Price JC. Sexually Acquired Hepatitis C Infection in HIV-Uninfected Men Who Have Sex with Men Using Preexposure Prophylaxis Against HIV. JID 2019; 219:1373-76.

Cases of sexually acquired hepatitis C virus (HCV) infection among men who have sex with men (MSM) were first reported about 10 years ago. The number of reported cases of HCV in MSM has increased in recent years and has paralleled the use of PrEP (FTC/TDF) for HIV prevention. This publication describes 15 news cases of HCV infection that occurred  among 14 MSM from 2013 through 2018 (including one case of re-infection) who were seen at clinical sites in New York City and San Francisco. All of the men had been taking PrEP for a median of 12 months before their HCV diagnosis. None of them became HIV-infected during this time. Almost all (13/15) were asymptomatic and diagnosed by routine laboratory screening due to elevation in alanine transaminase (ALT) or the presence of HCV antibody. Their primary hepatitis diagnosis was confirmed by detection of HCV viremia in the setting of HCV antibody seroconversion.  Five of the men reported injection drug use with methamphetamine and all 14 engaged in anal receptive intercourse. Six (40%) of the men were concurrently diagnosed with bacterial STIs.  Of note, 3 (20%) spontaneously cleared their HCV infection based on undetectable HCV-RNA levels over 12 weeks from the initial diagnosis. Eight of the men were treated for HCV and cured and treatment is ongoing in 3 others. The authors encourage incorporation of ALT testing at baseline and for follow-up visits for MSM on PrEP, noting that elevation in ALT is more sensitive than HCV antibody during acute infection. They also acknowledge support for current AASLD/IDSA guidelines that recommend annual HCV antibody screening in MSM using PrEP who report multiple sex partners.

Commentary: This paper adds to our data from other cohorts in France and Amsterdam that also reported new cases of HCV in MSM. Baseline HCV screening is currently recommended by the CDC before initiation of PrEP but not as part of the follow-up assessment. It certainly should be considered based on sexual histories obtained at the time of the interval visits for PrEP.