Gay and bisexual men’s attitudes to hepatitis C, and the potential role of treatment-as-prevention approaches

By Dr Dean Murphy | Research Fellow at the Kirby Institute, UNSW and Senior Research Associate in the Department of Gender and Cultural Studies, University of Sydney.

In our recent study of hepatitis C virus (HCV)-related attitudes and awareness among gay and bisexual men—in which one third of the sample comprised men living with HIV—we found knowledge about new HCV treatments to be surprisingly low.

This finding was somewhat surprising given that Australia’s fifth National Hepatitis C Strategy 2018-2022 aims to eliminate HCV as a public health threat, and identifies people living with HIV as a priority population. In addition, at an international level, gay and bisexual men living with HIV have been identified as a population in which achieving HCV elimination prior to the WHO goal of 2030 is highly likely.

More recently, attention has also turned to the population-level benefits of HCV treatment through averting onward transmission of the virus. This can be conceptualised as a ‘treatment-as-prevention’ (TasP) approach. Although there are some significant differences from the way in which HIV TasP is conceptualised, these differences being related to viral clearance versus suppression of viral replication, the basic principle will be sufficiently familiar to the HIV Australia readership, namely that onward transmission of the virus can be prevented through the identification—and immediate treatment—of existing/new infections. Indeed, there have been recent calls for ‘immediate’ HCV treatment in order to meet the WHO elimination goals, and for universal access for all HIV-infected men regardless of infection stage. Recent modelling studies have also suggested that treating at the acute stage is not only cost effective but could also be considerably cheaper than treating at the chronic-infection stage. Current prescribing guidelines, however, are only for treatment of chronic, not acute, infection.

As mentioned above, identification of existing and new HCV infections is important. However, our study found that men’s awareness of their own testing history was somewhat questionable, with almost one in five men not knowing if they had ever been tested for HCV. Also, among men living with HIV, most believed they were being tested for HCV alongside their regular HIV monitoring, although this was rarely discussed with their clinician.

While there has long been a focus on HCV among men living with HIV, it is becoming increasingly apparent that sexual transmission of HCV is also occurring among HIV-negative men. However, guidelines have generally only recommended routine testing of HCV for men living with HIV. This situation may be changing, with the current Australian PrEP clinical guidelines advising the monitoring of men engaging in ‘sexually adventurous sex’, with at least annually testing recommended. We also understand that new draft Australian guidelines for STI testing among men who have sex with men recommend annual testing for HIV-negative men currently on PrEP, as well as for HIV-negative men eligible for PrEP.

An important aspect of HCV TasP—and one which makes it conceptually distinct from HIV—is that of reinfection. High rates of reinfection among men after treatment have raised questions about the feasibility and impact of HCV TasP approaches among men living with HIV—and their sexual partners. However, a counterargument has been made along the lines that re-infection should be anticipated in this group, and that ‘rapid HCV treatment scale-up and provision of re-treatment for re-infected individuals will limit its impact at a population level’. Again, this calls for increased attention to testing, with a particular focus on those who have previously been infected with HCV.

Our study also found there is currently not a strong culture of disclosure and negotiation around HCV, with less than half gay/bisexual men expecting that a sex partner with HCV would disclose this information. Our previous research also found a relationship between testing and attitudes, with those gay and bisexual reporting more negative attitudes to HCV being less likely to have ever tested for the virus. Our findings suggest that HCV education and prevention strategies may be more effective if they draw on the well-established HIV prevention infrastructures that have been developed by men who identify as gay or bisexual.