As a gay man without Human Immunodeficiency Virus (HIV), am I at risk for Hepatitis C Virus (HCV) infection?

Hepatitis C Risk in Gay Men Without HIV

You are still at risk for hepatitis C infection as a gay man without HIV, though your risk is lower than HIV-positive men who have sex with men (MSM). Current guidelines recommend universal one-time screening for all adults aged 18 and older, regardless of sexual orientation or HIV status, which means you should be tested at least once 1.

Understanding Your Risk Level

Baseline Risk in HIV-Negative MSM

• HIV-negative MSM have an HCV incidence of approximately 1.48 per 1,000 person-years, which is significantly lower than the 6.08 per 1,000 person-years seen in HIV-positive MSM 2.

• Recent data shows surprisingly high HCV antibody prevalence (17%) among HIV-negative MSM in urban US settings, challenging the assumption that this is exclusively a high-prevalence population only when HIV-positive 3.

• The risk difference between HIV-positive and HIV-negative MSM is 3.45 per 1,000 person-years, meaning HIV-positive MSM are approximately 4.1 times more likely to acquire HCV, but HIV-negative MSM still face measurable risk 2.

When HIV-Negative MSM Become Higher Risk

You would be considered higher risk requiring annual screening (not just one-time) if you engage in 1:

• Injection drug use (current or past, even once)
• Intranasal drug use (sharing straws/notes for snorting cocaine, methamphetamine, or other drugs)
• "Slamming" (injecting drugs in sexual contexts)
• Unprotected receptive anal intercourse with multiple partners
• Group sex or "chemsex" activities (sex under the influence of party drugs)
• Receptive fisting
• Concomitant sexually transmitted infections, particularly syphilis, which has been associated with acute HCV seroconversion in MSM 4

Current Screening Recommendations

Universal Screening Applies to You

• All adults aged 18 years and older should receive one-time HCV screening, regardless of risk factors, according to the 2020 AASLD-IDSA guidelines 1.

• This universal recommendation specifically aims to identify cases in populations not traditionally considered high-risk, including younger adults (ages 20-39) and those without obvious risk factors 1.

Risk-Based Annual Screening

• Annual HCV testing is recommended only for people who inject drugs and HIV-positive men who have unprotected sex with men 1.

• For HIV-negative MSM without injection drug use, periodic repeat testing frequency should be determined on a case-by-case basis based on your specific sexual behaviors and substance use patterns 1.

Sexual Transmission Risk in MSM

The Evidence on Sexual Transmission

• Sexual transmission of HCV is much less efficient than hepatitis B or HIV transmission, but it does occur in MSM populations 5.

• The risk of sexual HCV transmission in monogamous heterosexual couples is essentially negligible, but this data may not apply to MSM, particularly those with high-risk sexual practices 5.

• Recent case series have documented acute HCV seroconversion in HIV-infected MSM where unprotected anal intercourse and unsafe oral sex with concomitant syphilis were the only identifiable risk factors 4.

Behavioral Factors That Increase Risk

• Studies show no statistical differences in risk behaviors between HIV-positive and HIV-negative MSM, including rates of unprotected receptive anal intercourse (32%), group sex (12%), and recreational drug use (30%) 6.

• Substance use counseling history is associated with 2.5 times higher odds of HCV antibody positivity (OR 2.51,95% CI 1.80-3.51), and unstable housing doubles the risk (OR 2.16,95% CI 1.40-3.33) 3.

• Higher HCV RNA viral loads increase transmission probability, though the exact threshold is not well-defined 5.

Practical Screening Algorithm for You

Step 1: Get One-Time Universal Screening

• Request HCV antibody testing with reflex HCV RNA PCR as your initial screening test 1, 7.

• This reflex testing approach requires only one blood draw and automatically proceeds to RNA confirmation if antibody-positive, preventing loss to follow-up 7.

Step 2: Determine Your Need for Repeat Testing

You need annual screening if you:

• Inject drugs (even occasionally) 1
• Use intranasal drugs with shared equipment 1
• Engage in "slamming" or chemsex 6

You need periodic screening (frequency based on clinical judgment) if you:

• Have multiple sexual partners (>10 in past 3 months) 6
• Engage in unprotected receptive anal intercourse 6
• Participate in group sex 6
• Have concomitant STIs, especially syphilis 4
• Use recreational drugs during sex 6

You likely need only one-time screening if you:

• Are in a monogamous relationship
• Do not use injection or intranasal drugs
• Consistently use condoms
• Have no other risk factors

Common Pitfalls to Avoid

Assuming Zero Risk Without HIV

• The assumption that HCV screening is unnecessary for HIV-negative MSM is outdated, as recent data shows 17% HCV antibody prevalence in this population in urban settings 3.

• Failure to screen HIV-negative MSM represents missed opportunities for cure and prevention of progressive liver disease 8.

Relying Only on Antibody Testing

• If you have recent exposure (within 6 months), a negative antibody test does not rule out acute infection, and you should have HCV RNA testing or repeat antibody testing at 6 months 1, 7.

• If you were previously infected and cleared HCV (spontaneously or with treatment), antibody tests will remain positive, so RNA testing is required to detect reinfection 1, 7.

Missing the Substance Use Connection

• Nearly one-third of MSM report recreational drug use, with cocaine, methamphetamine, and ketamine being most common 6.

• Sharing straws or notes for intranasal drug use is a significant HCV transmission route that many patients and providers overlook 1.

• 18.5% of MSM report sharing drug paraphernalia for snorting drugs, which is a clear HCV risk factor 6.

Bottom Line

While you are not in the highest-risk category for HCV as an HIV-negative gay man, you are definitively not in a "no-risk" category either. You should receive at least one-time universal screening as recommended for all adults, and if you engage in any of the higher-risk behaviors outlined above—particularly injection or intranasal drug use, unprotected anal intercourse with multiple partners, or group sex—you should discuss annual or periodic screening with your healthcare provider 1, 3.