). During follow-up, five reinfections were observed, but none were in phylogenetic clusters.

Conclusion

This study found a high proportion of phylogenetic relatedness, predominantly among younger people and gay and bisexual men reporting high-risk sexual behavior. Despite this, few reinfections were observed, and reinfections demonstrated little relationship with known clusters. These findings highlight the importance of rapid HCV treatment initiation, together with monitoring of the phylogeny.

Prevalence and incidence of hepatitis C infection amongst men who have sex with men in a population-based pre-exposure prophylaxis program in British Columbia, Canada

BACKGROUND

Men who have sex with men (MSM) are at risk for sexually-transmitted hepatitis C (HCV). Evidence for HCV infection in the context of pre-exposure prophylaxis (PrEP) use in North America is limited. We sought to characterize baseline HCV prevalence and incidence in MSM receiving PrEP in British Columbia (BC), Canada.

METHODS

We followed individuals in the BC PrEP program from January 2018 to August 2019. We evaluated baseline prevalence and incident seroconversions (newly positive HCV antibody). A multivariable logistic regression model was performed in MSM for factors associated with HCV prevalence at enrollment, including reported prior sexually transmitted infection (STI), HIV Incidence Risk Index for MSM score, PrEP use because of a partner living with HIV, and location of residence.

RESULTS

The median age of the cohort was 33 years, 98.3% male, with 3058 person years (PY) of follow-up. Baseline HCV prevalence was 0.82% (31/3907 MSM enrollees) and HCV incidence (n = 3) was 0.15 per 100 PY (95% confidence interval [CI] 0.03-0.45). In multivariable analysis, initiating PrEP because of a partner living with HIV (adjusted odds ratio [aOR] 5.02; 95% CI 1.87-13.47) and prior STI (aOR 2.34; 95% CI 1.04-5.24) were associated with positive HCV status.

CONCLUSIONS

Baseline HCV prevalence and incidence was low amongst MSM in a population-based PrEP program in BC, Canada. HCV was associated with bridging from populations living with HIV and evidence of a reported prior STI as a PrEP indicator condition amongst MSM. PrEP initiation may be an opportunity for linkage to HCV screening and treatment.

Decreasing prevalence and stagnating incidence of Hepatitis C-co-infection among a cohort of HIV-1-positive patients, with a majority of men who have sex with men, in Germany, 1996-2019

Co-infection with Hepatitis C virus (HCV) among HIV-positive patients leads to accelerated progression of liver disease and AIDS. Due to increased HCV prevalence and incidence, co-infection requires monitoring trends among HIV-positive individuals. This will help target prevention strategies and support to reach the global goals of eliminating viral hepatitis as a public health threat. In this analysis HCV prevalence and incidence were determined for the years 1996-2019 from yearly blood samples and questionnaire details among HIV-1-positive patients, with a majority of men who have sex with men, belonging to a nationwide, multicentre observational, prospective cohort study. The results show that HCV prevalence for acute/chronic and resolved infection increased until 2014 to 12%. Since then, prevalence of acute/chronic HCV infection rapidly decreased and prevalence of resolved infections showed a steady increase. HCV incidence was highest in 2010 and lowest in 2017; however, no significant change in HCV incidence could be seen over the years. Therefore, the introduction of directly-acting antiviral agents for HCV treatment notably decreased prevalence and potentially incidence of acute/chronic HCV infection. Nevertheless, prevalence and incidence of HCV among these HIV-1-positive study participants remain high compared with the general population and justify the need for continuous HCV prevention and treatment efforts among HIV-positive individuals.

Hepatitis C prevalence among men who have sex with men attending a gay bathhouse

Background and Aim

Related research has found that men who visit public sex environments such as a gay bathhouse engage in unprotected anal intercourse and tend to have multiple sexual partners during their visit. We aimed to assess the risk of hepatitis C virus (HCV) transmission among men attending a gay bathhouse.

Methods

A prospective study of the prevalence of HCV among men attending a gay bathhouse was conducted in Bangkok, Thailand, from October 2019 to March 2020. HCV risks and risk perceptions were evaluated using a self-administered questionnaire. HCV testing with result notification was provided on site.

Results

Of the 40 participants (median age 30 years), one subject (2.5%) was positive for HCV antibody. Bathhouse patrons reported engaging in high-risk sexual behavior, including sexually transmitted infection history and Chemsex experience. The subject tested positive for HCV antibody reported a frequency of attending gay bathhouse of around 2-4 times monthly and had multiple partners while attending a gay bathhouse. Only 15% of subjects realized that hepatitis C can be transmitted through sexual intercourse.

Conclusion

Our findings support HCV transmission-reducing guidelines recommending providing selective HCV testing among men who have sex with men (MSM). Bathhouse patrons reported low literacy levels on HCV transmission. Nevertheless, HCV screening should cover a population exhibiting high-risk sexual behaviors such as attending a gay bathhouse.

The prevalence of hepatitis C and hepatitis B in lesbian, gay, bisexual and transgender populations: a systematic review and meta-analysis

OBJECTIVES

This study aimed to systematically review the literature on the prevalence of hepatitis C virus (HCV) and hepatitis B virus (HBV) infections in transgender and LGBT people and determine their pooled estimates worldwide.

METHODS

Databases (PubMed, Scopus, Web of Science, Embase, Ovid, Cochrane, PsycInfo) were searched from April 2000 to July 2021. The analyses were executed using the random-effects model in Stata 16.

RESULTS

Ten studies, including eight studies on four transgender people and two studies on 2150 LGBTs, were included. The pooled prevalence of HCV and HBV in all transgender populations globally were 9% (95% CI 3-15%) and 11% (95% CI 2-20%), respectively. The corresponding prevalence in male-to-female transgender people were estimated as 5% (95% CI 1-9%) and 6% (95% CI 3-10%), respectively. These estimates in American transgenders were 10% (95% CI 5-25%) and 16% (95% CI 8-23%), respectively.

CONCLUSION

This study was identified the overall prevalence of HBV and HCV infections in transgender people, which were higher than those in the general population.

Prevalence and the associated factors of hepatitis B and hepatitis C viral infections among HIV-positive individuals in same-day antiretroviral therapy initiation program in Bangkok, Thailand

Background

Viral hepatitis is highly prevalent among people with HIV (PWH) and can lead to chronic liver complications. Thailand started universal hepatitis B vaccination at birth in 1992 and achieved over 95% coverage in 1999. We explored the prevalence of hepatitis B and C viral infections and the associated factors among PWH from same-day antiretroviral therapy (SDART) service at the Thai Red Cross Anonymous Clinic, Bangkok, Thailand.

Methods

We collected baseline characteristics from PWH enrolled in the SDART service between July 2017 and November 2019. Multivariable logistic regression was performed to determine factors associated with positive hepatitis B surface antigen (HBsAg) and hepatitis C antibody (anti-HCV).

Results

A total of 4011 newly diagnosed PWH who had HBsAg or anti-HCV results at baseline: 2941 men who have sex with men (MSM; 73.3%), 851 heterosexuals (21.2%), 215 transgender women (TGW; 5.4%), and 4 transgender men (0.1%). Median age was 27 years. Overall seroprevalence of HBsAg and anti-HCV were 6.0 and 4.1%, respectively. Subgroup prevalence were 6.2 and 4.7% among MSM, 4.6 and 2.4% among heterosexuals, and 9.3 and 3.7% among TGW, respectively. Factors associated with HBsAg positivity were being MSM, TGW, born before 1992, CD4 count < 200 cells/mm³, and alanine aminotransferase ≥ 62.5 U/L. Factors associated with anti-HCV positivity were being MSM, age > 30 years, alanine aminotransferase ≥ 62.5 U/L, creatinine clearance < 60 ml/min, and syphilis infection.

Conclusions

Around 5–10% of newly diagnosed PWH in Bangkok had hepatitis B viral infection after 25 years of universal vaccination. Anti-HCV positivity was found in 4–5% of PWH who were MSM and TGW. As World Health Organization and Thailand national guidelines already support routine screening of hepatitis B and C viral infections in PWH and populations at increased risk of HIV including MSM and TGW, healthcare providers should reinforce this strategy and provide linkage to appropriate prevention and treatment interventions. Catch-up hepatitis B vaccination should be made available under national health coverage.

