HCV coinfection approaches zero in Spain: but cirrhosis and reinfection among gay men are still significant even with high rates of cure

26 November 2024. Related: Conference reports, Hepatitis coinfection, HIV 17 Glasgow 2024.

Simon Collins, HIV i-Base

An impressive oral presentation at HIV Glasgow 2024 reported on how increasing access to effective hepatitis C treatment has dramatically reduced HCV prevalence among people living with HIV in Spain. [1]

The study, presented by Juan Berenguer from Gregorio Marañón Hospital in Madrid, combined results from nine cross-sectional studies from the last 20 years. It included results from 43 centres in 32 cities in 14 of the 17 regions in Spain and represented approximately a third of the people living with HIV nationally. It included approximately 47,000 people each year, of whom >99% were on ART and had HCV test results.

Over 20 years, as HIV increasingly affected gay and bisexual men rather than people who inject drugs, the prevalence of HCV coinfection based on HCV antibody results dropped from 60% in 2002 to 27% in 2023. The prevalence of active HCV based on HCV RNA results dropped from roughly 50% in 2002 to <1% by 2021 to 2023. Among HIV positive people injecting drugs, prevalence of active HCV dropped from 86% down to 3% and for those with heterosexual HIV transmission it dropped from 14% down to <1% by 2018. Rates of active HCV in gay and bisexual men also dropped from 8% to 0.5%.

Active HCV in all HIV groups dropped most dramatically in the DAA era since 2015 by 94%, 100% and 71% in the three groups respectively. Uptake of DAA treatment exactly mirrored the prevalence of HCV reaching 99% and 1% respectively by 2023. When new HCV diagnoses do occur, these are increasingly recent with half of diagnoses being in 2023. Among people with active coinfection, there have been no cases of cirrhosis since 2021 and no cases of decompensated liver of HCC since 2019.

However, rates of cirrhosis remain significant and in 2023 included about 4% of people who had sustained viral responses (SVR) with earlier DAA treatment. This means roughly 6,000 to 7,000 of the estimated 140,000 to 160,000 people living with HIV in Spain also have cirrhosis, despite being cured of HCV.

Continued transmission was also reported among gay and bisexual men however and also reported in a separate poster. [2]

This was a prospective muti-centre study that enrolled 1372 gay and bisexual men in Madrid from 2021–2023 (with 733 HIV positive and 639 HIV negative). This included 266 men who had previously had HCV infection (252/733 and 14/639 in the HIV+ and HIV– groups, respectively).

Assessments at baseline and months 6 and 12 included behaviour, drug use, HCV serology and RNA, and STI testing.

At baseline, both groups had high rates of previous STIs (75% vs 68%) and chemsex (33% vs 27%). However, irrespective of HIV status, previous HCV strongly correlated with the risk of subsequent HCV infection. See Table 1.

People with vs those without previous HCV had a prevalence ratio of 6.93 (95% CI: 3.07 to 15.66) and an incidence rate ratio (IRR) of 8.41 (95% CI 2.96 to 23.88).

Table 1. HCV prevalence at baseline and HCV incidence during follow-up (FU)

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These studies show the incredible impact access to DAAs can have on the prevalence and incidence of HCV on a population level.

However, the relatively high rates of cirrhosis that remain after HCV is cured shows the importance of earlier treatment and the risk of continued complications.

This issue of HCV reinfection risk among gay men shows a need for specialist support for those at risk despite previously being cured of HCV.

This supports the recent inclusion of a section on chemsex in the latest update to the EACS guidelines and the importance of developing specialist services to help. [3]

References

1. Berenguer J et al. Prevalence trends of active HCV infection among people with HIV in Spain (2002-2023): nearing elimination. Oral abstract O45.
2. Ryan P et al. Acute/recent infections and reinfections by HCV in MSM with and without HIV in the region of Madrid (ATHENS study). Poster abstract P376.
3. EACS guidelines v12.1.