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Share your thoughts on this presentation with #IAS2019 Crystal methamphetamine use and group sex fuel an explosive HCV epidemic among HIV+MSM in Bangkok, Thailand Tanyaporn Wansom, MD tanya@dreamlopments.com Share your thoughts on this presentation with #IAS2019

Hepatitis C Virus among HIV+ MSM Background HCV is an important comorbidity for people living with HIV Direct acting antivirals (DAA) provide opportunity for cure, but limited access in resource constrained settings HCV outbreaks documented in resource-rich settings among HIV+ MSM who deny IDU Limited data available on HCV prevalence and incidence among HIV+MSM in resource constrained settings Study objectives Measure HCV prevalence and incidence among a predominantly MSM cohort of Thai individuals diagnosed during acute HIV infection Characterize risk factors that may be associated with HCV incidence

Hepatitis C Virus among HIV+ MSM Methods Participants enrolled in prospective cohort between 2009-2018 HCV Antibody (Anti-HCV), HbsAg, Anti-Hbs, RPR/TPHA measured at enrolment and then every 6 months or more often if clinically indicated Incident HCV infection defined as seroconversion from Anti-HCV negative to Anti-HCV positive, or detectable HCV RNA in the setting of clinical hepatitis HCV genotype conducted by linear array Drug and alcohol use captured by computer assisted questionnaire and physician interview Chi squared test used to compare incidence trend by year Hazard ratios calculated in univariate and multivariate analysis to assess risk factors associated with incident HCV infection

Baseline Characteristics All (N=573) Anti-HCV - (N=525) Anti-HCV + (N=48) p-value Age (years)* 26 (22 – 31) 25 (22 – 31) 0.599 Sex Assigned at Birth, n (%) 0.658 Female 15 (2.6) 15 (2.9) 0 (0) Male 558 (97.4) 510 (97.1) 48 (100.0) Behavior risk, n (%) 0.776 MSM 538 (93.9) 491 (93.5) 47 (97.9) Heterosexual male 20 (3.5) 19 (3.6) 1 (2.1) Heterosexual female Number of sexual partners in the past month* 2 (1 – 3) 2 (1 – 4) 0.017 More than 1 sexual partner in the past month 327 (57.1) 293 (55.8) 34 (70.8) 0.048 Group sex, n(%) 111 (19.4) 90 (17.1) 21 (43.8) <0.001 Alcohol use, n (%) 126 (22.0) 115 (21.9) 11 (2.9) 0.856 Drug use, n (%) 122 (21.3) 101 (19.2) Hepatitis B surface antigen positive 29 (5.1) 28 (5.3) 1 (2.1) 0.499 History of syphilis (Positive TPHA/RPR) 82 (14.3) 73 (13.9) 9(18.8) 0.387 Fiebig stage, n (%) 0.870 I 81 (14.1) 75 (14.3) 6 (12.5) II 130 (22.7) 122 (23.2) 8 (16.7) III 259 (45.2) 234 (44.6) 25 (52.1) IV 67 (11.7) 61 (11.6) V-VI 36 (6.3) 33 (6.3) 3 (6.3) CD4 T cells* (cells/µL), median (IQR) 361 (264 – 496) 361 (265 – 505) 360 (234 – 470) HIV RNA at time of HIV diagnosis (log10copies/mL), median (IQR) 5.94 (5.24 – 6.75) 5.93 (5.23 – 6.73) 6.06 (5.39 – 6.89)

Epic Rise in HCV Incidence No incident cases detected from 2009-2013 Incidence increased in 2013-2015 between 6.1-8.8/1000 PY Drastic rise in incidence in 2017 and 2018 Highest incidence documented to date 33.0/1000 PY in 2018

Risk Factors Associated with HCV Incidence Incident Cases Univariate Multivariate Risk Factors Total (N=563) No (N=524) Yes (N=39) Crude HR (95%CI) P-value Adjusted HR (95%CI) Group sex 456 (81.0) 434 (82.8) 22 (56.4) Ref. 107 (19.0) 90 (17.2) 17 (43.6) 3.74 (1.99 – 7.08) <0.001 2.54 (1.26 – 5.12) 0.009 Alcohol use 367 (65.2) 341 (65.1) 26 (66.7) 196 (34.8) 183 (34.9) 13 (33.3) 0.87 (0.44 – 1.69) 0.677 Methamphetamine use 465 (82.6) 441 (84.2) 24 (61.5) 98 (17.4) 83 (15.8) 15 (38.5) 4.05 (2.10 – 7.79) 2.33 (1.13 – 4.8) 0.02 Drug injection 556 (98.8) 519 (99.1) 97 (94.9) 7 (1.2) 5 (0.9) 2 (5.1) 3.65 (0.84 – 15.78) 0.083 History of syphilis 343 (60.9) 331 (63.2) 12 (30.8) 220 (39.1) 193 (36.8) 27 (69.2) 3.02 (1.53 -5.96) 0.001 2.43 (1.22 - 4.85) 0.01

Conclusions Group sex, methamphetamine use, and history of syphilis all associated with incident HCV infection in this cohort of HIV+MSM Clinicians should ask about these risk factors, educate HIV+MSM about potential for HCV transmission Thai National Guidelines should consider including HIV+MSM in risk group to be screened for anti-HCV at regular intervals if at risk Need for access to DAAs to decrease HCV-related morbidity and mortality as well as onward transmission