CROI 2017: Higher than Expected HCV Prevalence Among HIV- Gay Men in Amsterdam PrEP Program

An unexpectedly high number of HIV-negative gay and bisexual men taking pre-exposure prophylaxis (PrEP) in Amsterdam were found to have hepatitis C virus (HCV) infection, suggesting HCV is being transmitted sexually between men with and without HIV, according to a presentation last month at the Conference on Retroviruses and Opportunistic Infections in Seattle.

Starting in the early 2000s researchers in the U.K. and elsewhere in Europe have reported clusters of apparently sexually transmitted acute HCV infection among HIV-positive men who have sex with men (MSM). Similar outbreaks followed in Australia and the U.S.

Several risk factors have been implicated — including condomless anal sex, fisting, use of sex toys, other sexually transmitted infections (STIs), and non-injection drug use — but these have not been consistent across studies. Experts have traditionally assumed that HCV is transmitted through sexual activities that involve blood, but the virus has also been detected in semen, rectal secretions, and faeces.

To date sexually transmitted HCV has mostly been seen among HIV-positive MSM, with much lower rates (generally around 1% or less) among HIV-negative men, comparable to that of the general population. But cases of apparent sexually acquired HCV have been reported among HIV-negative gay men as well – including in the Kaiser Permanente San Francisco PrEP program and the U.K. PROUD and French Ipergay PrEP studies– and there is some evidence these may be increasing.

Elske Hoornenborg and colleagues looked at HCV prevalence among HIV-negative gay and bi men at high risk for acquiring HIV who enrolled in the Amsterdam Pre-Exposure Prophylaxis Project (AMPrEP) run by the Amsterdam Public Health Service.

Men seeking PrEP were tested for HCV antibodies (indicating that someone has ever been infected, including those who spontaneously cleared the virus or were successfully treated) and HCV RNA (indicating active viral replication).

Among those who tested positive for HIV RNA, part of the HCV NS5B gene was sequenced and used to construct phylogenetic trees. These show how closely related viruses from different people are and can shed light on transmission networks. The researchers compared HCV sequences from 375 HIV-negative AMPrEP participants and 182 HIV-positive gay and bi men with acute HCV infection in the Dutch MOSAIC cohort.


  • 18 of the HIV-negative AMPrEP participants, or 4.8%, tested positive for either HCV antibodies or HCV RNA at baseline.
  • Most men (15, or 83%) had detectable HCV RNA showing active infection, including 1 without detectable antibodies, suggesting very recent infection.
  • HCV genotyping showed that most HIV-negative men (73%) had genotype 1a, which is common in Europe and the U.S.; 3 men (20%) had genotype 4d, which is predominant in the Middle East and North Africa but also often seen in MSM clusters in Europe; and 1 man (7%) had genotype 2b.
  • Of the 15 participants with detectable HCV RNA, 13 (87%) were part of 6 MSM-specific clusters with related virus, and these all included both HIV-positive and HIV-negative gay men.
  • All HIV-negative men with HCV genotype 4d and the single man with 2b were in these clusters, while 9 of the 11 men with genotype 1a belonged to 4 separate clusters.
  • Nearly a quarter of the gay men testing positive for HCV (4 out of 18) reported injecting drugs during the 3 months before starting PrEP — much higher than the 3% (11 out of 357) among HCV-negative participants; the majority, however, did not have injection-related risk.
  • Men who tested positive for HCV were younger on average than those without HCV (median 33 vs 40 years), had more anal sex partners (median 20 vs 15), and were more like to have been recently diagnosed with chlamydia, gonorrhea, or syphilis (61% vs 35% in the past 6 months) and to have engaged in “chemsex,” or use of certain recreational drugs during sex (83% vs 40% in the past 3 months).

“HCV prevalence among HIV-negative MSM who started PrEP was higher than expected (based on the literature),” the researchers concluded. “HIV-negative MSM with HCV infection were infected with HCV strains already circulating among HIV-positive MSM, which suggests overlap between HIV-positive and HIV-negative MSM.”

Based on these findings, they recommended that routine HCV testing should be offered to gay and bi men at high risk for HIV, especially those enrolling in PrEP programs.

