Trouble with bleeding: risk factors for acute hepatitis C among HIV-positive gay men from Germany--a case-control study

Abstract

Objectives: To identify risk factors for hepatitis C among HIV-positive men who have sex with men (MSM), focusing on potential sexual, nosocomial, and other non-sexual determinants.

Background: Outbreaks of hepatitis C virus (HCV) infections among HIV-positive MSM have been reported by clinicians in post-industrialized countries since 2000. The sexual acquisition of HCV by gay men who are HIV positive is not, however, fully understood.

Methods: Between 2006 and 2008, a case-control study was embedded into a behavioural survey of MSM in Germany. Cases were HIV-positive and acutely HCV-co-infected, with no history of injection drug use. HIV-positive MSM without known HCV infection, matched for age group, served as controls. The HCV-serostatus of controls was assessed by serological testing of dried blood specimens. Univariable and multivariable regression analyses were used to identify factors independently associated with HCV-co-infection.

Results: 34 cases and 67 controls were included. Sex-associated rectal bleeding, receptive fisting and snorting cocaine/amphetamines, combined with group sex, were independently associated with case status. Among cases, surgical interventions overlapped with sex-associated rectal bleeding.

Conclusions: Sexual practices leading to rectal bleeding, and snorting drugs in settings of increased HCV-prevalence are risk factors for acute hepatitis C. We suggest that sharing snorting equipment as well as sharing sexual partners might be modes of sexual transmission. Condoms and gloves may not provide adequate protection if they are contaminated with blood. Public health interventions for HIV-positive gay men should address the role of blood in sexual risk behaviour. Further research is needed into the interplay of proctosurgery and sex-associated rectal bleeding.

Figure 1. Venn diagram for overlap of exposures (frequent receptive fisting without gloves, frequent anal bleeding, group sex & consumption of NADs).

*Unexposed: Respondents who neither had been frequently fisted without gloves (or with gloves that were shared), nor frequently experienced anal bleeding when having sex, nor reported group sex activities plus consumption of NADs. The circular areas correspond with the respective presence of exposures; intersecting areas reflect only roughly the given percentages.

Figure 2. Venn diagram for overlap of exposures (frequent use of PDE-5 inhibitors, frequent anal bleeding, history of major surgery).

*Unexposed: Respondents who neither had frequently used PDE-5 inhibitors, nor frequently experienced anal bleeding when having sex, and who did not report multiple surgical interventions. The circular areas correspond with the respective presence of exposures; intersecting areas reflect only roughly the given percentages.