Scaling up screening and treatment for elimination of hepatitis C among men who have sex with men in the era of HIV pre-exposure prophylaxis

Abstract

Background: Routine HIV pre-exposure prophylaxis (PrEP) and HIV care appointments provide opportunities for screening men who have sex with men (MSM) for hepatitis C virus infection (HCV). However, levels of screening required for achieving the WHO elimination target of reducing HCV incidence by 90% by 2030 among all MSM are unknown. Methods: An HCV/HIV transmission model was calibrated to UK prevalence of HIV among MSM (4¢7%) and chronic HCV infection among HIV-positive MSM (9¢9%) and HIV-negative MSM (1.2%). Assuming 12¢5% coverage of PrEP among HIV-negative MSM, we evaluated the relative reduction in overall HCV incidence by 2030 (compared to 2018 levels) of HCV screening every 12/6-months (alongside completing direct acting antiviral treatment within 6-months of diagnosis) in PrEP users and/or HIV-diagnosed MSM. We estimated the additional screening required among HIV-negative non-PrEP users to reduce overall incidence by 90% by 2030. The effect of 50% reduction in condom use among PrEP users (risk compensation) was estimated. Results: Screening and treating PrEP users for HCV every 12 or 6-months decreases HCV incidence by 67¢3% (uncertainty range 52¢7À79¢2%) or 70¢2% (57¢1À80¢8%), respectively, increasing to 75¢4% (59¢0À88¢6%) or 78¢8% (63¢9À90¢4%) if HIV-diagnosed MSM are also screened at same frequencies. Risk compensation reduces these latter projections by <10%. To reduce HCV incidence by 90% by 2030 without risk compensation, HIVnegative non-PrEP users require screening every 5¢6 (3¢8À9¢2) years if MSM on PrEP and HIV-diagnosed MSM are screened every 6-months, shortening to 4¢4 (3¢1À6¢6) years with risk compensation. For 25¢0% PrEP coverage, the HCV elimination target can be reached without screening HIV-negative MSM not on PrEP, irrespective of risk compensation. Interpretation: At low PrEP coverage, increased screening of all MSM is required to achieve the WHO HCVelimination targets for MSM in the UK, whereas at higher PrEP coverage this is possible through just screening HIV-diagnosed MSM and PrEP users.

Incidence of recently acquired hepatitis C virus infection among HIV‐infected patients in southern Spain

“…Specific behavioural and educational programmes are required, but such interventions may be difficult to implement because MSM using chem‐sex usually do not identify themselves as drug users [33]. Enrolment in HIV pre‐exposure prophylaxis (PrEP) programmes might reduce HCV incidence due to a reduction in risky behaviour [34], but they do not seem to achieve it, probably because HIV‐infected MSM and HIV‐negative MSM using PrEP share similar risk practices [35]. In fact, a recent study in a cohort of HIV‐negative MSM using PrEP in the Netherlands reported high IR of RAHC and of HCV reinfection, similar to the rates that we have found herein [36].…”

The cost‐effectiveness of case‐finding strategies for achieving hepatitis C elimination among men who have sex with men in the UK

“…However, significant HCV infection resides in HIV‐negative MSM (1.2% prevalence in UK in 2008/2009), 7 especially among those on HIV pre‐exposure prophylaxis (2.1% in PROUD study) 8 . Although three recent European studies have demonstrated scaling‐up HCV treatment can result in substantial reductions (51%–77%) in HCV incidence among HIV‐positive MSM, 6,9,10 our modelling suggests that screening and treatment is also needed in HIV‐negative MSM to reach the HCV elimination targets among all MSM 11 …”

“…We adapt a previous deterministic continuous‐time model of HIV and HCV transmission among all UK MSM 11,16 to include stages for HCV‐related liver disease progression and prior exposure to infection (full details and further parameter discussion in supplementary material Appendix ). The model (Figure ) stratifies MSM by compartments for HIV and PrEP status (susceptible on/off PrEP, acute HIV infection on/off PrEP, undiagnosed chronic HIV infection and diagnosed chronic HIV infection); HCV‐status (susceptible without HCV antibodies, susceptible with HCV antibodies, acute HCV‐infection, undiagnosed and diagnosed chronic HCV‐infection); stage of liver disease progression (undamaged, fibrosis stages F1 through to F4, decompensated cirrhosis, hepatocellular carcinoma (HCC), liver transplantation and post‐liver transplantation) and either low‐ or high‐risk sexual behaviour, defined by the number of anal sex partners (high‐risk defined as ≥15/year).…”

“…PrEP has also become readily available in Wales and Scotland, 13 and is being rolled out in England 14 . In this changing environment, our previous modelling suggested that numerous screening strategies could achieve HCV elimination among MSM without the need for behavioural change, with options including differing levels of screening among HIV‐diagnosed MSM and HIV‐negative MSM on or off PrEP 11 . To help inform policy decisions for achieving HCV elimination, this analysis uses modelling to determine which of these HCV screening strategies is the most cost‐effective for achieving HCV elimination among MSM in the UK.…”

Allocating treatment resources for hepatitis C in the UK: a constrained optimization modelling approach

“…Stratifications by high and low injecting risk, with high-risk being defined as being homeless and/or a crack cocaine injector that has been shown to increase the risk of HCV infection acquisition among PWID, which results in more benefit of ‘treatment as prevention’. The future model could simulate the movement of MSM through different interaction behaviour with sexual partnerships [ 104 ], HIV pre-exposure prophylaxis states, and HIV infection status [ 105 ]. Stratifications by sexual partnerships could include ‘regular partnerships’ (relationships lasting more than one time step), ‘casual partnerships’ (individuals who meet up with for casual sex on more than one occasion), and ‘random partnerships’ (individuals who meet up with for only a single interaction) to capture different sexual risk and the potential compliance to treatment.…”