Presenting similar data at the recent HepHIV 2017 meeting in Malta, Maria Prins from the Amsterdam team suggested that diagnosing and treating hepatitis C early in high-risk gay and bi men could potentially bring about a rapid reduction in overall HCV incidence in this population.

Another study presented at CROI indicates this may already be happening. Bart Rijnders and colleagues reported that new HCV infections among HIV-positive gay and bi men at health centers throughout the Netherlands have dropped by half in just over a year since the country instituted a policy of unrestricted access to direct-acting antivirals for hepatitis C treatment.


This research highlights the need for baseline and routine regular Hepatitis C screening to be included within PrEP programs among gay and bisexual men. Whilst sexual transmission of Hepatitis C is not common, it has been increasing among gay men and particularly HIV+ men, as demonstrated by these (and other) studies. The mechanisms driving increased sexual transmission of Hepatitis C among gay and HIV+ men are not fully understood, but some risk factors are associated such as recreational drug use during sex (chem-sex), and where prolonged or rough sex may incur tears or abrasions where blood-to-blood contact may be increased.  Sharing unwashed sex toys, snorting straws and barrels for ‘booty bumping’ (anal drug administration) may also increase the risks of sexual transmission of Hepatitis C.  A useful fact sheet by Positive Life NSW is available here:

The good news is that new direct acting antivirals (DAAs) pills may cure 95% of hepatitis C in as little as 8-12 weeks (2-3 months) of treatment. These comprise taking a single daily pill (or sometimes 2), with little or no side effects.  However, it is possible to be re-infected with Hepatitis C, but retreatment options are possible.

Currently there are no PBS listed DAA treatments for all Hep C virus (HCV) genotypes, but this is expected very soon. Although an all genotype (‘pan-genotypic’) treatment is an exciting new option in the wait, the existing effective treatments for specific Hep C genotypes will still have a place in treatment options and are presently able to treat most, if not all genotypes (1 to 6).  Genotypes 5 and 6 still require the older interferon (injection) & ribavirin (pill) treatments, but treatment is greatly reduced to 12 weeks with the addition of Sofosbuvir (one of the new DAAs). Genotype 1 and 3 are the most common in Australia, although all genotypes do occur.

Presently, the current (interferon-free) pill-based Hep C treatments for genotypes 1 to 4 are:

HARVONI (a single dual combo pill containing sofosbuvir + ledipasvir) for genotype 1- OR –

SOVALDI (Sofosbuvir) and DAKLINZA (daclatasvir) for genotype 1 and 3 – OR –

SOVALDI (Sofosbuvir) with IBAVYR* (ribavirin) for genotype 2 and 3 – OR

ZEPATIER (grazoprevir + elbasvir) for genotype 1 and 4 (the most recently PBS approved new treatment 01 January 2017, prior to which there were no interferon-free treatments approved for genotype 4 – OR –

VIEKIRA PAK (paritaprevir/ritonavir/ombitasvir/dasabuvir) for genotype 1, although used less frequently.

The older pill IBAVYR* (ribavirin) may still used in some circumstances (dependent upon previous HCV treatment and liver condition), combined with one of the above treatments except Harvoni.  In some situations (not all) the addition of Ribavirin may involve 16 weeks (4 months) or 24 weeks (6 months) of treatment.

Not to worry though, your doctor will chose the treatment more suited to your HCV genotype, and your medical/treatment history, including your HIV meds your liver condition. Even if you previously had the older Hep C treatment (interferon + ribavirin or first generation HCV protease inhibitor) that did not work, you can retry these new more effective and simpler treatments.

About 20% of people will naturally clear the Hep C virus (without any treatment), although this may be less likely in people with HIV/HCV coinfection. Nonetheless, with these new short-term treatments, people with HIV can be cured of Hep C virus (HCV) just as easily as people with HCV only. 100% adherence to the treatment will give the best chance of clearing Hep C, along with avoidance of alcohol as much as possible during this usually short treatment period.


More Info?


E Hoornenborg, M Prins, RCA Achterbergh, et al. High prevalence of hepatitis-C virus among HIV negative MSM in Amsterdam PrEP Project. Conference on Retroviruses and Opportunistic Infections. Seattle, February 13-16, 2017. Abstract 519.

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Article by Liz Highleyman. Published on Wednesday, 22 March 2017
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