Hepatitis C infection has increasingly been seen among men who have sex with men (MSM), particularly human immunodeficiency virus (HIV)–infected MSM, in Europe and the East Coast of the United States.1,2 Increasing prevalence of hepatitis C virus (HCV) among MSM has also been reported among those without a history of intravenous drug use (IDU).3,4 We previously reported low levels of HCV infection among non-IDU HIV-infected MSM in San Francisco.5 We now report on data collected in 2011 among HIV-infected and HIV-uninfected MSM in San Francisco with and without history of IDU.
We tested blood specimens collected during 2011’s National HIV Behavioral Surveillance (NHBS) MSM3 for HCV.6 Antibody testing was performed using the Abbott Architect Anti-HCV test on an i1000 instrument (Abbott Diagnostics, Abbott Park, IL). Per Centers for Disease Control and Prevention recommendations, specimens with a signal-to-cutoff (S/CO) value of at least 5.0 were considered true-positive infections. Specimens with an immunoassay S/CO value from 0.80 to 0.99 (“grayzone”) or 1.0 to 4.99 (10/474 specimens tested; 2.1%) were subject to HCV RNA testing (Abbott RealTime m2000; Abbott Molecular, Des Plaines, IL) for confirmation. None of those specimens were found to possess HCV RNA at levels at least 12 IU/mL. A previous study described that the positive predictive value of specimens with an S/CO value from 0.80 to 4.99 was at least 10.6%.7 Considering the lack of RNA in the specimens, we therefore classified these as “not infected.” Intravenous drug use status was measured by a question that asked whether participants had ever used injection drugs. Previous HCV diagnosis was measured by self-report. We calculated χ2 and Fisher exact statistical tests comparing HCV-infected and HCV-uninfected men. We produced point estimates and corresponding 95% confidence intervals (CIs) to compare HCV infection among HIV- and non–HIV-infected men by IDU status. Participants of the NHBS provided consent for specimen banking for future testing. The NHBS had institutional review board approval from the University of California, San Francisco’s Committee on Human Research.
Of 474 specimens tested, we had complete behavioral data and HIV status on 466 MSM. Table 1 shows age, ethnicity, injection drug status, and HIV infection among all men and then by HCV status. Men infected with HCV were older (47.6% were 51 years or older) compared with HCV-uninfected men, where 19.1% were 51 years or older (P = 0.002). There were no significant differences in race/ethnicity between HCV-infected and HCV-uninfected men. Men with a history of IDU were more likely to be HCV infected (57.1%) compared with HCV-uninfected men (14.6%) (P < 0.001). Hepatitis C virus–infected men were also statistically significantly more likely to be HIV infected (P < 0.001). Among these 466 MSM, overall HCV prevalence was 4.5% (95% CI, 2.6–6.4). When stratified by ever IDU (ever having engaged in injection drug use), 15.5% (95% CI, 7.3–23.9) of ever-IDU MSM were HCV infected, whereas 2.3% (95% CI, 0.8–3.8) of non-IDU were HCV infected. Almost half of the ever-IDU HCV cases had been previously diagnosed with HCV, whereas all of the never-IDU cases had been previously diagnosed with HCV. We further stratified the sample by HIV infection status, with 108 and 358 MSM being HIV infected and HIV uninfected, respectively. Among the HIV-infected MSM, overall HCV prevalence was 15.7% (95% CI, 8.8–22.7), whereas HCV prevalence among IDU and never-IDU HIV-infected MSM was 22.9% (95% CI, 8.2–37.5) and 12.3% (95% CI, 4.6–20.1), respectively. As for previous diagnosis of HCV among HIV-infected MSM who had a history of IDU, less than half had been previously diagnosed, and all of the never-IDU HIV/HCV-coinfected men had a previous diagnosis of HCV. Among HIV-uninfected MSM, 9.5% (95% CI, 0.3–18.8) of those with a history of IDU were infected with HCV, whereas none of the HIV-uninfected MSM without a history of IDU were infected with HCV (Table 2).
Our results reinforce earlier findings that HCV infection is most common among older individuals8 but does not echo other findings that suggest race/ethnicity differences in HCV infection. Indeed, our study suggests that in San Francisco, white MSM are more likely to be HCV infected than MSM of color. Hepatitis C virus infection among HIV-infected non-IDU MSM detected in this study is somewhat higher than that found in 2004 (8.7%; 95% CI, 1.9–13.2) and 2008 (4.5%; 95% CI, 0.1–8.9)5; however, these differences were not statistically significant. Our findings suggest that there is a background high level of HCV among non-IDU HIV-infected MSM that appears stable over the last several years. Moreover, all HCV cases among HIV-infected non-IDU MSM were previously diagnosed by a health care provider, suggesting that these infections may not be recent infections. Hepatitis C virus prevalence among non-IDU MSM overall is not higher than estimates for the general population,9 and our study found no infections among HIV-negative non-IDU MSM. An additional point is that our findings underscore the association of HCV infection with a history of IDU and HIV rather than with sexual behavior alone. Although reports have suggested sexual transmission to be a factor among HIV-infected MSM,1 we were not able to investigate this further because our study is cross sectional after the timing of HIV and HCV infections could not be determined. However, it is of note that among HIV-infected non-IDU men, HCV prevalence is more than 8 times higher than among the general population in the United States.9 Despite the finding that our city has not experienced the rise in HCV among non-IDU MSM seen in Europe and the East Coast of the United States, health care providers and public health officials should maintain vigilance around HCV among HIV-infected MSM in care and among those newly diagnosed.
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