HIV and hepatitis C co-infection: can we avert another epidemic in Australia by acting fast

HIV and hepatitis C co-infection: can we avert another epidemic in Australia by acting fast

HIV Australia | Vol. 11 No. 2 | July 2013

In this opinion piece, DAVID PIEPER provides reflections on the emergence of the sexual transmission of hepatitis C among HIV-positive gay men.

With ground-breaking new hepatitis C treatments now available in Australia, he says it’s time for both gay men and their doctors to address the silence and lack of knowledge surrounding hep C, to avert a new sexual health crisis among gay men living with HIV.

Since 2002, researchers in UK, Europe and USA have been documenting the rise of sexually transmitted cases of hepatitis C (HCV), mainly among HIV-positive gay men.1

Hepatitis C is transmitted from blood to blood. In Australia, this occurs mainly through the sharing of equipment used for injecting drugs such as needles and tourniquets.

Hep C is not classified as a sexually transmitted infection (STI). Long-term studies of heterosexual couples have confirmed that instances of sexual transmission of hepatitis C in monogamous relationships are extremely rare;2 however, it is now recognised that the risk of sexual transmission of HCV is higher for people with HIV, as well for as people who have multiple sexual encounters with partners who have HCV.3

Initially researchers doubted what they were being told by patients when gay men with HIV – but with no history of injecting drug use and no other risk factors – were presenting with recently acquired hep C infections.

Many in the medical profession initially denied the possibility of a new wave of sexually transmitted HCV, preferring to believe that gay men – who had survived an epidemic that had seen half their friends and lovers go to an early grave and who had been instrumental in fighting for access to drugs to ensure their own survival – would hide key health information from their doctor.

Sadly, one of the consequences of this denial has been a ten year delay in the response to what is now described as an epidemic, but not before it cut a huge swathe through the ‘hard sex’ scenes in London, Berlin and several other European and American cities.

From the HIV perspective, it is difficult to understand why researchers would question patient accounts of their exposure risk.

While trust and cooperation between HIV patients and their GPs has continued to be at the forefront of medical breakthroughs since the HIV epidemic began, this is not the case for most other diseases, including HCV.

Control of hep C treatment remains firmly with the gastroenterologists and hepatologists, despite the presence of s100 prescribing GPs with a long history of treating HIV patients and a trust developed over many years.

We need to build patient trust in relation to hep C rather than question it.

We should be using the strength of this doctor-patient relationship to encourage people into treatment, rather than creating a barrier to treatment by referring hep C patients to unfamiliar liver clinics.

But it’s not just the medical profession that has had difficulty coming to terms with sexual transmission of hep C.

With over 80% of those living with chronic hep C in Australia being people who inject drugs, organisations representing people who use drugs have felt a sense of ownership of the hep C epidemic for a long time.

I know of several people in the injecting communities who distanced themselves from the need to practice safe sex to prevent sexual transmission of hep C on the grounds that ‘it’s blood to blood, not sex’.

The presence of a whole new cohort of gay men with sexually transmitted hep C poses a threat to this comfortable position.

If you define sex as the act of penis inserted into a vagina, then yes, there is no such thing as sexual transmission of hep C, but to do so negates the sexual expression of gay men, lesbians, transgender people and pretty much anyone who goes beyond the missionary position; a stance which has as its foundation an attitude that says ‘I’m OK with gays, but what you do in bed as sex is not exactly sex’ – that’s homophobia.

STIs also still provoke horror and hysteria among heterosexuals in a way they have long since ceased to do among gay men.

In the early days of the HIV epidemic, when HIV was still considered a ‘death sentence’, many people considered a blood borne virus such as hep C less of a ‘dirty secret’ than a sexually transmitted infection like HIV.

The Hepatitis organisations in Australia and elsewhere have their hands full providing advocacy and services for the communities that comprise the majority of the hep C patient load.

In Australia, that’s current and former users of injecting drugs, people in prison and Aboriginal and Torres Strait Islanders.

Young people are high risk group too, because the median age for initiation into injecting drug use is 19 and because of the rise of tattooing and piercing in unsterile conditions overseas, and by unlicensed operators.

Gay men with HIV hardly even make it onto the radar among the other 225,000 Australians living with hep C (that’s 10 times the number of people with HIV alone).

But we as gay men are also complicit in the hep C denial. A recent community forum held by ACON and Hepatitis NSW highlighted that approximately 500 to 1,000 HCV cases have so far been identified among HIV-positive Australian gay men; in these cases it is clear that transmission did not occur through the most common routes of transmission.

Did we really think we could get away with serosorting and barebacking, happily ignoring hep C?

Or were we let down by the organisations who we relied on for this information, that had also not yet come to terms with the issue?

While HIV organisations have the resourcing and community connections to lead the response to HCV sexual transmission among HIV-positive gay men, they did not have the mandate to act.

Way back in the early 90s, when there were suggestions of using the might of ACON to service the hep C community, I know I was one who resisted, naming hep C as the ‘junkies’ disease.

We were not involved in ‘dirty’ business of sharing needles and besides we were far too busy taking care of our own, who were then sick and dying of HIV.

