HCV in Key Populations: Men Who Have Sex With Men

Incidence and Risk Factors for HCV Infection Among 
Men Living With HIV Infection Who Have Sex With Men

Several outbreaks of sexually transmitted HCV infection among men living with HIV infection who have sex with men (MSM) have been reported since 2000 (Ingiliz, 2024); (Popping, 2022); (Wandeler, 2012); (van de Laar, 2010); (Urbanus, 2009); (Matthews, 2007). A systematic review reported an HCV prevalence of approximately 7% among MSM who are living with HIV infection (Shabil, 2024), similar to a 2017 meta-analysis that found an HCV incidence of 6.35/1000 person-years among MSM living with HIV infection (Jin, 2017). The determinants of sexually transmitted, incident HCV among MSM living with HIV infection have not been thoroughly characterized but risk factors have been identified. Among MSM with HIV infection, group sex practices that can cause trauma to rectal mucosal tissue (eg, receptive anal intercourse without a condom and receptive fisting) and rectal bleeding are associated with HCV transmission (Shabil, 2024); (Daskalopoulou, 2017); (Page, 2016); (Apers, 2015); (Vanhommerig, 2015); (Witt, 2013); (Wandeler, 2012); (CDC, 2011); (Schmidt, 2011); (Danta, 2007).

The proliferation of chemsex (also known as party and play, or PNP)—use of crystal methamphetamine, mephedrone, or gamma-hydroxybutyrate, sometimes with phosphodiesterase type 5 inhibitors (which lowers inhibitions, creates feelings of invulnerability, increases stamina, and inhibits ejaculation) before or during sex—has also been associated with incident HCV infection (Schmidt, 2024); (Gonzalez-Serna, 2021); (Pufall, 2018); (Hegazi, 2017); (NHS, 2014). These HCV infections have been occurring especially in men who already have ulcerative and rectal sexually transmitted infections including syphilis, lymphogranuloma venereum, and genital herpes (Bottieau, 2010); (van de Laar, 2007); (Gambotti, 2005); (Gotz, 2005); (Browne, 2004); (Ghosn, 2004).

While it is not completely clear why higher rates of incident HCV have been reported in MSM living with HIV compared with MSM without HIV infection, behavioral factors such as serosorting (sex between partners of the same HIV status with the aim of minimizing HIV transmission risk) and increased rates of anal sex without condoms by men living with HIV infection have been implicated (Mao, 2011). In a study among 33 MSM with HIV/HCV coinfection, one-third shed HCV in their semen (Turner, 2016). In addition to being found in semen, rectal shedding of HCV has also been reported in persons with HIV/HCV coinfection (Foster, 2017b).

Incidence and Risk Factors for HCV Infection Among
Men Without HIV Infection Who Have Sex With Men

Acute HCV infections have been reported among MSM without HIV infection who present for HIV pre-exposure prophylaxis (PrEP) (Hoornenborg, 2017). These HIV-uninfected men became infected with HCV strains known to be circulating in HIV sexual transmission networks. Thus, there is growing concern that with the implementation of PrEP, high-risk MSM without HIV infection may be at increased risk of incident HCV infection through unprotected sexual intercourse with MSM with HCV infection. The risk factors for acute HCV infection in these persons remain unknown but may be similar to those reported in MSM living with HIV infection.

Testing

Recommendations for Testing and Prevention of HCV Infection in Men Who Have Sex With Men (MSM)
RECOMMENDED	RATING
Annual HCV testing is recommended for sexually active HIV-infected adolescent and adult MSM living with HIV infection. Depending on the presence of high-risk sexual and/or drug use practices, more frequent testing may be warranted.	IIa, C
HCV testing at HIV pre-exposure prophylaxis (PrEP) initiation and at least annually thereafter (while on PrEP) is recommended in MSM without HIV infection. Depending on sexual and/or drug use risk practices, more frequent testing may be warranted.	IIa, C
All MSM should be counseled about the risk of sexual HCV transmission with high-risk sexual and drug use practices, and educated about measures to prevent HCV infection or transmission.	IIa, C

Screening for HCV Infection Among MSM

Practitioners treating adolescent and adult MSM with HIV infection should be on high alert for acute HCV infection, which is most often asymptomatic (see the HCV in Children section). In accordance with US Centers for Disease Control and Prevention sexually transmitted infections (STIs) guidelines (Workowski, 2021), HCV screening should be performed at least annually and may be done more frequently depending on the presence of local and individual factors such as high HCV prevalence and/or incidence locally, high-risk sexual behavior (eg, unprotected [by a condom] receptive anal intercourse, group sex, fisting, chemsex), and ulcerative STI(s), or STI-related proctitis (Workowski, 2021); (Pufall, 2018); (Daskalopoulou, 2017); (Page, 2016); (Apers, 2015); (Vanhommerig, 2015); (NHS, 2014); (Witt, 2013); (Wandeler, 2012); (CDC, 2011); (Schmidt, 2011); (Bottieau, 2010); (Danta, 2007); (van de Laar, 2007); (Gambotti, 2005); (Gotz, 2005); (Browne, 2004); (Ghosn, 2004).