Global Burden and Changing Trend of Hepatitis C Virus Infection in HIV-Positive and HIV-Negative MSM: A Systematic Review and Meta-Analysis

Background: The disease burden of hepatitis C virus (HCV) infection in HIV-positive and HIV-negative men who have sex with men (MSM) is changing. We aim to provide an updated comprehensive estimate of HCV prevalence and incidence among the HIV-positive and HIV-negative MSM population at the country, regional, and global levels and their changing trends over time. Methods: PubMed, Embase, PsycINFO, CINAHL, and conference databases were searched and eligible records on the prevalence and incidence of HCV antibodies were selected and pooled via a random-effects model. Meta-regression was performed to demonstrate the association between the pooled rates and study year. Results: A total of 230 articles reporting 245 records from 51 countries with 445,883 participants and 704,249 follow-up person-years were included. The pooled prevalence of HCV in MSM was 5.9% (95% CI: 5.1-6.8), with substantial differences between countries and regions. Low- and lower-middle-income countries (12.3 and 7.0%) manifested a larger disease burden than high- and upper-middle-income countries (5.8 and 3.8%). HCV prevalence in HIV-positive MSM was substantially higher than in HIV-negative MSM (8.1 vs. 2.8%, p < 0.001). The pooled incidence of HCV was 8.6 (95% CI: 7.2-10.0) per 1,000 person-years, with an increasing trend over time, according to meta-regression (p < 0.05). Conclusion: Global HCV prevalence in MSM varies by region and HIV status. Behavior counseling and regular HCV monitoring are needed in HIV-positive subgroups and high-risk regions. Given the upward trend of HCV incidence and sexual risk behaviors, there is also a continued need to reinforce risk-reduction intervention. Systematic Review Registration: PROSPERO, identifier CRD42020211028; https://www.crd.york.ac.uk/prospero/.

Hepatitis C virus (HCV) incidence among men who have sex with men (MSM) living with HIV: results from the French Hospital Database on HIV (ANRS CO4-FHDH) cohort study, 2014 to 2017

BackgroundDespite the availability of highly effective direct-acting antivirals (DAAs) and the expected treatment as prevention (TasP) effect, transmission of hepatitis C virus (HCV) persists in men who have sex with men (MSM) who engage in high-risk sexual behaviours.AimWe aimed to estimate the incidence of primary HCV infection among MSM living with HIV in France when DAA was readily available.MethodsWe used data from a large French hospital cohort of persons living with HIV (ANRS CO4-FHDH) prospectively collected between 2014 and 2017. HCV incidence rates were calculated using person-time methods for HCV-negative MSM at inclusion who had serological follow-up from 1 January 2014 to 31 December 2017. Sensitivity analyses were performed by varying the main assumptions to assess their impact on the results.ResultsOf 14,273 MSM living with HIV who were initially HCV-seronegative, 330 acquired HCV during follow-up over 45,866 person-years (py), resulting in an overall estimated incidence rate of 0.72/100 py (95% CI: 0.65-0.80). HCV incidence significantly decreased from 0.98/100 py (95% CI: 0.81-1.19) in 2014 to 0.45/100 py (95% CI: 0.35-0.59) in 2017 (54% decrease; 95% CI: 36-67). This trend was confirmed by most of the sensitivity analyses.ConclusionThe primary incidence of HCV was halved for MSM living with HIV between 2014 and 2017. This decrease may be related to unrestricted DAA availability in France for individuals living with HIV. Further interventions, including risk reduction, are needed to reach HCV micro-elimination in MSM living with HIV.

Factors associated with testing for HIV and hepatitis C among behaviorally vulnerable men in Germany: a cross-sectional analysis upon enrollment into an observational cohort

BACKGROUND

HIV and hepatitis C virus (HCV) have shared routes of transmission among men who have sex with men (MSM). Routine testing facilitates early diagnosis and treatment, thereby preventing morbidity and onward transmission. We evaluated factors associated with HIV and HCV testing in a behaviorally vulnerable cohort of predominantly MSM.

METHODS

From June 2018 through June 2019, the BRAHMS study enrolled adults at ten German outpatient clinics that serve gender and sexual minority populations. Participants completed behavioral questionnaires that captured prior experience with HIV and HCV testing. Multivariable robust Poisson regression was used to evaluate factors potentially associated with testing in the previous 6 months.

RESULTS

Among 1017 participants with median age 33 (interquartile range 28-39) years, 1001 (98.4%) reported any lifetime history of HIV testing and 787 (77.4%) reported any HCV testing, including 16 (1.6%) known to be living with HCV. Testing within the last 6 months was reported by 921 (90.6%) and 513 (50.4%) for HIV and HCV, respectively. Recent HIV testing was more common among participants with higher education level and recent HCV testing. Recent HCV testing was more common among participants with non-cisgender identity, lifetime history of illicit drug use, hepatitis B immunity or infection, and recent HIV testing.

CONCLUSION

Prior testing for HIV was common in this cohort, but interventions are needed to improve HCV risk stratification and access to testing. HIV testing infrastructure can be successfully leveraged to support HCV testing, but differentiated preventive care delivery is needed for some vulnerable populations.

Sexually Transmitted Infections Treatment Guidelines, 2021

These guidelines for the treatment of persons who have or are at risk for sexually transmitted infections (STIs) were updated by CDC after consultation with professionals knowledgeable in the field of STIs who met in Atlanta, Georgia, June 11-14, 2019. The information in this report updates the 2015 guidelines. These guidelines discuss 1) updated recommendations for treatment of Neisseria gonorrhoeae, Chlamydia trachomatis, and Trichomonas vaginalis; 2) addition of metronidazole to the recommended treatment regimen for pelvic inflammatory disease; 3) alternative treatment options for bacterial vaginosis; 4) management of Mycoplasma genitalium; 5) human papillomavirus vaccine recommendations and counseling messages; 6) expanded risk factors for syphilis testing among pregnant women; 7) one-time testing for hepatitis C infection; 8) evaluation of men who have sex with men after sexual assault; and 9) two-step testing for serologic diagnosis of genital herpes simplex virus. Physicians and other health care providers can use these guidelines to assist in prevention and treatment of STIs.

Evaluation of the Hepatitis C Testing Strategy for Human Immunodeficiency Virus-Positive Men Who Have Sex With Men at the Sexually Transmitted Infections Outpatient Clinic of Amsterdam, the Netherlands

INTRODUCTION

As the incidence of hepatitis C virus (HCV) infections remains high among human immunodeficiency virus (HIV)-positive men who have sex with men (MSM) an HCV testing strategy was introduced at the sexually transmitted infections (STI) clinic in Amsterdam in 2017. We aimed to evaluate this HCV testing strategy.

METHODS

The HIV-positive MSM and transgender women (TGW) were eligible for HCV testing (anti-HCV and HCV ribonucleic acid) at the STI clinic if they did not visit their HIV clinician in the 3 months before the consultation and had not been tested for HCV at the STI clinic in the previous 6 months. All eligible individuals were administered the 6 questions on risk behavior of the HCV-MSM observational study of acute infection with hepatitis C (MOSAIC) risk score; a risk score of 2 or greater made a person eligible for testing.

RESULTS

From February 2017 through June 2018, 1015 HIV-positive MSM and TGW were eligible for HCV testing in 1295 consultations. Eleven active HCV infections (HCV ribonucleic acid positive) were newly diagnosed (positivity rate, 0.9%; 95% confidence interval [CI], 0.4-1.5%). Sensitivity and specificity of the HCV-MOSAIC score for newly diagnosed active HCV infections were 80.0% (95% CI, 49.0-94.3%) and 53.7% (95% CI, 50.8-56.5%), respectively. If an HCV-MOSAIC score of 2 or greater were used to determine whom to test, 46.6% of individuals currently tested for HCV would be eligible for testing.

CONCLUSIONS

Using the new HCV testing strategy, HCV testing was done in 1295 consultations with HIV-positive MSM and TGW in 17 months. We newly diagnosed 11 active HCV infections. The HCV-MOSAIC risk score could reduce the number of tests needed, but some active HCV infections will be missed.

Interventions to reduce acute hepatitis C virus in HIV-positive MSM

PURPOSE OF REVIEW

The WHO has set ambitious targets for hepatitis C virus (HCV) elimination by 2030. In this review, we explore the possibility of HCV micro-elimination in HIV-positive (+) MSM, discussing strategies for reducing acute HCV incidence and the likely interventions required to meet these targets.

RECENT FINDINGS

With wider availability of directly acting antivirals (DAAs) in recent years, reductions in acute HCV incidence have been reported in some cohorts of HIV+ MSM. Recent evidence demonstrates that treatment in early infection is well tolerated, cost effective and may reduce the risk of onward transmission. Modelling studies suggest that to reduce incidence, a combination approach including behavioural interventions and access to early treatment, targeting both HIV+ and negative high-risk groups, will be required. HCV vaccine trials have not yet demonstrated efficacy in human studies, however phase one and two studies are ongoing.

