The incidence of the hepatitis A virus (HAV) is increasing in Europe . Sixteen European countries have reported 1500 cases of confirmed HAV and 2660 cases of probable or suspected HAV since June 2016: the cases mostly involved adult MSM. Confirmed cases were related to three distinct clusters of genotype IA. In France, increased cases of HAV have been reported within the Paris area since January 2017 and this outbreak is now spreading to other regions of France .
In our hospital, 257 HIV-positive MSMs and 31 HIV-negative MSMs taking preexposure prophylaxis (PrEP) were followed through specialized consultations. The median age of HIV-positive MSMs was 48.9 years (range: 41–56) and was 33.7 years (range: 31.1–36.4) for MSMs taking PrEP. Between January and May 2017, we recorded four cases of acute HAV infections among HIV-positive MSMs but no incidences amongst MSMs taking PrEP .
In order to control this outbreak of HAV, the European Center for Disease Control (ECDC) recommends European countries offer and promote vaccination of MSMs against HAV . In France, this vaccination has been recommended for MSMs since 2002 . However, this outbreak is occurring within the context of a shortage of HAV vaccine . Thus, the French national-health authorities have given priority to vaccinate MSMs with HAV vaccines, and have directed HAV vaccines into hospitals and clinics specialized in sexually transmitted diseases since March 2017. Before this date, the HAV vaccine was only available in pretravel consultations.
We reviewed HAV immunization of HIV-infected MSMs and MSMs taking PrEP in March 2017 in order to vaccinate nonimmunized individuals. HAV seronegative and individuals with an unknown serological status were contacted by phone to check their serological status. Seronegative individuals were offered HAV immunization to be delivered at the hospital's pharmacy. If the HAV-immunization status was unknown, HAV serology was assessed before vaccination. HAV immunization of individuals, including those that had received a first dose of vaccine, was then assessed later on 1 October 2017.
In March 2017, HAV antibodies were found in 76% of HIV-positive MSMs, with about 25% of these cases secondary to HAV vaccination. HAV-immunization was far lower in HIV-negative MSMs taking PrEP: 61% were seronegative. Between 25 March and 31 July 2017, all but one HAV seronegative patient who could be contacted received HAV vaccination. We vaccinated 32 HIV-positive MSMs and 18 MSMs taking PrEP. After the first dose of vaccine, anti-HAV antibodies were found in 85% of vaccinated individuals.
HAV immunization of individuals, including those that had received a first dose of vaccine, increased from 76% to 84% in HIV-positive MSMs and from 20 to 89% in MSMs taking PrEP. No case of HAV was reported in our cohort between 25 March and 1 October 2017, although the HAV outbreak still remains high at a regional level. As MSMs taking PrEP are younger than HIV-positive MSMs, and because immunization against HAV increases with age , this younger population is at higher risk of contracting HAV infection.
Despite the recommendations of the French health authorities to give priority to vaccinate MSMs for HAV, this outbreak continues in France, probably because of the slow implementation of vaccination . We show here that a targeted active vaccination program can significantly increase HAV immunization in MSMs, with a rapid and positive decrease in acute HAV infections. In the context of this outbreak spreading in France, improved access to the HAV vaccine and monitoring of the implementation of HAV vaccination are urgently needed.
The authors thank Dr Frédéric GOYET and Dr Jean-Michel TASSIE from the Agence Regionale de Santé (ARS) for their help in the management of targeted vaccination.
Conflicts of interest
There are no conflicts of interest.
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