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Hepatitis C in MSMs; a review of testing practices in the GUIDe clinic & a description of recent cases N. LYNN*, J DEAN**, E QUINN**, G FARRELL*, C MURRAY* , F LYONS*, C BANNAN*. C. DEGASCUN**, C. BERGIN* * DEPARTMENT OF GENITOURINARY MEDICINE AND INFECTIOUS DISEASE, ST. JAMES’S HOSPITAL ** NATIONAL VIRUS REFERENCE LAB Background • Hepatitis C emerging as an STI in MSM¹ • Epidemiology of Hep C transmission changing² • Since 2000 , longitudinal cohort studies confirm ↑ HCV incidence in HIV+ MSM, but not HIV- MSM • Reported incidence of HCV infection in HIV+ MSM 0.6 - 0.9/100 person years³ • The odds ratio of sexual transmission of HCV ↑ in HIV+ MSM (adjusted ratio 4.1-5.7) 1. http://www.hpsc.ie/A-Z/EMIToolkit/appendices/app23.pdf 2. http://www.sciencedirect.com/science/article/pii/S1201971216310736 3. Lauer GM, Walker BD. Hepatitis C virus infection. New Engl J Med 2001;345(1):41-52. 4. Tohme RA, Holmberg SD. Is sexual contact a major mode of hepatitis C virus transmission? Hepatology 2010;52(4):1497-505 Hx chemsex/drug use HIV+ve patients sex associated with trauma rectal LGV +ve Audit Methods HIV+ MSMs attending a HIV clinic in January 2016 Electronic Patient Record (EPR) reviewed Descriptive column statistics used for data analysis Audit Results n=198 198 HIV+ MSM - 8 clinics – Jan 2016 Median age 38 (IQR 31,50) 14% (n=13) detectable HIV VL (45-68409) 96% (n=191) HCV Ab/PCR on EPR Median 28% 68% time to last Ab/PCR: 107 days (0-5222 days) (n=57) Ab/PCR done @ OPD Ab -ve (n=135) Hepatitis C Ab/PCR test <365 days* Ab +ve * As per BASHH Guidelines no Ab on EPR MSM STI testing in HIV OPD 84% (n=167) STI screen on EPR 27% (n=54) MSM STI screen @ clinic 71% (n= 141) MSM STI screen in the past year* Median time since last screen 115 days (range 0 – 2083) 82% (n=138) last screen negative *as per BASHH Guidelines Conclusion Good compliance with HCV & NAATs BASHH testing Guidelines (66% & 71%) Poor documentation of sexual practices, chemsex & drug use Strategies to improve testing: Add full MSM STI screen to annual HIV bloods Include hepatitis C Ab in routine MSM STI testing Improve access to results from other services (e.g GMHS) Universal patient number to limit duplication of testing Audit findings will be presented at departmental level Cycle 2 of Audit - after implementation of the above strategies Hepatitis C outbreak in MSM CDC Definition¹ Confirmed: Negative Ab/PCR < 12/12 Probable: meets clinical criteria, no testing in past 12/12 Clinical Criteria: Lab Criteria: T◦/ HA/Malaise/Anorexia/Vomiting/Diarrhoea/Abdo Pain Anti HCV + AND Jaundice OR PCR+ ALT Peak >200 Antigen+ 1. https://wwwn.cdc.gov/nndss/conditions/hepatitis-c-acute/case-definition/2016/ Results 19 MSM 1 Aug 2015 – 21 Oct 2016 Average age 36 (range 23-56) 89% (n=17) previously tested for HCV Median days since last test 239 (range 60-3088) 63% (n=12) previous test within 1 year % 37% (n=7) test >1 year ago Hep B immune 74% (n = 14) GUIDe clinic GMHP Rooms HIV & STI Results HIV STI testing (n=18) 78% (n=15) Average CD4 571 VL UD VL 73% (n=11) Detectable 27% (n=4) Detectable VL Median 60,096 Range 56- 124,831 positive STI screen negative STI screen no screen STI screen +ve (66%, n=12) Pharyngeal GC Urethral GC Rectal GC LGV T Pall HSV Rectal CT Acute Hepatitis C Genotype 90% Genotype 1 (n = 17) 5% Genotype 3 (n = 1) 5% PCR -ve prior to genotyping (n = 1) Transaminases Median Range AST @ Dx 119 25-1104 ALT @ Dx 264 28-2272 Peak AST 211 28-1104 Peak ALT 475 34-2272 NS3 Sequencing Clade I w/ Q80K Clade I w/ V55A 1 1 PCR –ve 1 HCV viral load; log 2 IU/ml 1 Did not amplify 1 G3 Clade II w/ N174G Clade II w/o N174G 5 8 G1a n = 15 1 GT 1a 1a 1a 1a 1a 1a 1a 1a 1a 1a 1a 1a 1a 1a 1a 3 1a Clade II II II II II I I I I I I I I I II NS3 Result N174G N174G N174G N174G N174G Q80K Q80K Q80K Q80K Q80K Q80K Q80K Q80K V55A 89% Clade I: Q80K mutation GT 1a H77 Ref GT 1a Clade I GT 1a Clade II GT 1a H77 Ref GT 1a Clade I GT 1a Clade II Where are they now and how are they doing? n = 19; n=18 managed in GUIDe “Chronic” HCV (n=2) Spontaneous clearance (n=3) PCR +ve @ last visit (Aug-Nov ‘16) (n=11)* DAAs in GUIDe (n=1)** Travelled for treatment/meds (n=3): HCVL UD Post Rx (n = 2) HCVL <12 W2 Rx (n = 1) *1 due DAAs, Fibroscan score 9 **Fibroscan score 8.7 STI screens in HCV Urethral CT Syphilis Pharyngeal GC Rectal GC positive Oct '16 positive Sept '16 positive Sept '16 <12 Week 2 HCV Treatment positive Aug '16 positive Oct '16 Conclusion: Anecdotal cases noted at clinic visits – differing sites No strong association with LGV Viral sequencing to support epi and PN data in managing outbreak Concern re: transmitted resistance - treatment implications Preclusion to rx based on criteria Staging of liver disease High rates of new STIs Thanks; GUIDe Clinic: C Bannan, C Bergin, G Farrell, C Murray, F Lyons NVRL: C De Gascun, J Dean, E Quinn SJH Lab: B Crowley, M Kelleher GMHP: S O’Dea, G Courtney [email protected]