SUMMARY

Some progress towards the WHO HCV elimination targets has been reported. Achieving sustained HCV elimination is likely to require a combination approach including early access to DAAs in acute infection and reinfection, validated and reproducible behavioural interventions and an efficacious HCV vaccine.

Barriers to uptake of hepatitis C virus (HCV) health intervention among men who have sex with men in Southwest China: A qualitative study

Men who have sex with men (MSM) are at risk of contracting the hepatitis C virus (HCV). Previous studies have documented low uptake of sexually transmitted disease (STD) prevention and health services among Chinese MSM. We carried out qualitative research among MSM in Southwest China. By taking the Health Brief Model (HBM) as a framework, we aimed to determine the underlying factors related to use of HCV health intervention services among MSM. From May to July 2018, we conducted in-depth interviews in Southwest China with 20 participants. Our research revealed that a lack of knowledge about HCV prevention was the main reason why MSM failed to perceive their susceptibility to HCV and had low motivation to seek preventive services. Poor service accessibility and unpleasant experiences seeing doctors also exerted negative influences on health care-seeking behaviour in MSM. More trust and understanding needs to be built between health providers and MSM. Protection of privacy for MSM should be guaranteed in the delivery of health interventions. In addition, the interviewees showed refusal to engage with health interventions being specifically targeted at MSM, which would create a sense of being 'labelled'. Tailored health interventions may overemphasise their sexuality, segregate them from heterosexuals, and make them feel alienated. Therefore, we speculate that differential treatment may be an obstacle for MSM to become involved in health interventions.

Characteristics and Specialist Linkage to Care of Patients Diagnosed With Chronic Hepatitis C Across Different Settings in an Urban Academic Hospital: Implications for Improving Diagnosis and Linkage to Care

Introduction

Chronic hepatitis C virus (HCV) infection is a significant public health problem. Strategies to identify more HCV infections and improve linkage to care (LTC) are needed. We compared characteristics, treatment and LTC among chronic HCV patients in different health care settings.

Methods

Newly diagnosed HCV antibody positive (anti-HCV+) patients within settings of acute care, inpatient and outpatient in one health system were studied. Proportion of LTC and treatment were analyzed only for HCV RNA positive patients. Chi-square, one-way ANOVA and logistic regression were used to compare the characteristics and outcomes in the three care settings. Patients in acute care settings were excluded from multivariate analyses due to low sample size.

Results

About 43, 368, and 1159 anti-HCV+ individuals were identified in acute care, inpatient, and outpatient, respectively. Proportion of RNA positivity in acute, inpatient, and outpatient were 47.8, 60.3 and 29.2%, respectively (p < 0.01). After adjusting for age, insurance type, race, and gender, outpatients had higher odds of LTC and of treatment (OR 4.7 [2.9, 7.6] and 4.5 [2.8, 7.3]).

Conclusions

Inpatients had lower proportion of LTC and treatment compared to outpatients. Use of LTC coordinators and the provision of integrated service for specialty care may improve outcomes.

Hepatitis C virus infection in HIV-infected men in Singapore, 2006-2018: incidence and associated factors

Background The epidemiology of hepatitis C virus (HCV) infection in people living with HIV has been evolving, with increasing evidence of permucosal (sexual) transmission identified predominantly in HIV-positive men who have sex with men (MSM). The aim of this study was to estimate the incidence rate and elucidate epidemiological factors associated with HCV infection among HIV-infected men in Singapore from 2006 to 2018.

METHODS

A retrospective cohort study was conducted using a clinical database maintained by the Clinical HIV Program at the National Centre for Infectious Diseases, Singapore. Factors associated with incident HCV infections were identified using Cox proportional hazards regression analyses.

RESULTS

Among 1348 HIV-infected male patients who were HCV seronegative at baseline, 64 (4.7%) subsequently tested positive for HCV, giving an incidence of 0.88 per 100 person-years of follow-up (PYFU) (95% confidence interval (CI) 0.69-1.13). The incidence rate of HCV seroconversion increased from 0.33 (95% CI 0.12-0.71) per 100 PYFU in 2010-2012 to 1.93 (95% CI 1.36-2.67) in 2016-2018. Independent factors associated with incident HCV infection were younger age groups at HIV diagnosis versus ≥45 years, HIV acquisition via MSM or via both sexual contact and intravenous drug use versus heterosexual transmission, HIV diagnosis in later periods versus 2006-2009, and recent syphilis acquisition.

CONCLUSIONS

An increasing trend of incident HCV infection was seen in HIV-infected men, particularly for MSM. Preventive and behavioural interventions should be targeted at HIV-infected individuals engaged in high-risk sexual behaviour.

Incidence of recently acquired hepatitis C virus infection among HIV-infected patients in southern Spain

OBJECTIVES

Spain is close to HCV microelimination, so rates of recently acquired HCV infection (RAHC) should decrease. Nowadays, men who have sex with men (MSM) carry the highest risk of HCV acquisition. Our aim was to estimate the incidence of and the factors associated with RAHC, together with reinfection rates, among patients sexually infected by HIV.

METHODS

Primary RAHC infection was diagnosed when anti-HCV antibody seroconversion was documented. In anti-HCV positive patients, initially without HCV viraemia, a diagnosis of reinfection was established if plasma HCV RNA was detected.

RESULTS

All 350 patients tested negative for anti-HCV at baseline and had at least one follow-up visit. Among them, there were 16 RAHC cases from 2016 to 2019. RAHC incidence rates [IR (95% confidence interval, CI)] per 100 person-years were 3.77 (0.5-12.9) in 2016, 1.85 (0.6-4.3) in 2017, 1.49 (0.4-3.8) in 2018 and 1.98 (0.6-4.5) in 2019. Only previous sexually transmitted infections [incidence rate ratio (IRR) = 18.23, 95% CI: 1.93-172.1; P = 0.011], male sex (IRR = 8.33, 95% CI: 1.38-54.15; P = 0.026) and sharing chem-sex drugs (IRR: 4.93, 95% CI: 1.17-20.76; P = 0.030), were independently associated with RAHC. Four out of 42 (9.5%) patients became reinfected.

CONCLUSIONS

The incidence of RAHC among HIV-infected patients showed a decrease after 2016, although a lower but steady incidence of residual cases still remains. HCV reinfections showed a similar pattern. New infections were associated with sharing chem-sex drugs among MSM.

Prevalence and incidence of hepatitis C virus infection in men who have sex with men: a systematic review and meta-analysis

BACKGROUND

WHO has set targets for hepatitis C virus (HCV) elimination by 2030. We did a global systematic review of HCV prevalence and incidence in men who have sex with men (MSM) to provide updated estimates that can guide community education and public health policy.

METHODS

We did a systematic review and meta-analysis of studies published and listed on MEDLINE or Embase between Jan 1, 2000, and Oct 31, 2019, including conference proceedings. Studies were eligible if they reported measures of HCV prevalence or HCV incidence (or both) among MSM. Studies that relied on participants' self-reported HCV status with no laboratory confirmation were excluded. Pooled HCV estimates in MSM were stratified by HIV status and by injecting drug use, then by WHO region and by income level. Random-effects meta-analysis was done to account for between-study heterogeneity and examined using the I² statistic. Pooled HCV prevalence was also compared with HCV estimates in the general population and presented as prevalence ratios (PRs). In HIV-negative MSM, incidence estimates were stratified by use of HIV pre-exposure prophylaxis (PrEP). The systematic review was registered with PROSPERO, number CRD42020156262.

FINDINGS

Of 1221 publications identified, 194 were deemed to be eligible and included in the systematic review and meta-analysis. Overall, the pooled HCV prevalence in MSM was 3·4% (95% CI 2·8-4·0; I²=98·0%) and was highest in Africa (5·8%, 2·5-10·4) and South-East Asia (5·0%, 0·0-16·6). Globally, HCV prevalence was 1·5% (1·0-2·1) in HIV-negative MSM and 6·3% (5·3-7·5) in HIV-positive MSM. Compared with the general population, HCV prevalence was slightly higher in HIV-negative MSM (PR 1·58, 95% CI 1·14-2·01) and markedly higher (6·22, 5·14-7·29) in HIV-positive MSM. Pooled HCV prevalence was substantially higher in MSM who had ever injected drugs (30·2%, 22·0-39·0) or currently injected drugs (45·6%, 21·6-70·7) than in those who never injected drugs (2·7%, 2·0-3·6). In HIV-negative MSM, the pooled HCV incidence was 0·12 per 1000 person-years (95% CI 0·00-0·72) in individuals not on PrEP and 14·80 per 1000 person-years (9·65-20·95) in individuals on PrEP. HCV incidence in HIV-positive MSM was 8·46 per 1000 person-years (6·78-10·32).

