In a special series, Dr Laura Waters from Mortimer Market Centre is focussing over the next few issues on the main sexually transmitted infections gay men are at risk from. This week it’s Hepatitis C.
Hepatitis C is a virus that affects the liver and around 150,000 people in England live with the infection. It’s transmitted mainly through injecting drugs, but we’ve learned more about sexual transmission over recent years.
Historically the risk of getting hep C through sex was considered very low but from the mid-2000s we saw a rise in infections in gay men with HIV. Most cases were associated with chem sex: snorting/slamming drugs combined with high risk sexual activities (fisting, group sex, shared sex toys). It was difficult to know how much infection was down to drug use or sex. Since then we’ve learned that men with HIV and hep C have higher levels of hep C in their semen. There’s enough hep C in rectal fluid to transmit through anal sex and HIV causes changes in the lining of the rectum that make hep C infection more likely.
Since U=U (Undetectable = Untransmittable, meaning someone with HIV and an undetectable viral load on treatment has zero risk of passing the virus to sexual partners) has been established and more people are using HIV PrEP we’ve seen more new hep C cases in HIV-negative gay men. This is likely due to less condom use and less ‘sero-sorting’ (where people only have condomless sex with someone of the same HIV status).
Also, when we analysed our figures at the Mortimer Market Centre, 1 in 4 new hep C cases were in men whose only reported risk was anal sex without a condom. The numbers of hep C in sexual health clinics remain much lower than other STIs so it probably isn’t very infectious sexually but we advise all gay men having condomless anal sex with new partner(s), or using drugs, to have a hep C blood test with every sexual health check-up.
Ask your clinic which test they do: some still use an antibody test (antibodies are your body’s response to fighting the virus) which can take up to 6 months to become positive (or longer if you HIV) whereas our clinic is amongst those that have shifted to antigen testing (antigen is part of the virus itself) which will be positive within 4 weeks of an infection, so detects hep C sooner.
In the early stages of hepatitis C there may be no symptoms, some people feel generally unwell and some will look yellow (jaundice). If you have regular blood tests for HIV or another condition the first sign may be an abnormality in your liver results. Some people with early hep C will clear the virus themselves but 3 in 4 won’t. Untreated hepatitis C can cause liver scarring and a higher risk of liver cancer – many people won’t get liver problems but it’s difficult to predict who will, so treatment is recommended for everyone.
There has been a huge change in treatment – we used to rely on treatments including injections with lots of side effects, requiring lots of blood tests and, at the end of it all, only about a 50% chance of being cured. Because of that, clinics tended to wait until the liver was already scarred before offering treatment. However it’s all change over the last 5 years as we now have very effective, easy to take, tablet only options. As more people are treated, there will be fewer new infections – the global goal is to eliminate hep C altogether by 2030 and NHS England say they can achieve this even sooner!
Currently NHS England won’t fund re-infection cases but that’ll change soon. Re-infection is common in HIV-positive gay men (1 in 4 over 2 years in a Chelsea & Westminster Hospital study). There is NO VACCINE and being infected once does NOT protect you from future infection.
Ask partners if they’ve tested; using condoms, not sharing lube, sterilizing sex toys (diluted bleach or a dishwasher!) and using your own stuff for slamming/snorting all reduce your risk. Eventually routine testing won’t be necessary but ask your clinic whether you need regular tests as part of your sexual health check-ups.