Then Freddy Mercury died and the whole world lost its innocence over HIV and began to talk about it. And gay men haven’t stopped talking about it since – inventing the language of safe sex, serosorting, and strategic positioning and even ‘don’t ask, don’t tell’.

But when it comes to hep C we’ve been silent; far too silent for far too long.

While we as gay men are now more comfortable discussing HIV status (be it negative or positive) and very comfortable negotiating our sex lives and relationships – either in light of, or around, or even in spite of differences in serostatus – we are crap when it comes to talking about hep C.

Men who are hep C positive – even those who are quite open about their HIV status – are afraid to disclose their status for fear of rejection.

The level of knowledge about how to stay safe is disappointingly low from a community that is in every other way so well informed about its sexual health.

Worst of all, the uptake of hep C treatment is well below what is needed to get this thing under control in our community, or indeed, just to treat people with moderate to serious liver disease – let alone start treatment as prevention.

The new deal is in town, the rules have all changed and we need to develop the language to negotiate our way through it.

But we are never going to get there until we can talk about it openly and honestly. While the exact mechanism of sexual transmission is not yet completely understood, some things are clear.

Sexual transmission of hep C between gay men is linked to a combination of risk factors: being HIV-positive; previous exposure to other STIs; participation in a sex parties; use of party drugs, especially crystal meth, recreational use of Viagra™; use of sex toys; and especially fisting.

None of these behaviours in isolation is implicated, but microscopic amounts of blood transmitted between partners where several of these risk factors are present seems to cover the majority of cases.

Unlike HIV transmission, hep C does not appear to be transmitted through semen, although this is currently under further investigation.4 5

By a stroke of luck – or more precisely, targeted political advocacy borne of the same fighting spirit that achieved compassionate access to HIV medicine that brought back so many of our friends and lovers from the brink of death in 1995 – there are new drugs now available on the PBS to treat the most common and difficult to treat genotype of hepatitis C.

A pioneering advocacy project launched by Hepatitis NSW last year has contributed to the PBS listing of boceprevir and telaprevir, more than 18 months earlier than might ordinarily have been expected if government processes were left to run their natural course.

These new direct acting antiviral (DDA) drugs – of the type that people with HIV have been taking for years now – when taken in combination with the backbone treatment of interferon and ribavirin, will halve the duration of treatment people with hep C genotype 1 from 12 months to 6 months and increase an individual’s chance of success in permanently clearing the hep C virus from around 50% up to 80%.

That’s got to be good news. I suggest that for people co-infected with HIV and hepatitis C, it is good news on the same scale as the news of combination therapy to effectively control HIV, as announced at the World Aids Conference in Vancouver in 1996.

While co-infection with HIV and hep C presents a set of unique problems – including faster progression to liver disease and complications in the treatment of HIV – it also presents a particular opportunity that should not be overlooked.

Unlike most people with hep C, gay men with HIV who acquire hep C through sexual transmission typically have years of experience managing their health with a chronic condition and are often already being closely monitored by their doctor.

This means that a hep C diagnosis is more likely to be picked up in the acute phase (within the first few months of infection), sometimes even as a result of a seroconversion illness.

Treatment during the acute phase provides the best possible chance of clearing the virus. But doctors must follow guidance on regular testing of HIV patients for hep C and the onus is on the patient to commence treatment as soon as possible.

Taking the lead from ACON’s new treatment as prevention initiative, Ending HIV, and Australia’s history of rapid effective and peer-led response to controlling the spread of HIV, we have the chance to get this virus under control in our community by encouraging gay men infected with hep C not to wait, but to treat their hep C as soon as possible after diagnosis.

Treatment will not only reduce the number of men on the scene carrying the hep C virus, but will provide an incentive for us to discuss and discover effective strategies to stay hep C free while pursuing pleasure.

If you are a gay man with hep C, now is the right time to think about treatment.

You can contact the Hepatitis Helpline on 1300 437 222.


1 For example see: van der Helm, J., Prins, M., del Amo, J.,Bucher, H., Chêne, G., Dorrucci, M., et al. (2011). The hepatitis C epidemic among HIV-positive MSM: incidence estimates from 1990 to 2007. AIDS, 25(8),1083–91.

2 Terrault, N., Dodge, J., Murphy, E., Tavis, J., Kiss, A., Levin, T., et al. (2013). Sexual transmission of hepatitis C virus among monogamous heterosexual couples: the HCV Partners Study. Hepatology 57(3), 881–9. DOI:10.1002/hep.26164, 2013

3 Centres for Disease Control (CDC). (2012). Hepatitis C FAQs for public [online]. Retrieved from:

4 Briat, A., Dulioust, E., Galimand, J., Fontaine, H., Chaix, M., Letur-Könirsch, H., et al. (2005). Hepatitis C virus in the semen of men coinfected with HIV-1: prevalence and origin. AIDS, 19(16), 1827–35. DOI:10.1089/apc.2009.0111

5 Leruez-Ville, M., Kunstmann, J., De Almeida, M., Rouzioux, C., Chaix, M. (2000). Detection of hepatitis C virus in the semen of infected men. Lancet, 356(9223), 42–3.

David Pieper is the Coordinator of the C me Project at Hepatitis NSW and Co-convenor of the SexC Project, an alliance between ACON and Hepatitis NSW.