Sexual Transmission of HCV in Gay Men Should Not Be a PrEP Deterrent, Say Advocates
After two men on pre-exposure prophylaxis (PrEP) at the Kaiser Permanente San Francisco Medical Center tested positive for the hepatitis C virus (HCV), clinicians at the center penned a letter to the editor of the journal Clinical Infectious Diseases calling for routine HCV testing in gay men who are currently on PrEP. The two men were among 485 HIV-negative gay men receiving PrEP at the clinic between 2011 and 2014.
Both men had a history of several rectal sexually transmitted infections (STIs) while on PrEP and no non-sexual risk factors, such as using injection drugs or getting a tattoo or piercing. While the HCV incidence rate among the HIV-negative gay men at the clinic is much lower than the incidence rate among HIV-positive gay men in general, these findings add to the "larger dialogue about having sex without a condom while on PrEP," AIDSmeds said in its write-up on the topic.
Jeremiah Johnson, HIV prevention research and policy coordinator at Treatment Action Group (TAG), says that these findings are important to discuss, but that PrEP still holds an immense amount of value for those who wish to take it. "It's always important for an intervention that we have for HIV to account for some of the potential unintended side effects, but the problem is that we can't throw the baby out with the bathwater. PrEP isn't perfect; it's not appropriate for all sexual risks -- neither are condoms."
Most importantly, Johnson added, we must allow people to mitigate their own HIV risk and choose a prevention method that they are comfortable with. "We have no perfect HIV prevention intervention, so in the meantime we have to find out how to make [condoms and PrEP] work together and have open discussions without shutting it down with hysteria."
"We're always going to be looking for potential complications, but that doesn't mean because PrEP isn't perfect, we stop using it and expect gay men to adopt impossibly high rates of condom usage. That never worked and it never will. No population uses them 100% of the time," Johnson added.
The biggest threat for HCV in PrEP users may stem from a lack of clear information on the potential for transmission. "I'm not overly worried, just confused about the risk of transmission through sexual contact," said Adrian Mills, 29, a PrEP user.
Mills added that, while recent sexual behavior has made him cognizant of his risk for HCV, he does not think that should deter anyone from taking PrEP -- and it should not fuel further PrEP criticism. "It is up to the individual how they choose to use PrEP, and all we can hope is that they are working with an informed comfort zone," he said.
The threat of HCV for sexually active gay men is a conversation that few are willing to have, according to Mills.
Another gay man, Jarad Ringer, 38, said that he never had a conversation about sexually transmitted HCV until he contracted it in 2010. The infection came up on routine bloodwork with his doctor, after which he was referred to Mt. Sinai to participate in a study of HCV-positive HIV-negative gay men. According to Ringer, conversations around HCV rarely happen among gay men. "No, I don't think it's a conversation that gay men have at all. It's not a conversation that I've had with sexual partners in the past."
Mills also reported that HCV goes undiscussed in gay circles. "Lately, [HCV] is more of an ominous warning given to individuals on PrEP, from what I've seen. In fact, I don't think I heard any discussion prior to PrEP about hepatitis A, B or C," he said.
After his acute infection, and during his six-month treatment with interferon to cure his HCV, Ringer said he changed up his STI protection regimen. "I did have sex a few times during my course of treatment, but I did use a condom or my partner used a condom during those sexual encounters while I was undergoing treatment."
Ringer was adamant that the potential for HCV transmission should not deter PrEP use, saying "there's a relatively low risk to become infected with hep C through sexual contact."
Mills concurred that HCV should not deter people from taking PrEP.
"If someone is really concerned about hepatitis C, that exists outside PrEP," he explained. "They need to act accordingly based on that concern. The same goes for any STI."