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Epidemiological trends (MSM) in HCV transmission and prevalence in the Viennese HIV+ population
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Overall, we observed a successful implementation of routine screening for HCV coinfection in our HIV+ cohort (n = 1806/1874; 96.4%). While HIV+ PWIDs remain an important reservoir for HCV (anti-HCV seroprevalence 93.2% at BL and 90.3% at FU), we observed a relevant increase in anti-HCV seroprevalence among MSM from 3.7% at BL to 6.5% at last FU. Importantly, 61.0% of all incident HCV diagnoses were recorded in MSM. Considering the fact that historically, HIV/HCV coinfection used to almost exclusively affect PWIDs,7, 37-39 these findings mark an important change in HIV/HCV epidemiology in Austria and support previously published data, reporting an increasing HCV incidence in MSM that is likely driven by high-risk sex practices including chemsex.8-13 However, the potential use of intravenously injected drugs within our cohort of MSM remains unclear as the available data are solely based on self-reported behaviour. The HCV transmission risk in MSM specifically related to IDU versus high-risk sex practices should be assessed in future studies in order to provide more detailed data on these combined risk factors.
Importantly, screening for HCV within at-risk populations needs to be enforced. According to European guidelines, people at high risk for HCV infection should be screened by anti-HCV serology at least once a year. These 'key populations' include HIV-infected patients as well as HIV-negative MSM, PWIDs, people in prisons, sex workers and transgender populations. Additionally, there are specific national recommendations in Austria including not only annual testing of key populations but also systematic recall strategies.46
While people who inject drugs (PWIDs) are known to have an increased risk for the acquisition of HIV and HCV, recent trends in risk behaviour, especially among HIV+ men who have sex with men (MSM) and transgender women, have been reported as another main HCV transmission route.7-10 The use of drugs to enhance sexual experience ('chemsex') has become a major contributing factor in the current HCV epidemic among MSM as it stimulates high-risk sexual behaviour including promiscuity, traumatic anal intercourse and extensive sex duration as well as condomless sex, which in turn promotes the transmission of HIV, HCV and other sexually transmitted infections.9-13 While in PWIDs, especially in case of ongoing intravenous drug use (IDU) or opioid substitution, rates of HCV diagnosis and treatment uptake still remain low, MSM tend to show high treatment uptake and SVR rates.13, 14 French data collected between 2012 and 2016 showed a considerable fluctuation in the incidence of HCV reinfections after treatment-induced SVR in HIV+ MSM that exceeded the incidence of first infections, suggesting that a subgroup of MSM continues to engage in high-risk practices after SVR.13
04 February 2020
Background & Aims

Human immunodeficiency virus (HIV)/hepatitis C virus (HCV) coinfection is common in people who inject drugs (PWIDs). Recently, 'high-risk' behaviour among men who have sex with men (MSM) has emerged as another main route of HCV transmission. We analysed temporal trends in HCV epidemiology in a cohort of Viennese HIV+ patients.
Hepatitis C virus parameters were recorded at HIV diagnosis (baseline [BL]) and last visit (follow-up [FU]) for all HIV+ patients attending our HIV clinic between January 2014 and December 2016. Proportions of HIV+ patients with anti-HCV(+) and HCV viraemia (HCV-RNA(+)) at BL/FU were assessed and stratified by route of transmission.
In all, 1806/1874 (96.4%) HIV+ patients were tested for HCV at BL. Anti-HCV(+) was detected in 93.2% (276/296) of PWIDs and in 3.7% (31/839) of MSM. After a median FU of 6.9 years, 1644 (91.0%) patients underwent FU HCV-testing: 167 (90.3%) of PWIDs and 49 (6.7%) of MSM showed anti-HCV(+). Among 208 viraemic HCV-RNA(+) patients at BL, 30 (14.4%) had spontaneously cleared HCV, 76 (36.5%) achieved treatment-induced eradication and 89 (42.8%) remained HCV-RNA(+) at last FU. Among 1433 initially HCV-naive patients, 45 (3.5%) acquired de-novo HCV infection (11.1% PWIDs/80.0% MSM; incidence rate (IR) 0.004%; 95% confidence interval [CI] 0.0%-0.022%) and 14 had HCV reinfections (85.7% PWIDs/14.3% other; IR 0.001%; 95% CI 0.0%-0.018%) during a median FU of 6.7 years (interquartile range 7.4).
Hepatitis C virus testing was successfully implemented in the Viennese HIV(+) patients. Anti-HCV(+) prevalence remained stable in HIV+ PWIDs but almost doubled in HIV+ MSM. De-novo HCV infection occurred mostly in MSM, while HCV reinfections were mainly observed in PWIDs. HCV treatment uptake was suboptimal with 42.8% remaining HCV-RNA(+) at FU. 59 new HCV-infections (including 17 PWIDs and 36 MSM) were recorded during a median FU of 6.7 years, resulting in an incidence rate (IR) of 0.004% (95% confidence interval [CI] 0.0%-0.022%) for de-novo HCV infections and 0.001% (95% CI 0.0%-0.018%) for HCV reinfections. While 18.1% of the initially anti-HCV(-) and/or HCV-RNA(-) PWIDs acquired a new HCV infection during FU, MSM made up for 61.0% of all incident HCV infections (i.e. de-novo infections or reinfections) throughout the observation period.
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