Does PrEP lead to an increase in hepatitis C among gay and bisexual men?

Pre-exposure prophylaxis (PrEP) has the potential to significantly reduce HIV transmission. However, medical monitoring is crucial to prevent other sexually transmitted diseases from increasing in the shadow of PreP.

A commentary by Benjamin Hampel, medical co-head of Checkpoint Zurich, on a new study from Holland.

For a long time, the main route of transmission of hepatitis C was the bloodstream, for example during blood transfusions or when sharing needles during intravenous substance use such as heroin, cocaine or methamphetamines.

Hepatitis C also sexually transmitted

For about ten years, however, an increase in hepatitis C has been observed among gay and bisexual men living with HIV - also in Switzerland. Only a few of them are at risk of infection through intravenous substance use, but they usually have changing sexual partners. Further research results confirmed the suspicion that there is also a sexual transmission of hepatitis C, especially during anal sex.

However, there are now more and more reports from other countries that an increase in hepatitis C is also being observed in gay men without HIV. Here it concerns especially the group of those who take the so-called HIV pre-exposure prophylaxis (PrEP). PrEP is a drug that provides very effective protection against HIV infection, so most users of PrEP do not use a condom during anal and vaginal intercourse. It is therefore feared that there will be a renewed wave of hepatitis C among gay and bisexual men.

No increase in hepatitis C among PrEP users in Switzerland

In Switzerland, we have not seen such an increase so far. The PrEP is also becoming increasingly popular in this country among men who have sex with men (MSM). The Checkpoint Zurich is the largest health centre for MSM in Switzerland and serves over 700 people who use PrEP. Since April 2019 it has also been the study centre of the SwissPrEPared Study of the University of Zurich, which is researching the development of PrEP in Switzerland. In this study, no increase in hepatitis C among PrEP users has been observed so far. This may be due in part to the large-scale HCVree study of the University Hospital of Zurich: In this study, more than 90 percent of homo- and bisexual men who have both HIV and hepatitis C infection were cured. This massively reduced the risk of other men becoming infected with hepatitis C during sexual intercourse in Switzerland.

Thanks to regular check-ups decrease of sexually transmitted infections

Persons using PrEP also receive a check every three months for hepatitis C and the most common sexually transmitted diseases. In other countries, this early detection and treatment has already been shown to reduce the incidence of sexually transmitted infections such as gonococcal disease and syphilis. In some of the foreign reports, hepatitis C infection was diagnosed before the start of PrEP. It is precisely this regular testing of persons at increased risk that therefore offers a chance of earlier detection and treatment of hepatitis C in at-risk persons - and not a threat.

Better prevention and education regarding low-risk consumption

The SwissPrEPared study also identifies other risk factors. With regard to hepatitis C, intravenous and nasal substance consumption is particularly important: If a person is at risk, they can be informed about risk reduction directly at the PrEP consultation. This is often information to which many people still have no access or simply do not dare to ask for it. In addition, utensils for low-risk consumption are also handed out at Checkpoint Zurich - another benefit of PrEP controls.