Sexual transmission of hepatitis C: Practical recommendations

Medicine and Health Rhode Island,  Jun 2003  by Myung, Patricia,  Mallette, Carol,  Taylor, Lynn,  Allen, Scott,  Feller, Edward

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WHO IS AT HIGH RISK FOR SEXUALLY TRANSMITTED HCV?

Patients with increased risk of sexually-acquired HCV are those with multiple sexual partners. An important competing risk in this group is the potential higher incidence of IVDU. Commercial sex workers and patients at sexually transmitted disease (STD) clinics have been reported to have an increased incidence of HCV infection, but these groups may have an increased incidence of other competing high-risk behaviors (principally IVDU). Median rates of HCV seropositivity are 6% in commercial sex workers in the USA.19, 25 In a representative study of non-IVDUs at an STD clinic, 7% of men and 4% of women were anti-HCV positive, compared to a prevalence of 1.4% in the general population in the USA.23 Men who have sex with men have been reported to have a prevalence as high as 4.6% , but risk is strongly correlated with the small percentage who are IVDU, and to a lesser extent, the number of lifetime sexual partners, failure to use condoms, or sexual practices traumatizing mucosa.24 Although HIV-positive patients have higher serum titers of HCV than HIV-negative individuals, the significance of this finding is unknown.26 Other data do not document a correlation between level of HCV viremia and infectivity; thus, unknown host or immune factors may be a contributing risk in HIV/HCV co-infected persons. Insufficient data exist to conclude that sexual transmission of HCV is increased or facilitated in men who have sex with men or in the presence of HIV co-infection.

HCV AND OTHER SEXUALLY TRANSMITTED DISEASE

In a large Veterans Administration study of 34,204 HCV-positive patients compared to HCV-negative controls, HCV was associated with a higher probability for other blood-borne viruses, including HIV (14.1% vs. 3%) as well as other sexually transmitted diseases27, risks for gonorrhea, syphilis, genital herpes, trichomonas, and viral warts were all increased. Pre-existing genital infection or mucosal inflammation may facilitate infectiousness. Presence of these diseases may identify groups with an increased risk, thereby justifying targeted HCV screening. Because of similar modes of transmission, serologic markers for HBV are increased in HCV-positive individuals, with as many as 67% having evidence of exposure to HBV compared to 3.5% in the general population.28 Immune status to HBV should be assessed in all HCV-positive individuals and HBV vaccination recommended to all who are not immune.

WHAT RECOMMENDATIONS SHOULD PHYSICIANS GIVE TO LONG-TERM MONOGAMOUS PARTNERS, ONE OF WHOM IS HCV RNA POSITIVE?

Only patients with the continued presence of HCV RNA in serum are likely to be infectious. Sexual transmission is possible, but is a rare event, occurring with a probability between 1 in 10,000 and 1 in 100 per year. Consensus opinion suggests an incidence of 12 per 1000 person-years in partners of HCV infected individuals. These figures translate to a cumulative risk of acquisition of approximately 5% over 20-30 years.28 Some authorities counsel that the risk is low enough not to require a change in sexual practice for monogamous couples, including men who have sex with men. Condoms may be used to further lower risk. Others advise condom use for all persons at risk of transmission.29 Barrier protection is, however, recommended for short-term, multiple sexual partners who are also at increased risk for other sexually transmitted diseases. Condoms are recommended in the presence of other sexually transmitted diseases, during menses, and with sexual practices that may injure the ano-genital mucosa. No restrictions are needed for less intimate contact, including kissing or sharing food. HCV is not transmitted by coughing, sneezing, or sweating. Because HCV is present in blood, an HCV-positive individual should avoid sharing razors, toothbrushes, nail clippers, or other personal items potentially having blood on them. A summary of these recommendations is in Table 2.