INTERPRETATION

HIV-positive MSM are at substantially increased risk of HCV. Overall, HIV-negative MSM had a slightly higher prevalence of HCV than the general population but had a lower prevalence than HIV-positive MSM. High HCV incidence in more recent PrEP studies suggests that as PrEP use increases, greater HCV transmission might occur. HCV burden in MSM varies considerably by region, which is likely to be associated with variation in the prevalence of injecting drug use and HIV.

FUNDING

World Health Organization.

Evolving trends in the prevalence of hepatitis C virus antibody positivity among HIV-infected men in a community-based primary care setting

Hepatitis C virus (HCV) infections in the United States occurred mostly among those born between 1945 and 1965. However, new infections continue to increase in recent years. To understand the changes in the prevalence and risk factors of HCV infection in different age and risk groups among men living with HIV, we performed a retrospective cross-sectional analyses of 1948 HIV-infected men at a multisite community health centre in urban/suburban and rural Maryland from 2003 through 2014. We used multivariate logistic regression to determine factors associated with HCV antibody (anti-HCV) positivity and restricted cubic spline method to model trends in anti-HCV prevalence over time. The overall anti-HCV prevalence was 24.2%. The annual prevalence declined in the full cohort, from 38% in 2003 to 24% in 2014, and among those ≥ 40 years old. However, the annual prevalence increased initially and then stabilized in the groups of men who were younger (<40 years old) or had injection-drug use and/or sex with men. Among the younger injection-drug users, the prevalence rose from 33% in 2003 to 79% in 2009 and then stabilized. The independent predictors for anti-HCV positivity differed between the men with and without injection-drug use and between those < 40 and ≥ 40 years old. Notably, a high prevalence of anti-HCV was observed among the younger, white injection-drug users residing in rural areas. Thus, the HCV epidemic continued unabated among high-risk individuals in this diverse population of HIV-infected men. The ongoing HCV transmission among young HIV-infected men poses a challenge en route to HCV eradication.

Proportion and Characterization of Co-infections of HIV and Hepatitis C or Hepatitis B among People with HIV in Alabama, 2007-2016

OBJECTIVES

People living with human immunodeficiency virus (HIV) have an increased risk of other infections, including viral hepatitis, which can complicate the treatment and progression of the disease. We sought to characterize Alabama cases of HIV co-infected with hepatitis C virus or hepatitis B virus.

METHODS

Using surveillance data, we defined co-infection as a person identified as having hepatitis C or hepatitis B and HIV during 2007-2016. We compared demographics, outcomes, and risk factors for co-infected versus monoinfected individuals with HIV. We mapped co-infected individuals' distribution.

RESULTS

Of 5824 people with HIV, 259 (4.4%) were co-infected with hepatitis C (antibody or RNA positive) and 145 (2.5%) with hepatitis B (surface antigen, e antigen, or DNA positive) during 2007-2016. Individuals with HIV and hepatitis C had a greater odds of injection drug use (adjusted odds ratio 9.7; 95% confidence interval 6.0-15.5). Individuals with HIV and hepatitis B had a greater odds of male-to-male sexual contact (adjusted odds ratio 1.7; 95% confidence interval 1.1-2.6). Co-infection was greater in urban public health districts.

CONCLUSIONS

We identified risk behaviors among Alabama populations associated with increased odds for HIV and viral hepatitis co-infection. Outreach, prevention, testing, and treatment resources can be targeted to these populations.

Using Sexual Orientation and Gender Identity to Monitor Disparities in HIV, Sexually Transmitted Infections, and Viral Hepatitis

OBJECTIVES

To quantify sexual orientation and gender identity (SOGI) disparities in incidence of HIV, other sexually transmitted infections (STIs), and viral hepatitis.

METHODS

We performed a records-based study of 19 933 patients visiting a federally qualified health center in Los Angeles, California, between November 2016 and October 2017 that examined HIV, STIs, and viral hepatitis incidence proportions. We created multivariable logistic regression models to examine the association between incidence proportions and SOGI among people living with HIV and HIV-negative patients.

RESULTS

Among those who were HIV-negative at baseline (n = 16 757), 29% tested positive for any STI during the study period, compared with 38% of people living with HIV. Stratified by birth sex, STI positivity was 32% among men and 11% among women. By SOGI, STI positivity was 35% among gay and bisexual cisgender men, 15% among heterosexual cisgender men, 11% among cisgender women, 25% among transgender women, 13% among gay and bisexual transgender men, 3% among heterosexual transgender men, and 26% among nonbinary people.

CONCLUSIONS

Stratifying by SOGI highlighted disparities that are obscured when stratifying by birth sex. Public Health Implications. To monitor and reduce disparities, health jurisdictions should include SOGI data with infectious disease reporting.

Providing competent, comprehensive and inclusive sexual health services for men who have sex with men in low- and middle-income countries: a scoping review

Although men who have sex with men (MSM) are disproportionately affected by HIV and other sexually transmissible infections, sexual health services for MSM in low- and middle-income countries (LMIC) remain under-resourced and are poorly understood. A scoping review of literature on MSM sexual health in LMIC was conducted in order to identify key clinical services and gaps in knowledge. Three databases were searched, in addition to hand-reviewing key journals and bulletins, to identify literature with a focus on MSM sexual health. Key services related to providing care to MSM in LMIC that emerged from our review are described. These services include creation of safe and confidential clinic environments, HIV testing services, behavioural interventions, HIV pre-exposure prophylaxis (PrEP), rapid antiretroviral therapy (ART) initiation and STI services. Compared with high-income settings, major differences in LMIC include lack of diagnostic technology, unfavourable legal environments and lack of funding for MSM health. Innovative approaches to healthcare delivery, such as harnessing mobile technology, self-testing and crowdsourcing interventions, can improve health services among MSM in LMIC. There are gaps in the evidence about how best to provide sexual health services for MSM in LMIC settings. Implementation research and scale-up of existing biomedical and behavioural interventions, such as HIV/STI testing services, PrEP and early antiretroviral initiation are urgently needed in LMIC.

Hepatitis C virus infection status and associated factors among a multi-site sample of people who used illicit drugs in the Amazon region

BACKGROUND

Elevated rates of Hepatitis C Virus (HCV) infection have been reported in epidemiological studies with people who used illicit drugs (PWUIDs) in different Brazilian regions. In Brazil's Amazon region, studies have already identified the common use of illicit drugs among adolescents and the high prevalence of HCV infections among PWUIDs. However, all studies done with PWUIDs were conducted with small samples and within limited geographic coverage. This study determined the prevalence and risk factors for HCV infection in PWUIDs in the Amazon region, northern Brazil, as well as estimating the prevalence and factors associated with the HCV spontaneous clearance (HSC).

METHODS

This cross-sectional study accessed 1666 PWUIDs from multiple municipalities of the Amazon region. Socio-demographic, economic, drug use and health-related information were collected through interviews. Blood samples collected were tested for the presence of anti-HCV antibodies and RNA-HCV. HCV genotypes were identified by real-time polymerase chain reaction (PCR). Logistic regressions were run to identify factors independently associated with HCV infection status and HSC.

RESULTS

In total, 577 (34.6%) featured HCV antibodies, of which 384 (23.1%) had active HCV infection and 193 (11.6%) indicated HSC. Genotypes 1 (80.2%) and 3 (18.8%) were detected. HCV infection status was associated with the length of illicit drug use history, factors related to parenteral and sexual transmission, and factors of socio-economic marginalization leading to potential risk activities for HCV. HSC was associated with the ethnic (including indigenous) background of participants.

CONCLUSIONS

High levels of HCV infection were detected in PWUIDs. Genotype 1 was predominant. Intense use of illicit drugs, unprotected sexual intercourse, high number of sexual partners and social marginalization were associated with all HCV infection. HSC was associated with origin (Amazonian-born) and non-white (e.g., Black or Indigenous) of PWUIDs. These findings emphasize the need for improve HCV prevention and control services and care for PWUIDs in the Brazilian Amazon region.