Screening should be performed using an HCV antibody test in most instances. However, individuals with self-reported recent high-risk exposures and/or newly elevated alanine aminotransferase levels should have HCV screening with both HCV antibody and HCV RNA tests due to concern for acute HCV infection. Those found to have chronic HCV infection should be offered antiviral treatment to prevent liver disease progression and transmission to others. These persons should also be counseled about risk factors for HCV transmission and the potential for HCV reinfection after cure (Ingiliz, 2017); (Ingiliz, 2014); (Lambers, 2011). Subsequent care for acute HCV infection should be as detailed in the Management of Acute HCV section.

Prevention of HCV Infection

To reduce the risk of sexually transmitted HCV and other STIs, MSM should be counseled to use condoms with all sex acts. They should also be informed about the substantial risk of HCV transmission associated with sharing any equipment used for preparing and injecting or snorting drugs. If indicated (and available), clinicians should offer referrals to syringe service programs and culturally competent counseling/drug treatment, and encourage individuals to seek testing for STIs if they have been at risk. Among persons who are using opioids, discussion of preventing HCV infection is also an opportunity to provide opioid education and naloxone distribution, which is an effective intervention to prevent overdose deaths. 

Although PrEP can prevent sexual transmission of HIV, it is not protective against HCV or other STIs. MSM without HIV infection who present for PrEP should receive risk reduction counseling. MSM without HIV infection on PrEP should also receive at least annual HCV screening for identification of incident infection.

Treatment

Recommendation on Treatment of HCV in Men Who Have Sex With Men (MSM)
RECOMMENDED	RATING
Antiviral treatment for MSM with HCV infection should be coupled with ongoing counseling about the risk of HCV reinfection, and education about methods to reduce HCV reinfection risk after cure.	I, B

Because MSM may be at high risk of transmitting HCV to others, HCV infection should be treated both for individual benefit and to prevent HCV transmission. MSM with HIV infection are considered an important population for HCV elimination through treatment as prevention (WHO, 2022); (NASEM, 2017); (Martin, 2015). The population-level benefit of expansion of HCV treatment in populations of MSM with HIV infection has been evaluated in modeling studies (Wu, 2024); (Martin, 2016); (Salazar-Vizcaya, 2016). Additionally, real-world data support the potential for HCV treatment as prevention in cohorts of MSM with HIV/HCV coinfection. Analysis of data from the Dutch acute HCV in HIV study group showed a 50% reduction in acute HCV incidence between 2014 and 2016 within 1 year of expansion of HCV therapy through unrestricted direct-acting antiviral availability to MSM with HIV infection (Boerekamps, 2018). Similarly, a pooled analysis from 6 cohorts of people living with HIV infection who had previous HCV infection that either cleared spontaneously or had been cured through treatment found that as access to direct-acting HCV therapy expanded, the incidence of HCV reinfection fell (Sacks-Davis, 2024).

HCV treatment should be coupled with education addressing the potential for HCV reinfection and risk factors for transmission to reduce the risk of transmission to others and subsequent reinfection after HCV cure. Brief counseling interventions delivered in clinical settings have been shown to reduce HIV transmission risk and may be effective in reducing HCV transmission risk (Boerekamps, 2018); (Myers, 2010); (Richardson, 2004).

Testing for HCV Reinfection

Recommendation on Prevention of HCV Reinfection in Men Who Have Sex With Men (MSM)
RECOMMENDED	RATING
At least annual (and risk-based, if indicated) HCV testing with HCV RNA is recommended for sexually active MSM after successful treatment or spontaneous clearance of HCV infection.	IIa, C

High HCV reinfection rates, ranging from 7.3 to 15.2/100 person-years, have been reported after HCV treatment and cure among MSM with HIV infection (Munari, 2023); (Ingiliz, 2017); (Martin, 2015b); (Lambers, 2011). A 2023 meta-analysis that included 38 published studies of HCV reinfection rates demonstrated the incidence of reinfection among MSM was 7.37/100 person-years; that rate was statistically significantly higher than the rate of HCV reinfection among people who inject drugs (2.84/100 person-years) (Munari, 2023). In an analysis of 606 MSM from 8 centers in Europe, an increase in HCV reinfection incidence rates was reported with each subsequent reinfection (HCV reinfection incidence 7.3/100 person-years for the first reinfection and 18.8/100 person-years for the second reinfection) (Ingiliz, 2017). For this reason, it is important to provide individuals with clear, nonjudgmental, accurate information about reducing their risk for sexually transmitted HCV. This counseling should be ongoing. Additionally, clinicians should monitor and test for HCV reinfection in sexually active MSM after cure, regardless of HIV status. Individuals found to be HCV reinfected should be retreated. HCV treatment in this setting should be as detailed in the Initial Treatment of HCV section.