Hepatitis C test-and-treat programme reduces HCV by two-thirds among men who have sex with men in Swiss HIV Cohort

A systematic policy of test-and-treat cured 99% of men who have sex with men with hepatitis C in the Swiss HIV Cohort in an 8-month period and reduced the prevalence of hepatitis C by almost two-thirds, Dominique Braun of the University Hospital, Zurich, reported at the 16th European AIDS Conference (EACS 2017) last week in Milan.

Dr Braun was presenting results of the Swiss HCVree trial, a non-randomised study of hepatitis C virus (HCV) testing, treatment and behavioural counselling designed to eliminate chronic HCV infection in men who have sex with men with HIV/HCV co-infection in the Swiss HIV Cohort.

The Swiss HIV Cohort has seen a 20-fold increase in the prevalence of HCV in men who have sex with men since 1996, with the greatest increase occurring since 2008, in common with other western European countries.

Glossary

fibrosis

Scarring of the liver – the development of hard, fibrous tissue. See also ‘cirrhosis’, which is more severe scarring.

condomless

Having sex without condoms, which used to be called ‘unprotected’ or ‘unsafe’ sex. However, it is now recognised that PrEP and U=U are effective HIV prevention tools, without condoms being required. Nonethless, PrEP and U=U do not protect against other STIs. 

cure

To eliminate a disease or a condition in an individual, or to fully restore health. A cure for HIV infection is one of the ultimate long-term goals of research today. It refers to a strategy or strategies that would eliminate HIV from a person’s body, or permanently control the virus and render it unable to cause disease. A ‘sterilising’ cure would completely eliminate the virus. A ‘functional’ cure would suppress HIV viral load, keeping it below the level of detection without the use of ART. The virus would not be eliminated from the body but would be effectively controlled and prevented from causing any illness. 

loss to follow up

In a research study, participants who drop out before the end of the study. In routine clinical care, patients who do not attend medical appointments and who cannot be contacted.

pegylated interferon

Pegylated interferon, also known as peginterferon, is a chemically modified form of the standard interferon, sometimes used to treat hepatitis B and C. The difference between interferon and peginterferon is the PEG, which stands for a molecule called polyethylene glycol. The PEG does nothing to fight the virus. But by attaching it to the interferon (which does fight the virus), the interferon will stay in the blood much longer. 

Reducing onward transmission and prevalence of HCV requires a reduction in the number of people with chronic HCV infection and a reduction in risk behaviours. Chemsex – especially the use of drugs and sharing of injecting equipment during sex – and group sex are strongly implicated in the increase in hepatitis C in men who have sex with men.

In an 8-month period between October 2015 and May 2016 all men who have sex with men in the Swiss HCV Cohort were screened for active HCV infection. Screening identified 177 men with chronic HCV infection (4.8%) of which 147 had been diagnosed previously. Thirty new and previously undiagnosed HCV infections were diagnosed as a result of the screening exercise.

All men with genotype 1 or 4 infection were offered immediate treatment with a course of grazoprevir/elbasvir (Zepatier) for 12 or 16 weeks depending on baseline resistance, with additional ribavirin for all genotype 1a and 4 patients with previous experience of pegylated interferon and ribavirin, for previously untreated genotype 1a patients with baseline NS5A resistance mutations and genotype 1b patients with prior HCV protease inhibitor experience.

Of the 177 people diagnosed with chronic HCV infection, 122 took part in the study (34 received treatment elsewhere, 11 had a genotype other than 1 or 4, 6 had contraindications for treatment and the remainder were either lost to follow-up or unwilling to take part in the study).

Men who joined the trial had a median age of 46 years, 88% were white and all but one was taking antiretroviral therapy. Participants had been diagnosed with HCV a median of three years before joining the study and 79% had F0-F1 stage fibrosis, indicating little liver damage since infection. Six per cent had F3-F4 stage fibrosis.

The predominant genotypes were 1a (67%) and 4 (26%), with 7% having genotype 1b infection. HCV RNA was relatively low at baseline (865,279 IE/ml).

All participants except one achieved a sustained virologic response and was cured of hepatitis C infection. The exception was a previously untreated man with genotype 4 infection who experienced viral rebound after treatment.

Treatment was well tolerated with no serious drug-related adverse events. Drug-related adverse events were reported in 29% of participants and were predominantly fatigue, diarrhoea, nausea and itching.

Preventing onward transmission and reinfection

Sixty-eight men recruited to the study reported condomless sex with non-regular partners. Of these men, 51 agreed to take part in a four-session behavioural intervention devised by Professor Dunja Nicca of Zurich University that accompanied the treatment phase of the study.

The first session focused on emotional responses to safe sex problems, the second on individualised solutions, the third on developing a personal risk reduction plan and the fourth session a reflection on the post-treatment achievement of hepatitis C cure and how to maintain it.

The study found that 65% of men reported condomless anal intercourse as a potential risk factor for acquiring HCV; only 30% reported sharing injecting equipment or other equipment for snorting drugs and 29% reported sharing sex toys or fisting as potential risk factors. Forty out of 51 reported drug use, mainly methamphetamine (43%) and GBL or GHB (57%)

The overall completion rate of the behavioural intervention was 90%. No cases of reinfection have been identified to date.

References

Braun D et al. High SVR12 rates with grazoprevir/elbasvir +/- ribavirin for 12-16 weeks guided by genotypic resistance testing among HIV/HCV coinfected MSM in the Swiss HCVree trial. 16th European AIDS Conference, 25-27 October, Milan, abstract PS9/4, 2017.

Nicca D et al. Doing the impossible: an e-health-assisted counselling intervention to reduce risk in HCV-reinfection in men who have sex with men. 16th European AIDS Conference, 25-27 October, Milan, abstract PE25/24, 2017.