Sexual transmission of hepatitis C virus among gay and bisexual men: a systematic review

A systematic review was performed on the evidence of sexual transmission of hepatitis C virus (HCV) in gay and bisexual men (GBM). Studies conducted in industrialised countries and published in English from 2000 to 2015 with data on HCV in GBM were included. Pooled estimates of prevalence and incidence of HCV infection were stratified by study settings and participants' HIV status using random effect models. Case-series reports were summarised descriptively. Of the 38 cross-sectional studies, the pooled HCV prevalence was substantially higher in HIV-positive men (8.3%, 95% CI: 6.7-9.9) than in HIV-negative men (1.5%, 95% CI 0.8-2.1), and higher in those who reported injecting drug use (34.8%, 95% CI 26.9-42.7) than in those who did not (3.5%, 95% CI 2.4-4.5). Of the 16 longitudinal studies, the pooled HCV incidence was markedly higher in clinic-based (7.0 per 1000 person-years, 95% CI 4.6-9.5) than in community-based (1.4 per 1000 person-years, 95% CI 0.7-2.1) studies, and in HIV-positive men (6.4 per 1000 person-years, 95% CI 4.6-8.1) than in HIV-negative men (0.4 per 1000 person-years, 95% CI 0-0.9). Since the early 2000s, 15 case-series reports increasingly pointed to the importance of sexual transmission of HCV in mainly HIV-positive men. Injecting drug use remained the major transmission route of HCV in GBM. Receptive condomless intercourse and concurrent ulcerative sexually transmissible infections are likely drivers that facilitated HCV sexual transmission in HIV-positive men. HCV incidence remains very low in HIV-negative GBM.

Primary Incidence of Hepatitis C Virus Infection Among HIV-Infected Men Who Have Sex With Men in San Diego, 2000-2015

BACKGROUND

Little is known about the hepatitis C virus (HCV) epidemic among HIV-infected men who have sex with men (HIV+ MSM) in the United States. In this study, we aimed to determine the incidence of primary HCV infection among HIV+ MSM in San Diego, California.

METHODS

We performed a retrospective cohort analysis of HCV infection among HIV+ MSM attending 2 of the largest HIV clinics in San Diego. Incident HCV infection was assessed among HIV+ MSM with a negative anti-HCV test and subsequent HCV test between 2000 and 2017, with data censored to 2015. HCV reinfection was assessed among HIV+ MSM successfully treated for HCV between 2008 and 2015. Infection/reinfection rates were calculated using person-time methods.

RESULTS

Among 3068 initially HCV-seronegative HIV+ MSM, 178 new infections occurred over 15 796 person-years, giving an incidence of 1.13 per 100 person-years (/100py; 95% confidence interval [CI], 0.97-1.31). Incidence was stable from 2000 to 2014 (0.83/100py; 95% CI, 0.41-1.48), with an increase to 3.01/100py (95% CI, 1.97-4.42) in 2015 (P = .02). Among 43 successfully treated patients, 3 were reinfected.

CONCLUSIONS

HCV incidence is high among HIV+ MSM in San Diego, with evidence suggesting a recent increase in 2015. Strong HCV testing guidelines and active prevention efforts among HIV+ MSM are urgently needed that include rapid diagnosis, treatment, and risk reduction.

The effects of free condom distribution on HIV and other sexually transmitted infections in men who have sex with men

BACKGROUND

HIV and other sexually transmitted infections remain a burden on men who have sex with men in the era of effective combination antiretroviral therapy. New prevention efforts are therefore needed. One of these approaches is the current country-wide free condom distribution at gay bars with darkrooms and gay saunas in the Netherlands. This study assessed the effects of free condom distribution on incidence and burden of disease of HIV and other sexually transmitted infections.

METHODS

A static model was constructed to calculate the impact of free condom distribution on HIV, hepatitis C, chlamydia, gonorrhoea, and syphilis among men who have sex with men visiting these venues. Outcomes included new infections averted and disability-adjusted life years averted. Scenario studies were performed to predict the effects of a further increase of condom use, condom effectiveness and coverage. Lastly, cost-effectiveness and sensitivity analyses were performed.

RESULTS

Our model showed that condom use at public sex venues increased after the intervention. Annual incidence risk decreased, ranging from 5.73% for gonorrhoea to 7.62% for HIV. The annual number of new infections averted was largest for chlamydia and gonorrhoea (261 and 394 infections, respectively), but 42 new HIV infections were averted as well. In scenarios where condom use and condom effectiveness were further increased, the number of infections reduced more extensively. Over 99% of the decrease in burden of disease was due to HIV. The intervention was cost-effective and cost-saving (for every €1 spent on condom distribution, €5.51 was saved) and remained this in all sensitivity analyses.

CONCLUSIONS

Free condoms at public sex venues could reduce the transmission of HIV and other sexually transmitted infections. Condom distribution is an affordable and easily implemented intervention that could reduce the burden of disease in men who have sex with men substantially.

High clustering of acute HCV infections and high rate of associated STIs among Parisian HIV-positive male patients

BACKGROUND

Increasing incidence of hepatitis C virus (HCV) infection in human immunodeficiency virus (HIV)-positive men having sex with men (MSM) has been described in recent years. Phylogenetic analyses of acute HCV infections were undertaken to characterize the dynamics during the epidemic in Paris, and associated sexually transmitted infections (STIs) were evaluated.

METHODS

Sanger sequencing of polymerase gene was performed. Maximum likelihood phylogenies were reconstructed using FastTree 2.1 under a GTR+CAT model. Transmission chains were defined as clades with a branch probability ≥0.80 and intraclade genetic distances <0.02 nucleotide substitutions per sites. STIs detected ≤1 month before HCV diagnosis were considered.

RESULTS

Among the 85 studied patients, at least 81.2% were MSM. Respectively, 47.6%, 39.0%, 11.0% and 2.4% were infected with genotypes 1a, 4d, 3a and 2k. At least 91.8% were co-infected with HIV. HCV re-infection was evidenced for 24.7% of patients and STIs for 20.0% of patients. Twenty-two transmission chains were identified, including 52 acute hepatitis C (11 pairs and 11 clusters from three to seven patients).

CONCLUSIONS

These results revealed strong clustering of acute HCV infections. Thus, rapid treatment of both chronic and acute infections is needed among this population to decrease the prevalence of HCV, in combination with preventive behavioural interventions.

A latent class approach to identify multi-risk profiles associated with phylogenetic clustering of recent hepatitis C virus infection in Australia and New Zealand from 2004 to 2015

INTRODUCTION

Over the last two decades, the incidence of hepatitis C virus (HCV) co-infection among men who have sex with men (MSM) living with HIV began increasing in post-industrialized countries. Little is known about transmission of acute or recent HCV, in particular among MSM living with HIV co-infection, which creates uncertainty about potential for reinfection after HCV treatment. Using phylogenetic methods, clinical, epidemiological and molecular data can be combined to better understand transmission patterns. These insights may help identify strategies to reduce reinfection risk, enhancing effectiveness of HCV treatment as prevention strategies. The aim of this study was to identify multi-risk profiles and factors associated with phylogenetic pairs and clusters among people with recent HCV infection.

METHODS

Data and specimens from five studies of recent HCV in Australia and New Zealand (2004 to 2015) were used. HCV Core-E2 sequences were used to infer maximum likelihood trees. Clusters were identified using 90% bootstrap and 5% genetic distance threshold. Multivariate logistic regression and latent class analyses were performed.

RESULTS

Among 237 participants with Core-E2 sequences, 47% were in a pair/cluster. Among HIV/HCV co-infected participants, 60% (74/123) were in a pair/cluster, compared to 30% (34/114) with HCV mono-infection (p < 0.001). HIV/HCV co-infection (vs. HCV mono-infection; adjusted odds ratio (AOR), 2.37, 95% confidence interval (CI), 1.45, 5.15) was independently associated with phylogenetic clustering. Latent class analysis identified three distinct risk profiles: (1) people who inject drugs, (2) HIV-positive gay and bisexual men (GBM) with low probability of injecting drug use (IDU) and (3) GBM with IDU & sexual risk behaviour. Class 2 (vs. Class 1, AOR 3.40; 95% CI, 1.52, 7.60), was independently associated with phylogenetic clustering. Many clusters displayed homogeneous characteristics, such as containing individuals exclusively from one city, individuals all with HIV/HCV co-infection or individuals sharing the same route of acquisition of HCV.

CONCLUSIONS

Clusters containing individuals with specific characteristics suggest that HCV transmission occurs through discrete networks, particularly among HIV/HCV co-infected individuals. The greater proportion of clustering found among HIV/HCV co-infected participants highlights the need to provide broad direct-acting antiviral access encouraging rapid uptake in this population and ongoing monitoring of the phylogeny.

Understanding and Addressing Hepatitis C Virus Reinfection Among Men Who Have Sex with Men

Hepatitis C virus reinfection rates among men who have sex with men are high. Factors associated with infection point to varied sexual and drug-related risks that could be targeted for interventions to prevent infection/reinfection. Modeling indicates that tackling increasing incidence and high reinfection rates requires high levels of hepatitis C virus treatment combined with behavioral interventions. Enhanced testing strategies and prompt retreating of reinfection may be required to promptly diagnosed reinfections. Behavioral interventions studies addressing reinfection are required. Other interventions include traditional harm reduction interventions, adapted behavioral interventions, and interventions to prevent harms related to ChemSex and other risk factors.

