Sexual transmission of Hepatitis C

[Guest guest]

Sexual Transmission of HCV in MSM in Europe Jürgen K. Rockstroh, MD: Danta and colleagues[26] presented an update of an earlier paper addressing the recent outbreak in Europe of sexually transmitted acute hepatitis C virus (HCV) infection in men who have sex with men (MSM) (Capsule Summary). This was the first study to gather blood specimens from all pertinent sites where transmission has occurred and to perform phylogenetic analyses to determine if the viruses were related to each other.Indeed, comparisons of the phylogenetic samples showed that there were genetically related clusters and that the infectious strains were therefore related to each other. Travel among different countries, generally referred to as “country mixing,” is creating greater genetic diversity among viruses. The fact that these related clusters were found suggests that the different strains are not variations created by changes in pathogenicity of the virus, but that sexual transmission is the driving factor.Overall, I think it is clear that the HCV has entered certain groups of patients through sexual transmission, predominantly MSM. A poster from Germany reported risk factors for HCV infection in HIV-infected MSM,[27] and it appeared that sexual practices with a high risk of blood-blood contact were associated with the greatest risk. Other factors that independently increased risk of transmission were increasing numbers of sexual partners, having many concurrent partners, and the use of recreational drugs, such as cocaine.These studies are particularly important because they address the question of how to address this as-yet contained outbreak from a public health perspective. It is worrisome that sexually transmitted acute HCV cases in MSM have also recently been described in Australia and the United States. The prevalence of acute HCV infection appears to be increasing, and I do not believe that this increase cannot be explained simply by better screening practices. Rather, a high percentage of these patients—I would say two thirds—are symptomatic and have severe liver enzyme elevation or elevated bilirubin. This level of disease would manifest itself as severe jaundice and would be difficult to miss.There is absolutely no doubt in my mind that these reports reflect a new pattern of sexual HCV transmission. The question is why now? Perhaps recreational drug use is different in 2007 than it was in the past. The availability of drugs like sildenafil allow a single person to have more partners per night; also, the Internet has clearly allowed people with similar sexual interests to connect. P. Kotler, MD: This is one of several sexually transmitted diseases that have increased recently, at least in the United States. I believe that if HIV-infected patients screen positive for a sexually transmitted disease such as syphilis, they should be intensively screened for other diseases as well, including HCV. Not all cases of acute HCV infection are symptomatic, so identifying any of the other sexually transmitted diseases should lead to active screening. Carr, MD: I know some clinicians who advocate repeat testing for HCV infection every year in HIV-infected patients, rather than it being a baseline test only.Jürgen K. Rockstroh, MD: Unfortunately, there are insufficient data on the cost-effectiveness of routine screening, but I agree that many cases will inevitably be missed if some form of routine testing is not introduced. Carr, MD: In our own clinic, we have screened almost 1000 people who have presented for nonoccupational postexposure prophylaxis and very few of them have symptoms of active sexually transmitted diseases, but approximately 15% of them have an active sexually transmitted disease. For us, screening for sexually transmitted diseases has become routine, but there will no doubt be geographic differences that will define the practicality of screening everyone.