With better treatments for HIV and the arrival of PrEP, an increasing number of gay are thinking of ditching condoms.
However, condoms don’t just offer protection against HIV. They also help prevent the spread of other sexually transmitted infections. This is particularly relevant for an infection such as gonorrhea, which has shown increasing resistance to known antibiotics in recent years.
But what about hepatitis C? How concerned should gay men be about this potentially fatal illness?
What is hepatitis C?
Hepatitis C is an infection of your liver. As one of your vital organs, anything that goes wrong with your liver can have serious consequences.
Vaccines exist for hepatitis A and B, and all gay and bi men should take advantage of them. However, there is no vaccine for hepatitis C, which was only identified in the late 1980s.
If you acquire the hep C virus, you can have it for years before symptoms appear. This is one reason why, if never tested, you might want to ask about being screened.
‘It’s becoming more common to include hepatitis C in sexual health screens,’ says Joe Phillips, a Nurse Specialist in hepatitis C at 56 Dean Street, run by Chelsea and Westminster Hospital NHS Foundation Trust.
‘If someone is worried about hepatitis C from a recent risk they can certainly come in and request a test as part of their routine screen too.’
How do you know if you have hepatitis C?
If you have acquired the virus, symptoms can include the following: exhaustion; pain in the limbs; nausea; flatulence; feelings of fullness; pain in the abdomen; loss of appetite; and pale-colored stools or dark urine.
Hep C can wreak havoc on your liver before any of these symptoms appear. The severity of infection can range from a mild illness that lasts a few weeks soon after infection (‘acute’) to a life-long, ‘chronic’ condition.
Some people will be fortunate to recover from an acute hepatitis C infection of their own accord. However, around 60-80% of people who have acute hepatitis C will go on to develop the chronic condition.
This in turn can lead to cancer or cirrhosis of the liver, which can be fatal.
Gay poet Allen Ginsberg died from liver cancer in 1997 after suffering for many years with hep C. Singer Gregg Allman of the Allman Brothers died last year, aged 69, after complications related to a long-term hep C diagnosis.
How is hepatitis C transmitted?
The most common route for transmission of hepatitis C is via the blood of someone infected. This includes blood transfusions, sharing injecting needles, sharing razors and even toothbrushes with small quantities of blood on them.
For many years health experts believed hepatitis C was not sexually transmittable – so why do they now think gay men should be concerned?
It’s now believed that the virus can be present in small quantities in semen. However, this remains a less common route of transmission. What’s more common is if sexual activity includes any blood.
‘Although hepatitis C is predominantly passed on by blood-to-blood contact, and it isn’t as easily passed on sexually as other infections (such as syphilis), some more recent studies have shown that there are detectable levels of the virus in semen,’ says Phillips.
‘This is particularly true in HIV positive people with an early (or acute) infection and on-going research is looking at sexual transmission risk of hepatitis c in gay men in general.’
Rough sex and fisting
Gay men are thought to be at particular risk if they engage in certain practices, such as fisting – which can be more traumatic to your anus and anal lining.
Also, group sex carries particular risks. If someone vigorously fucks a guy or inserts a sex toy into him, and then pulls out and puts his cock/toy inside another man, blood from the first guy can be passed to the second – as well as any infections in that blood.
This bottom-to-bottom transmission partly explains what some gay men are testing positive for hepatitis C.
In the UK, an increase in the number of gay men attending chemsex parties, where they might have sexual encounters with multiple men, has been linked to an increase in the transmission of hepatitis C. It’s not uncommon for men at these parties to also inject drugs, and the sharing of needles can easily spread the virus.
How widespread is hepatitis C infection?
In the UK, around 214,000 have chronic hepatitis C infection. In the US, the Center for Disease Control estimates that around 2.7-3.9million people have chronic hepatitis C infection. The figure is 71million people globally.
WHO estimate that around 1.3million people died from hepatitis C infection in 2015. The majority of these deaths are in parts of the world where treatment is harder to access.
Countries with particularly high rates of hepatitis C include Egypt, Pakistan and parts of Africa. You might also want to think twice before visiting a tattoo parlor in a country where they’re unregulated!
The CDC says the risk of sexual transmission is low, but increases for rough sex or if someone has HIV or another sexual infection. However, it concludes: ‘More research is needed to better understand how and when hepatitis C can be spread through sexual contact.’
‘The risk of spreading hepatitis C through sex is low’
NHS England concurs: ‘The risk of spreading hepatitis C through sex is low.’
That risks increases if there is any blood present, ‘such as menstrual blood or during anal sex.
‘Condoms aren’t usually necessary for long-term heterosexual couples, but it’s a good idea to use them when having anal sex or sex with a new partner.’
In the US, around a quarter of those who have hep C also have HIV.
Phillips says people with HIV are more at risk.
‘At 56 Dean Street along with the other Chelsea and Westminster Hospital sexual health clinics we have seen large numbers of Hepatitis C infection in our HIV positive patients.
‘There is data showing that the viral load of hepatitis C in the semen of HIV positive men is higher than in HIV negative men. HIV disrupts mucosal barriers to infection and so it can make you more susceptible to being infected with hepatitis C from sex.’
Can you die from hepatitis C? What is the treatment?
According to the World Health Organization, ‘Antiviral medicines can cure more than 95% of persons with hepatitis C infection.’ Public Health England states, ‘Hepatitis C is a curable infection.’
Modern treatment includes administering direct-acting antiviral drugs (DAAs). These can stop the virus from replicating and greatly reduce its impact on your liver. If you’re in the acute stage, you may not even be given treatment. Doctors often first wait to see if your body is able to fight off the virus, and will only prescribe if you proceed to the chronic stage of infection.
If you do require medication, you may need to take the drugs for several weeks or months. You may also have to make lifestyle changes to minimize liver damage, i.e. reducing you alcohol intake or abstaining.
What should I do to minimize the risk of contracting hepatitis C during sex?
Wearing a condom for anal sex will offer protection. If you’re into fisting, wear latex gloves, and check your hands for any cuts or bleeding cuticles. Change the gloves between partners and use new lube.
Do not share sex toys with different partners. Use condoms on sex toys or wash them thoroughly.
Take a break from receptive anal sex if you’ve had any bleeding down there recently. This might be due to rough sexual activity or if you’re recovering from hemorrhoids.
Do not share drugs during sex. This doesn’t just include syringes. There is evidence that using a rolled-up banknote or straw to snort drugs, and then handing it to someone else, can pass on hepatitis C. Snorting drugs can often make your nose bleed, leading to particles of blood on any equipment you share.
So if I get diagnosed before it does too much damage, I’ll be OK?
‘Generally speaking,’ says Phillips at 56 Dean Street, ‘the earlier hepatitis C is treated the better the outcome.
‘That being said, hepatitis C is a slow progressing condition that only really causes problematic, long term liver problems if it is left untreated for many years. Although the liver will be inflamed in an early infection it is very unlikely to sustain any long-term damage if the infection is treated early enough.
‘New treatments for hepatitis C are effective at clearing the virus in over 95% of people.’