Rethinking Risk, Culture, and Intervention in Collective Sex Environments

This article provides a narrative overview of research on HIV/STI risk and collective sexual behavior based on an inclusive analysis of research on environments where people gather for sexual activity-sex clubs, swingers' clubs, bathhouses, parks, private sex parties, etc. The aim is to analyze how collective sex has been approached across disciplines to promote conversation across paradigms and suggest new lines of inquiry. Attention to context-such as the location of sex-was a necessary redress to universalizing models of sexual risk-taking behavior, leading to insights rooted in the particularities of each environment and its users. However, the identification of ever more precise risk groups or environmental idiosyncrasies eventually becomes theoretically restrictive, leading to an overestimation of the uniqueness of sexual enclaves, and of the difference between any given enclave and the broader social milieu. Using a theoretical framework of transgression to interpret the interdisciplinary literature, similarities in the spatial and social organization of collective sex environments are identified. Insights generated from this complementary perspective are then applied to understandings of collective sex: first, the example of male-female (MF) "swingers" is used to illustrate the need to establish, rather than assume, the distinctiveness of each non-normative sexual enclave, and to broaden the conceptualization of context; second, questions are raised about the practicality of interventions in collective sex environments. Finally, new lines of intellectual inquiry are suggested to shed light not just on collective sex but on sociosexual issues more generally, such as increasing protective sexual health behavior or negotiating consent in sexual encounters.

Hepatitis B, C, and D virus and human T-cell leukemia virus types 1 and 2 infections and correlates among men who have sex with men in Ouagadougou, Burkina Faso

BACKGROUND

Men who have sex with men (MSM) are considered to be at significant risk for sexually transmitted infections (STI) and bloodborne viruses including viral hepatitis types B, C, and D (HBV, HCV, and HDV) and human T-cell leukemia virus types 1 and 2 (HTLV 1&2). This study aimed to assess the seroprevalence and correlates of HBV, HCV, HDV, and HTLV 1&2 antibodies among MSM in Ouagadougou, Burkina Faso.

METHODS

We conducted a cross-sectional survey to assess the biological and behavourial characteristics among MSM in Ouagadougou from January to April 2013. Serum specimens obtained were tested for the presence of HBV, HCV, HDV and HTLV-1&2 infections. MSM 18 years and older were recruited using respondent driven sampling (RDS). Population estimates and 95% confidence intervals (CI) adjusted for the RDS design were calculated using RDS Analysis Tool (RDSAT) version 6.0.1 (RDS, Inc., Ithaca, NY). Bivariate and multivariate logistic regression analyses were conducted to assess correlates of these infections using Stata 14.

RESULTS

A total of 329 MSM were tested. Prevalence was 20.4% (95% CI: 16.4-25.1) for HBV, 11.0% (95% CI: 8.0-14.8) for HCV, and 0.0% for HDV. Anti-HTLV 1&2 antibodies were found in 4.0% (95% CI: 2.3-6.8) of MSM. Factors independently associated with HBV infection were lack of condom use during the last anal sex act with a main male sexual partner and experience of condom tearing during anal sex. Presence of anti-HTLV 1&2 antibodies was associated with history of genital or anal lesions and injection drug use. None of the variables included in our study were associated with HCV.

CONCLUSIONS

This study shows that HBV, HCV and HTLV 1&2 prevalence among MSM in Burkina is high and suggests that comprehensive STI prevention and sexual health education services for this group are needed.

Changing the odds: motives for and barriers to reducing HCV-related sexual risk behaviour among HIV-infected MSM previously infected with HCV

Background

Among HIV-infected MSM who have been treated for HCV infection, the HCV reinfection rate is high. It is therefore essential to understand their perceptions of HCV risk behaviour and risk-reducing strategies.

Methods

This qualitative study among 20 HCV-infected MSM, the majority treated in the era before direct acting antivirals, provides insight into their ideas, motives, and barriers concerning HCV risk reduction, and aims to strengthen prevention strategies for both primary HCV infection and HCV reinfection.

Results

The strongest motive to implement risk reduction strategies was the reward of avoiding HCV retreatment and its side effects, but this may change with the current implementation of less burdensome HCV treatment. Also, the sexual risk norms in the MSM scene, including social pressure towards risk-taking, HCV stigma, and non-disclosure of HCV status, all form barriers to safe sex. Drug use, strongly present in the context of clubs and group sex, directly impedes the self-efficacy of men to take risk reduction measures.

Conclusions

Tailored prevention messages, empowerment of self-efficacy for risk reduction, and more insight into risk behaviour over time are ingredients for effective HCV prevention among these men.

Hepatitis E virus seroprevalence and determinants in various study populations in the Netherlands

BACKGROUND

The epidemiology of hepatitis E virus (HEV) is not fully understood. In this study, we assessed putative risk factors for HEV seropositivity in various study populations in the Netherlands.

METHODS

Data and samples from five different study populations were analysed: (A) blood donors (n = 5,239), (B) adults reporting a vegetarian life style since the age of 12 years (n = 231), (C) residents of Amsterdam, the Netherlands, with different ethnic backgrounds (n = 1,198), (D) men who have sex with men (MSM) (HIV positive and HIV negative) (n = 197), and (E) persons who use drugs (PWUD) (HIV positive and HIV negative) (n = 200). Anti-HEV immunoglobulin M (IgM) and immunoglobulin G (IgG) testing was performed using ELISA test (Wantai).

RESULTS

HEV IgM seroprevalence was low across all study populations (<1% to 8%). The age and gender-adjusted HEV IgG seroprevalence was 24% among blood donors (reference group) and 9% among the vegetarian group (adjusted Relative Risk [aRR]:0.36, 95%CI:0.23-0.57). Among participants of different ethnic backgrounds, the adjusted HEV IgG seroprevalence was 16% among participants with a Dutch origin (aRR:0.64, 95%CI:0.40-1.02), 2% among South-Asian Surinamese (aRR:0.07, 95%CI:0.02-0.29), 3% among African Surinamese (aRR:0.11, 95%CI:0.04-0.34), 34% among Ghanaian (aRR:1.53, 95%CI:1.15-2.03), 19% among Moroccan (aRR:0.75, 95%CI:0.49-1.14), and 5% among Turkish (aRR:0.18, 95%CI:0.08-0.44) origin participants. First generation Moroccans had a higher risk for being IgG HEV seropositive compared to second generation Moroccan migrants. The statistical power to perform these analyses in the other ethnic groups was too low. In the MSM group the IgG HEV seroprevalence was 24% (aRR:0.99, 95%CI:0.76-1.29), and among PWUD it was 28% (aRR:1.19, 95%CI:0.90-1.58). The number of sexual partners in the preceding six months was not significantly associated with IgG HEV seropositivity in MSM. The association between HIV status and HEV seropositivity was significant in PWUD, yet absent in MSM. HIV viral load and CD4 cell count were not associated with HEV seropositivity in HIV positive MSM and PWUD.

CONCLUSIONS

Vegetarians were significantly less often HEV seropositive. Ethnic origin influenced the risk for being IgG HEV seropositive. MSM and PWUD were not at higher risk for being IgG HEV seropositive than blood donors.

Prevalence and mapping of hepatitis C infections among men who have sex with men in New York City

Emerging sexually transmitted hepatitis C virus (HCV) epidemics among men who have sex with men (MSM) have been reported worldwide, with higher HCV infection rates among those who are HIV-infected. This study aims to determine prevalence of recent and chronic HCV infections among community-recruited MSM in New York City (NYC), map HCV infections by home, social, and sexual neighborhoods, and identify clusters of genetically linked HCV variants using phylogenetic analysis. The NYC M2M study recruited MSM via modified time-space, venue-based sampling and internet/mobile app-based recruitment during 2010–13. Participants completed a Google Earth map on neighborhoods of where they lived, socialized, and had sex in the last 3 months, an ACASI questionnaire, and a sexual network inventory about their sex partners. The men received HIV testing and provided serum samples. Testing on stored serum samples included HCV antibody and RNA viral load, HCV antibody avidity assay (avidity index <30% with positive viral load is considered recently infected), and HCV RNA extraction and amplification to generate a 432 base-pair region of Core/E1 for sequencing and phylogenetic analysis. Historic local controls were included in the phylogenetic analysis. Of 1,028 MSM, 79.7% were HIV-negative and 20.3% HIV-positive. Twenty nine MSM (2.8%) were HCV antibody-positive. MSM who were HCV antibody-positive reported a median of 2 male sex partners in last 3 months, with 6.9% aged 18–24, 17.2% 25–29, 13.8% 30–39, and 62.1% 40 and over. 8.1% of HIV-positive MSM were HCV antibody-positive vs. 1.5% of HIV-negative men (p<0.0001). Of 29 HCV-antibody positive MSM, 12 (41%) were HCV RNA-positive (11 subtype 1a and 1 subtype 1b). Two of 12 HCV RNA-positive participants had low antibody avidity values, suggesting recent HCV infection. HCV antibody seropositivity was significantly associated with older age >40 years, adjusted odds ratio (aOR) 3.56 (95% CI 1.57, 8.08), HIV-positive serostatus, aOR 3.18 (95% CI 1.40, 7.22), any sexually transmitted infection (STI) in the last 3 months, aOR 2.81 (95% CI 1.11, 7.13), and injection drug use (IDU) ever, aOR 4.34 (95% CI 1.69, 11.17). Mapping of HCV infections differed slightly by home, social, and sexual neighborhoods. Based on phylogenetic analysis from 12 HCV RNA-positive samples, no evidence of a clustered HCV epidemic was found. Overall HCV seroprevalence was 2.8% among community-recruited MSM in NYC, with higher prevalence among HIV-positive MSM compared to HIV-negative MSM. Only two participants were found to have recent HCV infection, with no evidence of a clustered HCV epidemic based on phylogenetic analysis. Our results support testing of HCV infection among HIV-negative MSM if they report having a recent STI and IDU in the past rather than universal HCV testing in all HIV-negative MSM.

