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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]