Objectives of World Health Organization (WHO) are ambitious: 90% of cases diagnosed, 80% treated and a 90% reduction of new cases (to 5 per 100,000 a year).1 With the efficacy and tolerability of direct-acting antivirals (DAA) these goals should be possible, at least in certain scenarios where access to diagnosis and treatment is assured, as would be the case of persons living with HIV (PLHIV) and people in Pre-Exposure Prophylaxis (PrEP). In Spain, epidemiological trends of HCV infections have dramatically decreased with generalization of DAA in PLHIV.2 Nevertheless, data from incidental cases reported in the hepatitis C surveillance system are quite imprecise due to the lack of declaration of cases from many Autonomous Communities.3 A study from southern Spain, described incidence rates of recently acquired hepatitis C (RAHC) from 3.77 per 100 persons-year in 2016, 1.85 in 2017, 1.49 in 2018 and 1.98 in 2019 in PLHIV.4
Does anyone have doubts that HCV infection is another sexually transmitted infection (STI) in MSM?Most likely transmission risk factors are traumatic sex practices with increased risk for blood–blood contacts, concomitant other STIs and use of chemsex.5 Moreover, rectal shedding of HCV in HIV-coinfected MSM and transmission of HCV from dendritic cells have been discussed as contributors to the spread of acute HCV.6
Who is at risk of acquiring HCV currently?Since 2002, increases in sexually transmitted acute hepatitis C (AHC) have been observed among MSM living with HIV all around the world.7 New cases of HCV infections and re-infections nowadays worldwide, are mainly occurring in MSM (PLHIV or not) with high-risk behavoirs.4,7–10 In the present number of “Enfermedades Infecciosas y MicrobiologíaClinica”, Martín-Carbonero et al.11 present a cohort of RAHC infections in PLHIV. Characteristics of this population are “high-risk behaviors for STIs”: condomless anal sex, multiple sexual partners, fisting, chemsex or slamming, and are similar to those with RAHC in persons not living with HIV.8–10 People in PrEP programs (mainly MSM or transgender women) with high-risk behaviors for STI including HVC, are located and closely monitored, which facilitates early diagnosis and early treatment.12,13
How can we do the screening?In population at risk, periodic screening is recommended with ALT levels, serology (anti-HCV antibodies) or viremia (RNA-HCV) in cases with previous infections.14 We must take on account that >70% are asymptomatic.15
Can we do something else apart from behavioral interventions?As in other studies, results from this study show high rates of having had another STI previously (more than 90% had at least 1 STI ever and 52% in the year before HCV diagnosis) and even previous HCV (33.6%).9,13,15 This shows that behavioral changes regarding risk practices are difficult to carry out.
Recent guidelines recommend early treatment of RAHC especially in high-risk population in a “test&treat” strategy with pangenotypic DAA.16,17 In the absence of a vaccine, we must act on the target population that keeps the epidemic active and generates new cases, in addition to reach hidden undiagnosed HCV infected population acting as reservoir. In this sense, “test&treat” strategies and DAA access generalization is a priority to reduce the incidence.
Are the “test&treat” strategy and DAA generalization efficient?In this scenario, viral response is very high. In the study of Martin-Carbonero,11 94% presented sustained viral response (SVR) and only 11% (10 participants) had spontaneous clearance (SC). This data are consistent with what is reported in the literature, less than 15% of SC and SVR percentages above 90%.18 There is no doubt that to continue insisting on early treatment with “test&treat strategies” is a main point to achieve a reduction in AHC infections as shown in the Dutch cohort.19 Both national and international guidelines recommend initiating HCV treatment with pangenotypic DAA as soon as possible, without waiting for spontaneous resolution.16,17,20
What can we do with re-infections?HCV reinfection is also well known specially in MSM PLHIV with ongoing risk-behavoirs,9 hence the need to continue doing periodic screening with HCV-RNA determinations. Anyway, among people with virological failure following treatment of AHC or RAHC, various retreatment regimens have been successfully prescribed.18 There have been no documented cases of virological failure among people retreated with either a standard or salvage regimen after DAA treatment failure for AHC and RAHC infection, and the emergence of clinically significant resistance-associated substitution is uncommon.9,18,19
In the race toward hepatitis C elimination, despite major advances in therapeutics, prevention remains suboptimal. Furthermore, we do have a task ahead of us to implement and generalized educational interventions on sexual health from childhood, as well as harm reduction in chemsex users. Our efforts must be focused on promoting test&treat strategies. We know perfectly well the population at risk, have accurate screening and diagnostic tests and highly effective antiviral drugs, which means we have all the tools that would undoubtedly contribute to a progressive decrease in the incidence of this infection in this population.
In conclusion, a scenario in which new HCV infections occur is in MSM at risk of STIs, use of chemsex and slamming. The behavior is like another STI and the strategy should be similar to other STIs: advice on healthy habits and risk reduction, routine screening leading to early diagnosis, sexual partners tracing and use of pangenotypic DAAs as soon as possible in a treatment-as-prevention effect. Objective: to reduce community viremia.