The role of prevention strategies in achieving HCV elimination in Canada: what are the remaining challenges?

Background

The worldwide economic, health, and social consequences of drug use disorders are devastating. Injection drug use is now a major factor contributing to hepatitis C virus (HCV) transmission globally, and it is an important public health concern.

Methods

This article presents a narrative review of scientific evidence on public health strategies for HCV prevention among people who inject drugs (PWID) in Canada.

Results

A combination of public health strategies including timely HCV detection and harm reduction (mostly needle and syringe programmes and opioid substitution therapy) have helped to reduce HCV transmission among PWID. The rising prevalence of pharmaceutical opioid and methamphetamine use and associated HCV risk in several Canadian settings has prompted further innovation in harm reduction, including supervised injection facilities and low-threshold opioid substitution therapies. Further significant decreases in HCV incidence and prevalence, and in corresponding disease burden, can only be accomplished by reducing transmission among high-risk persons and enhancing access to HCV treatment for those at the greatest risk of disease progression or viral transmission. Highly effective and tolerable direct-acting antiviral therapies have transformed the landscape for HCV-infected patients and are a valuable addition to the prevention toolkit. Curing HCV-infected persons, and thus eliminating new infections, is now a real possibility.

Conclusions

Prevention strategies have not yet ended HCV transmission, and sharing of injecting equipment among PWID continues to challenge the World Health Organization goal of eliminating HCV as a global public health threat by 2030. Future needs for research, intervention implementation, and uptake in Canada are discussed.

Opposite outcomes of coinfection at individual and population scales

Coinfecting parasites and pathogens remain a leading challenge for global public health due to their consequences for individual-level infection risk and disease progression. However, a clear understanding of the population-level consequences of coinfection is lacking. Here, we constructed a model that includes three individual-level effects of coinfection: mortality, fecundity, and transmission. We used the model to investigate how these individual-level consequences of coinfection scale up to produce population-level infection patterns. To parameterize this model, we conducted a 4-y cohort study in African buffalo to estimate the individual-level effects of coinfection with two bacterial pathogens, bovine tuberculosis (bTB) and brucellosis, across a range of demographic and environmental contexts. At the individual level, our empirical results identified bTB as a risk factor for acquiring brucellosis, but we found no association between brucellosis and the risk of acquiring bTB. Both infections were associated with reductions in survival and neither infection was associated with reductions in fecundity. The model reproduced coinfection patterns in the data and predicted opposite impacts of coinfection at individual and population scales: Whereas bTB facilitated brucellosis infection at the individual level, our model predicted the presence of brucellosis to have a strong negative impact on bTB at the population level. In modeled populations where brucellosis was present, the endemic prevalence and basic reproduction number ([Formula: see text]) of bTB were lower than in populations without brucellosis. Therefore, these results provide a data-driven example of competition between coinfecting pathogens that occurs when one pathogen facilitates secondary infections at the individual level.

A qualitative assessment of the acceptability of hepatitis C remote self-testing and self-sampling amongst people who use drugs in London, UK

Background

Hepatitis C (HCV) diagnosis and care is a major challenge for people who use illicit drugs, and is characterised by low rates of testing and treatment engagement globally. New approaches to fostering engagement are needed. We explored the acceptability of remote forms of HCV testing including self-testing and self-sampling among people who use drugs in London, UK.

Methods

A qualitative rapid assessment was undertaken with people who use drugs and stakeholders in London, UK. Focus groups were held with men who have sex with men engaged in drug use, people who currently inject drugs and people who formerly injected drugs (22 participants across the 3 focus groups). Stakeholders participated in semi-structured interviews (n = 5). We used a thematic analysis to report significant themes in participants’ responses.

Results

We report an overarching theme of ‘tension’ in how participants responded to the acceptability of remote testing. This tension is evident across four separate sub-themes we explore. First, choice and control, with some valuing the autonomy and privacy remote testing could support. Second, the ease of use of self testing linked to its immediate result and saliva sample was preferred over the delayed result from a self administered blood sample tested in a laboratory. Third, many respondents described the need to embed remote testing within a supportive care pathway. Fourth, were concerns over managing a positive result, and its different meanings, in isolation.

Conclusions

The concept of remote HCV testing is acceptable to some people who use drugs in London, although tensions with lived experience of drug use and health system access limit its relevance. Future development of remote testing must respond to concerns raised in order for acceptable implementation to take place.

Online interventions to address HIV and other sexually transmitted and blood-borne infections among young gay, bisexual and other men who have sex with men: a systematic review

Introduction

Globally, young gay, bisexual and other men who have sex with men (gbMSM) continue to experience disproportionately high rates of HIV and other sexually transmitted and blood‐borne infections (STBBIs). As such, there are strong public health imperatives to evaluate innovative prevention, treatment and care interventions, including online interventions. This study reviewed and assessed the status of published research (e.g. effectiveness; acceptability; differential effects across subgroups) involving online interventions that address HIV/STBBIs among young gbMSM.

Methods

We searched Medline, Embase, PsycINFO, CINAHL, and Google Scholar to identify relevant English‐language publications from inception to November 2016. Studies that assessed an online intervention regarding the prevention, care, or treatment of HIV/STBBIs were included. Studies with <50% gbMSM or with a mean age ≥30 years were excluded.

Results

Of the 3465 articles screened, 17 studies met inclusion criteria. Sixteen studies assessed interventions at the “proof‐of‐concept” phase, while one study assessed an intervention in the dissemination phase. All of the studies focused on behavioural or knowledge outcomes at the individual level (e.g. condom use, testing behaviour), and all but one reported a statistically significant effect on ≥1 primary outcomes. Twelve studies described theory‐based interventions. Twelve were conducted in the United States, with study samples focusing mainly on White, African‐American and/or Latino populations; the remaining were conducted in Hong Kong, Peru, China, and Thailand. Thirteen studies included gay and bisexual men; four studies did not assess sexual identity. Two studies reported including both HIV+ and HIV− participants, and all but one study included one or more measure of socio‐economic status. Few studies reported on the differential intervention effects by socio‐economic status, sexual identity, race or serostatus.

Conclusion

While online interventions show promise at addressing HIV/STBBI among young gbMSM, to date, little emphasis has been placed on assessing: (i) potential differential effects of interventions across subgroups of young gbMSM; (ii) effectiveness studies of interventions in the dissemination phase; and (iii) on some “key” populations of young gbMSM (e.g. those who are: transgender, from low‐income settings and/or HIV positive). Future research that unpacks the potentially distinctive experiences of particular subgroups with “real world” interventions is needed.

Prevalence of hepatitis C infection and its associated factors in healthy adults without identifiable route of transmission

While hepatitis C virus (HCV) infection is long known to be associated with parenteral exposure, the specific route of transmission is not identified in a proportion of infected patients. Taking blood donors as the surrogate of healthy adults in the community in Hong Kong, we identified 91 HCV-infected donors (≤0.02% positive rate) in 2014-2016, of whom 46 were recruited in a mixed-method study to examine their transmission routes. A majority (75%) of the recruited donors were HCV RNA positive, with the predominant subtypes being 1b and 6a. From the results of the structured self-administered questionnaire and in-depth interviews, only 14 (30%) recruited donors could be traced to past history of contaminated blood transfusion (n = 9) or injection drug use (n = 5). Case-control analyses with 3 different control groups were performed to examine factors associated with HCV infection in multivariable analyses. High-risk sexual behaviour, body piercing, intramuscular injection and vaccine inoculation abroad, having lived abroad for >3 months were significantly associated with HCV in donors with otherwise nonidentifiable source of infection. While the specific route of transmission cannot be established for each person, associations with multiple parenteral exposures outside Hong Kong were observed. The World Health Organization has advocated for the global elimination of HCV by 2030. With a high proportion of HCV-infected persons who are unaware of their infections, HCV elimination could be hard to achieve.

