Hepatitis C in MSMs; a review of testing practices in the GUIDe clinic & a description of recent cases N. Lynn*, J Dean**, e quinn**, G Farrell*, C Murray* , F Lyons*, C Bannan*. C. DeGascun**, C. Bergin* * Department of Genitourinary Medicine and Infectious Disease, St. James’s Hospital ** National Virus Reference Lab

Background Hepatitis C emerging as an STI in MSM¹ Epidemiology of Hep C transmission changing² Since 2000 , longitudinal cohort studies confirm ↑ HCV incidence in HIV+ MSM, but not HIV- MSM Reported incidence of HCV infection in HIV+ MSM 0.6 - 0.9/100 person years³ The odds ratio of sexual transmission of HCV ↑ in HIV+ MSM (adjusted ratio 4.1-5.7) 1. http://www.hpsc.ie/A-Z/EMIToolkit/appendices/app23.pdf 2. http://www.sciencedirect.com/science/article/pii/S1201971216310736 3. Lauer GM, Walker BD. Hepatitis C virus infection. New Engl J Med 2001;345(1):41-52. 4. Tohme RA, Holmberg SD. Is sexual contact a major mode of hepatitis C virus transmission? Hepatology 2010;52(4):1497-505

Hx chemsex/drug use HIV+ve patients sex associated with trauma rectal LGV +ve

Audit Methods HIV+ MSMs attending a HIV clinic in January 2016 Electronic Patient Record (EPR) reviewed Descriptive column statistics used for data analysis

Audit Results 198 HIV+ MSM - 8 clinics – Jan 2016 Median age 38 (IQR 31,50) 14% (n=13) detectable HIV VL (45-68409) 96% (n=191) HCV Ab/PCR on EPR Median time to last Ab/PCR: 107 days (0-5222 days) 28% (n=57) Ab/PCR done @ OPD 68% (n=135) Hepatitis C Ab/PCR test <365 days* * As per BASHH Guidelines

MSM STI testing in HIV OPD 84% (n=167) STI screen on EPR 27% (n=54) MSM STI screen @ clinic 71% (n= 141) MSM STI screen in the past year* Median time since last screen 115 days (range 0 – 2083) 82% (n=138) last screen negative *as per BASHH Guidelines

Conclusion Good compliance with HCV & NAATs BASHH testing Guidelines (66% & 71%) Poor documentation of sexual practices, chemsex & drug use Strategies to improve testing: Add full MSM STI screen to annual HIV bloods Include hepatitis C Ab in routine MSM STI testing Improve access to results from other services (e.g GMHS) Universal patient number to limit duplication of testing Audit findings will be presented at departmental level Cycle 2 of Audit - after implementation of the above strategies

Hepatitis C outbreak in MSM CDC Definition¹ Confirmed: Negative Ab/PCR < 12/12 Probable: meets clinical criteria, no testing in past 12/12 1. https://wwwn.cdc.gov/nndss/conditions/hepatitis-c-acute/case-definition/2016/ Clinical Criteria: Lab Criteria: T◦/ HA/Malaise/Anorexia/Vomiting/Diarrhoea/Abdo Pain Anti HCV + AND PCR+ Jaundice OR ALT Peak >200 Antigen+

Results 19 MSM 1 Aug 2015 – 21 Oct 2016 Average age 36 (range 23-56) 89% (n=17) previously tested for HCV Median days since last test 239 (range 60-3088) 63% (n=12) previous test within 1 year 37% (n=7) test >1 year ago Hep B immune 74% (n = 14) All transaminitis, 2 new HIV, 3 new STI.

HIV & STI Results HIV STI testing (n=18) 78% (n=15) Detectable VL Average CD4 571 VL UD VL 73% (n=11) Detectable 27% (n=4) Detectable VL Median 60,096 Range 56- 124,831

STI screen +ve (66%, n=12)

Acute Hepatitis C Genotype Transaminases 90% Genotype 1 (n = 17) 5% PCR -ve prior to genotyping (n = 1) Median Range AST @ Dx 119 25-1104 ALT @ Dx 264 28-2272 Peak AST 211 28-1104 Peak ALT 475 34-2272

NS3 Sequencing 1 PCR –ve 1 HCV viral load; log 2 IU/ml 1 Did not amplify 1 G3 G1a n = 15

GT Clade NS3 Result 1a II N174G I Q80K V55A 3 89% Clade I: Q80K mutation

GT 1a H77 Ref GT 1a Clade I GT 1a Clade II GT 1a H77 Ref GT 1a Clade I GT 1a Clade II

Where are they now and how are they doing? n = 19; n=18 managed in GUIDe “Chronic” HCV (n=2) Spontaneous clearance (n=3) PCR +ve @ last visit (Aug-Nov ‘16) (n=11)* DAAs in GUIDe (n=1)** Travelled for treatment/meds (n=3): HCVL UD Post Rx (n = 2) HCVL <12 W2 Rx (n = 1) *1 due DAAs, Fibroscan score 9 **Fibroscan score 8.7

STI screens in HCV 33% positive STI screens

Conclusion: Anecdotal cases noted at clinic visits – differing sites No strong association with LGV Viral sequencing to support epi and PN data in managing outbreak Concern re: transmitted resistance - treatment implications Preclusion to rx based on criteria Staging of liver disease High rates of new STIs Attempt to describe the cohort in context of new cases. Threshold for access to treatment. No other STI where this applies.

Thanks; GUIDe Clinic: C Bannan, C Bergin, G Farrell, C Murray, F Lyons NVRL: C De Gascun, J Dean, E Quinn SJH Lab: B Crowley, M Kelleher GMHP: S O’Dea, G Courtney nlynn@stjames.ie