Sexual Transmission of Hepatitis C: Are HIV-Positive Gay and Bisexual Men at Risk?

By Jeff Reinhart
From Canadian AIDS Treatment Information Exchange

Spring 2011

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Sexual Transmission of Hepatitis C: Are HIV-Positive Gay and Bisexual Men at Risk?

Table of Contents

Introduction

Research shows that the hepatitis C virus (HCV) may be transmitted sexually, especially among HIV-positive gay men, bisexual men and other men who have sex with men (MSM). This article will look at the evidence that HCV can be transmitted sexually and why HIV-positive MSM appear to be at higher risk.

What Is Hepatitis C?

Hepatitis C is a liver disease caused by the hepatitis C virus. This virus is carried in the blood, infects liver cells and causes liver damage (inflammation, scarring, fibrosis and sometimes cirrhosis), which can result in sickness and death. There is no vaccine for hepatitis C, but treatment exists that can clear the virus from the body in about half the people who try it. Because the body does not develop immunity against the virus, it is possible for a person who has been successfully treated for hepatitis C to be re-infected, with either the same strain or a different strain of HCV.

Men and women who are living with both HIV and HCV face greater health and social challenges than those who are living with HCV or HIV alone. Each infection makes the other one worse.

More About Why HIV/HCV Co-Infection Matters

HIV/HCV co-infection can lead to:

Accelerated liver damage. HCV causes liver damage, but the presence of HIV increases the speed of this liver damage. Consequently, co-infected people may develop liver cirrhosis (serious scarring) and liver failure more quickly.^1-5
HIV that is more difficult to treat. HCV can make it more difficult to treat HIV because many anti-HIV drugs are processed by the liver. If the liver is badly damaged by HCV, then the body will not be able to process the drugs as well. There may also be a higher risk of side effects from HIV treatment. A person with chronic HCV may also experience smaller increases in CD4 counts after starting HIV treatment.
HIV disease that progresses more quickly. People who are co-infected can have lower CD4 counts, which can increase the likelihood that they will develop advanced HIV disease. Certain AIDS-defining illnesses, such as fungal or bacterial infections, may affect more people with co-infection than people with HIV alone. People who are co-infected are also more likely to develop other conditions, such as bone fractures, glucose abnormalities (such as diabetes), and kidney and heart disease.
Less chance of clearing HCV spontaneously or through treatment. Approximately 15-25% of people with HCV alone can spontaneously clear the virus. For the remaining 75-85% of people, treatment works approximately 50-80% of the time. These rates are generally cut in half for people who are co-infected with HCV and HIV.
More stigma and discrimination. Gay and bisexual men who are co-infected may be more stigmatized than men living with HIV alone, possibly because many people associate HCV with drug use and poverty. In contexts where HIV-positive men have found a sense of community with other HIV-positive men, HCV can threaten that sense of community and lead to increased stigma for men who have both HIV and HCV.⁶

How Does Someone Get Hepatitis C?

People get hepatitis C when their blood comes into contact with the blood of someone who has HCV (blood-to-blood contact). People can come into contact with blood containing HCV in many ways, including:

sharing equipment to inject drugs (such as filters, cookers, needles or syringes)
sharing equipment, jewelry or ink for piercing/tattooing
sharing pipes, straws or bills for smoking or snorting drugs
sharing toothbrushes, razors or nail clippers
accidental exposure of healthcare workers in a healthcare setting
unprotected sex
transmission to a fetus during pregnancy or childbirth
unsterilized and reused medical equipment (this is rare in Canada today, but may explain previous exposures or exposures in countries where procedures for controlling infection are less strict)

How Many People Have Hepatitis C in Canada?

An estimated 242,500 people in Canada were living with HCV in 2007 (this is the prevalence of HCV in Canada).⁷ This means that an estimated 0.78%, or almost 8 out of every 1,000 Canadians, were living with HCV in 2007.⁷ That same year, an estimated 7,945 people were newly infected with HCV in Canada (this is the incidence of HCV).⁷

An estimated 83% of people became infected with HCV as a result of sharing injection drug-use equipment with someone who has HCV.⁷ The remaining 17% of estimated new infections have been lumped together into one category and attributed to "other" causes, so it is impossible to know how many of these infections may be due to sexual transmission.

What Is the Evidence That HCV Can Be Transmitted Sexually?

While there is no conclusive evidence that HCV can be transmitted sexually, there is some evidence to suggest that it is occurring, especially among HIV-positive MSM. However we don't know how often it is occurring and why a higher proportion of HIV-positive MSM may be getting HCV than other populations.

How Prevalent Is Hepatitis C in HIV-Positive MSM?

Numerous studies tell us that a higher proportion of HIV-positive MSM are living with HCV infection than HIV-negative MSM. This suggests that there may be something about HIV-positive MSM that makes them more likely to become infected with HCV. However, it should be noted that not all studies have shown that HIV-positive MSM are at higher risk, so some controversy continues in the medical field.

More About These Studies

In a study of Ontario MSM, researchers found that 7.7% of (or 77 per 1,000) HIV-positive men also had HCV compared to only 1.4% of (or 14 per 1,000) HIV-negative men.⁸ This means that HIV-positive men were 5.5 times more likely to have HCV than HIV-negative men.
A study from Alberta reported an HCV prevalence rate of 9.3% among 54 HIV-positive MSM.⁹
Seven studies from Europe and Australia found that HIV-positive MSM have higher rates of HCV than HIV-negative MSM.^10-16

While most studies have found a higher prevalence of HCV among HIV-positive MSM, a few studies have not found any increased risk for HCV in HIV-positive MSM.^17-20

Research also suggests that the number of HIV-positive MSM infected with HCV each year may be on the rise. Studies from Amsterdam, the United Kingdom and France show us that rates of HCV are increasing in this population.^10,13,21,22 Since HCV started to affect MSM, its spread has continued at an increasing pace, as more and more HIV-positive MSM become infected with HCV.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.

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