HCV, HIV & Questions about PrEP

By: Marcus Hopkins, Blogger

In one of my recent pieces for HEAL Blog, I addressed the issue of transmission of HCV (Hepatitis C Virus) through sexual contact. A colleague and former professor of mine from East Tennessee State University reminded me that conventional wisdom tells us that “…HCV in inefficiently spread through sexual contact.”

For the most part, this holds true – for most people, HCV is inefficiently transmitted through sexual contact. Here at HEAL Blog, however, we are primarily concerned with HIV/HCV co-infection, and for patients who are currently living with HIV-infection, conventional wisdom may not hold true.

In a piece published on June 24th, 2014, for Healthline, News, David Heitz brings to the fore a study released in 2011 (Fierer, Daniel S., et al.) that suggests that HIV-infected MSM (Men who have Sex with Men) are more likely to transmit HCV through sexual intercourse than those who fall outside of those demographics.

While sexual transmission of HCV is generally rare, concurrent HIV infection results in increased HCV RNA levels, which is thought to increase the infectiousness of HCV acquired through sexual contact. Unprotected penetrative anal intercourse can often involve tearing of soft tissue within the body cavity, which allows the virus easier access to direct contact with the blood.

There are, however, some caveats to this study that should, in the effort of doing due diligence, be disclosed:

  1. This report suggests high-risk sexual behavior as a cause of HCV infection in New York City. In this instance, the term “high-risk” included unprotected receptive anal intercourse with ejaculation.
  2. Additionally, another key factor in these infections was the use of methamphetamine as the most important predictor of infection, meaning that the use of this drug, while not directly responsible for the infection, played a likely role in the subjects’ proclivity to engage in high-risk sexual behavior.

Those within the LGBT community have spent much of the last decade temporizing about the burgeoning meth usage crisis we face. It is no accident that, as meth usage increases, so does the incidence of new HIV infections and accompanying STDs/STIs. What this study suggests is that, in addition to Syphilis, HAV/HBV, and other curable infections, HCV, once thought to be almost exclusively the result of injection drug usage or blood transfusion, should now be considered of equal import in our educational and prevention efforts.

This having been stated, there seems no better time than to bring the reality of PrEP (Pre-Exposure Prophylaxis – Truvada) into the conversation.

PrEP has been making waves in the LGBT and HIV community for much of the past year, in no small part due to virulent opposition on the part of AHF (AIDS Healthcare Foundation) founder, Michael Weinstein.

Without delving into the micro-political issues that surround the controversy, there are several arguments being made with which I take issue:

  1. Mr. Weinstein’s suggestion that reliance on Truvada as an HIV prevention method will essentially reduce it to a “party drug” is likely irrelevant to the discussion, as is the accompanying outcry on behalf of his opponents. Given current condom usage statistics that suggest a mere 15% of MSM consistently and correctly use condoms while having sex, it seems to me that any sort of prophylaxis against HIV would be welcome to the fight. What should have been disregarded as nonsense was instead met with outrage, and revealed what I consider to be a sore subject in the HIV infection world – that “party drugs,” such as methamphetamine, frequently play a role in new infections.
  2. On the other side of the argument, it seems as if the proponents of PrEP are going out of their way to treat Truvada as a panacea that is certain to stop the progression of HIV. While the studies suggest that Truvada does a great deal (and a great job) of prevention transmission (is consistently and correctly used), what Truvada does not stem is the spread of other STDs/STIs – HCV, for example.
  3. When condoms are introduced into the conversation, proponents of PrEP are quick to mention that the FDA has never approved condoms for anal intercourse. This assertion, while true, seems ironic, given the effort into which these very same advocates once put into being vociferous adherents to the “You Must Use Condoms, Every Time” message that was, and continues to be, pushed onto the American populace over the past thirty years.

Part of what is so infuriating about this continuing debate is the alacrity with which members of the MSM HIV community have cottoned to PrEP as the Holy Grail of HIV prevention. Several message boards and social media information pages are filled with fantastic information about how PrEP works to stop the spread of HIV, but a consistent theme I have noticed while reading these posts is the tendency of these HIV advocates and educators to all put pillory commenters who have the temerity to rightly suggest that other diseases are of equal importance, and that Truvada does nothing to prevent their spread.

Image of opened condom wrapper with blue pill falling out (resembling Truvada pill)


Arguments on these threads can be fierce, and often very quickly devolve into ad hominem attacks, where advocates accuse people of being “…in league with Weinstein” (that is a direct quote), and even worse, “part of the problem.”

This leads me to beg the question – “What is the problem?

As an advocate and educator whose goal is to spread scientifically accurate information about how STDs/STIs are spread, it is important to me that I realize that HIV isn’t the only game in town – my students and lecture attendees expect for me to paint them a realistic picture of the risks associated with high-risk sexual behavior. To suggest that, because PrEP shows promising results in preventing the spread of HIV, condoms are no longer necessary is a fool’s errand.

Studies such as the Fierer study further show the need for continued adherence to the condom regimen, regardless of whether or not the FDA has approved their usage for anal intercourse. While PrEP may go a long way in fighting the HIV epidemic, we must remain vigilant in our efforts to stem the tide of other viruses, as well.

Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates.


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