Hepatitis C virus spread from HIV-positive to HIV-negative men who have sex with men

The aim of this study was to evaluate the potential transmission of HCV strains between HIV-positive men who have sex with men (MSM) and HIV-negative MSM. Since 2000, an ongoing epidemic of HCV infections is observed among HIV-positive MSM in high-income countries. However, HCV infections in HIV-negative MSM are investigated to a lesser extent due to the lack of follow-up in this population and only limited information is available on the risk of HCV transmission between HIV-positive MSM and HIV-negative MSM. We enrolled 49 MSM of which 43 were HIV-positive and 6 HIV-negative, including 4 being enrolled or waiting for enrolment in a preexposure prophylaxis (PrEP) program. All patients were diagnosed with acute HCV infection at the Infectious Disease Unit at the Hospices Civils de Lyon from 2014 to 2016. Risk factors for HCV infection were similar in both groups and included IV or nasal drug use, and rough sex practices. Typing and phylogenetic cluster analysis of HCV variants were performed by NS5B sequencing. Several clusters of infections were identified (genotype 1a: 3 clusters and 1 pair; genotype 4d: 1 cluster and 2 pairs), suggesting that several transmission events occurred within the study population. Every HCV strain identified in HIV-negative MSM was included in a cluster with HIV-positive MSM. Chronological analysis of contagiousness suggested the transmission of HCV from HIV-positive to HIV-negative patients. We conclude that recommendations for HCV surveillance should not be confined to HIV-positive MSM but should be extended to HIV-negative MSM with similar risk factors.

2016 United Kingdom national guideline on the sexual health care of men who have sex with men

This guideline is intended for use in UK Genitourinary medicine clinics and sexual health services but is likely to be of relevance in all sexual health settings, including general practice and Contraception and Sexual Health (CASH) services, where men who have sex with men (MSM) seek sexual health care or where addressing the sexual health needs of MSM may have public health benefits. For the purposes of this document, MSM includes all gay, bisexual and all other males who have sex with other males and both cis and trans men. This document does not provide guidance on the treatment of particular conditions where this is covered in other British Association for Sexual Health and HIV (BASHH) Guidelines but outlines best practice in multiple aspects of the sexual health care of MSM. Where prevention of sexually transmitted infections including HIV can be addressed as an integral part of clinical care, this is consistent with the concept of combination prevention and is included. The document is designed primarily to provide guidance on the direct clinical care of MSM but also makes reference to the design and delivery of services with the aim of supporting clinicians and commissioners in providing effective services. Methodology This document was produced in accordance with the guidance set out in the BASHH CEG's document 'Framework for guideline development and assessment' published in 2010 at http://www.bashh.org/guidelines and with reference to the Agree II instrument. Following the production of the updated framework in April 2015, the GRADE system for assessing evidence was adopted and the draft recommendations were regraded. Search strategy (see also Appendix 1) Ovid Medline 1946 to December 2014, Medline daily update, Embase 1974 to December 2014, Pubmed NeLH Guidelines Database, Cochrane library from 2000 to December 2014. Search language English only. The search for Section 3 was conducted on PubMed to December 2014. Priority was given to peer-reviewed papers published in scientific journals, although for many issues evidence includes conference abstracts listed on the Embase database. In addition, for 'Identification of problematic recreational drug and alcohol use' section and 'Sexual problems and dysfunctions in MSM' section, searches included PsycINFO. Methods Article titles and abstracts were reviewed and if relevant the full text article was obtained. Priority was given to randomised controlled trial and systematic review evidence, and recommendations made and graded on the basis of best available evidence. Piloting and feedback The first draft of the guideline was circulated to the writing group and to a small group of relevant experts, third sector partners and patient representatives who were invited to comment on the whole document and specifically on particular sections. The revised draft was reviewed by the CEG and then reviewed by the BASHH patient/public panel and posted on the BASHH website for public consultation. The final draft was piloted before publication. Guideline update The guidelines will be reviewed and revised in five years' time, 2022.

Prevalence of Human Immunodeficiency Virus, Hepatitis B Virus, and Hepatitis C Virus Infections Among Transgender Persons Referred to an Italian Center for Total Sex Reassignment Surgery

INTRODUCTION

The burden of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections in transgender population is an underestimated issue. We performed a study to evaluate the prevalence of such infections in transgender persons addressed our center for total sex reassignment surgery (SRS).

MATERIALS AND METHODS

All transgender persons undergoing SRS from 2000 to 2014 were evaluated retrospectively. Participant characteristics and results of HIV, HBV, and HCV testing were collected. Exact Fisher test, Cochran-Armitage tests for trend and correct prevalence ratios were estimated.

RESULTS

Among 498 transgender persons, 243 had confirmed serological data. Of them, 25 were female-to-male and 218 male-to-female (MtF) subjects. The prevalence of HIV, HBV and HCV infections was 0%, 4.0%, and 8.0% in female-to-male, and 12.1%, 4.6%, and 3.7% in MtF. Among MtF, younger age and earlier year of SRS were associated with lower HIV prevalence. From the multivariate model, the mutually adjustment prevalence ratios were 1.9 (95% confidence interval [95% CI], 1.2-3.1) for SRS in 2005-2010 and 3.6 (95% CI, 1.3-9.4) in 2010-2014, as compared with SRS in 2000-2004; and 4.7 (95% CI, 2.4-9.4) for South Americans as compared with others. Among the HCV-positive MtF, 57.1% were also HIV-positive. Regarding HBV, the immunity was 38.5% and, after mutual adjustment, the prevalence ratios were 2.1 (95% CI, 1.3-3.4) for South Americans versus others and 2.2 (95% CI, 1.6-3.1) for year of birth ≥ 1980.

DISCUSSION

The prevalence of HBV and HCV infections among our transgender persons overlaps that reported in the general population, but HCV prevalence was much higher in HIV-infected MtF. The high burden of HIV infection among MtF and its recent incremented prevalence points out that social and medical support should be strongly promoted in such population.

Earlier Detection of Hepatitis C Virus Infection Through Routine Hepatitis C Virus Antibody Screening of Human Immunodeficiency Virus-Positive Men Who Have Sex With Men Attending A Sexually Transmitted Infection Outpatient Clinic: A Longitudinal Study

BACKGROUND

In 2007, routine hepatitis C virus (HCV) antibody testing was introduced for men who have sex with men (MSM) with a human immunodeficiency virus (HIV)-positive or unknown status attending a Dutch sexually transmitted infection (STI) outpatient clinic. We evaluated whether this screening resulted in additional and earlier HCV diagnoses among MSM who also attend HIV clinics.

METHODS

At first STI consultation, HIV-positive MSM and MSM opting-out of HIV testing (HIV-status-unknown) were tested for HCV antibodies (anti-HCV). During follow-up consultations, only previously HCV-negative men were tested. Retrospectively, STI clinic and HIV clinic HCV diagnosis dates were compared.

RESULTS

One hundred twelve (6.4%) of 1742 (95% confidence interval [CI], 5.3-7.6%) HIV-positive and 3 (0.7%) of 446 (95% CI, 0.2-2.0%) HIV-status-unknown MSM tested anti-HCV-positive at first consultation. During follow-up consultations, 32 HIV-positive (incidence HCV-positive: 2.35/100 person years (PY) (95% CI, 1.66-3.33)) and 0 (1-sided, 97.5% CI, 0.0-3.76) HIV-status-unknown MSM became anti-HCV-positive. Four (11.8%) of 34 HIV-positive MSM notified by their sexual partner of HCV tested anti-HCV-positive.Of 163 HIV-positive MSM with HCV antibodies, 78 reported a history of HCV. HCV diagnosis data at the HIV clinic was requested for the remaining 85 MSM and available for 54 MSM. Of these 54 MSM, 28 (51.9%) had their first HCV diagnosis at the STI clinic, of whom 7 concurrently with HIV. At their next scheduled HIV clinic consultation, 3 HCV cases probably would have been missed.

CONCLUSIONS

The introduction of routine anti-HCV testing at the STI outpatient clinic resulted in additional and earlier HCV detection among HIV-positive MSM. Testing should be continued among HIV-positive MSM, at least for those not (yet) under the care of an HIV clinic and those notified of HCV by their sexual partner.