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What’s Behind London’s Falling HCV Rates in HIV+ MSM?

SEATTLE — Rates of hepatitis C infection dropped dramatically among HIV-positive men who have sex with men (MSM) in London following the rollout of direct-acting antivirals (DAAs), as well as a host of risk-behavior modification adjustments, a researcher said here.

Since 2015, and the peak of the HCV epidemic in London, there was a 79% reduction in the incidence of first hepatitis C infection, as well as a 68% reduction of overall hepatitis C incidence in HIV-positive MSM, reported Lucy Garvey, MD, of Imperial College Healthcare NHS Trust in London.

However, there has been a rise in reinfection rates since DAAs were made widely available in 2015, indicating there is still progress to be made, according to a presentation at the Conference on Retroviruses and Opportunistic Infections.

Garvey spoke about “microelimination” of hepatitis C, which is trying to eliminate the virus within defined populations. Indeed, she noted, the British HIV Association issued a statement about hoping to cure hepatitis C virus coinfection in 100% of people living with HIV by 2021.

To accomplish this in a defined population, such as HIV-positive MSM, requires a significant scale-up in treatment, and risk-reduction work, Garvey said, although she added that data from European cohorts demonstrated that wider use of DAAs in this population are linked with declines in the incidence of HCV.

“London is well placed for targeting microelimination in this population,” she said. “As a global fast-track HIV city [the first global city to exceed the UNAIDS 95-95-95 targets] it has demonstrated high rates of engagement in care and treatment outcomes for people living with HIV.”

The researchers examined data from three central London HIV clinics that provide care for an estimated 6,000 HIV-positive MSM from 2013 to 2018. Garvey noted that the National Health Service began its DAA treatment program in 2015, although decompensated cirrhotics were the priority.

Overall, there were 256 acute HCV diagnoses during the study time period — 211 first infections, and 45 reinfections. Patients were a median age of 43 at the time of acute HCV diagnosis, 90% were on antiretroviral therapy, 85% had HIV RNA <50 copies/ml at the time, and three-quarters were HCV genotype 1a.

The peak incidence rate was in late 2015 (17/1,000 person years of follow-up), and since the second half of 2015, those rates declined substantially to around 6/1,000. The incidence of first infection also declined dramatically, from 15/1,000 to around 3/1,000, respectively.

“We believe that these two factors in combination – wider access to DAAs, plus shorter time to start treatment have really driven these rates down,” Garvey said.

Indeed, Garvey and colleagues found that at the beginning of the study period, the average time to starting treatment was 41 months, falling to just 3 months in 2018. She noted that this faster access was potentially driven by “clinical trial availability at these centers.”

However, there have been some setbacks. While the incidence of all infections and first infections has fallen, the proportion that are reinfections has skyrocketed. Notably, in the second half of 2017 and the first two quarters of 2018, reinfections comprised 43% and 47% of all HCV diagnoses — when they comprised 7% of diagnoses in the first half of 2017.

Garvey noted the high reinfection rate, stating that this highlighted “the ongoing need to promote and improve risk-reduction strategies and design appropriate screening policies in HIV-positive and HIV-negative MSM.” She also stated that, similar to other research presented at this meeting, the rates of sexually transmitted infections increased over the same time period.

The authors disclosed no conflicts of interest.