How to Face the Outbreak of Viral Hepatitis A in Men Who Have Sex With Men in France Without Vaccines?

To the Editor—Sexual transmission of hepatitis A virus (HAV) among men who have sex with men (MSM) has been well described since 1981 [1], and multiple outbreaks have already occurred worldwide. Recently, 30 cases have been reported in Berlin [2], 17 in the Netherlands [3], 28 in the United Kingdom [4], and >1000 cases in Taiwan [5]. The European Centre for Disease Prevention and Control (ECDC) launched a rapid risk assessment in December 2016 (updated 23 February 2017) reporting 287 cases in 13 European Union countries since February 2016 originating from 3 clusters of virus [6]. Vaccination against HAV is very efficacious and, according to the ECDC, vaccination is the main preventive measure in the context of current outbreaks of HAV. For the MSM population, HAV vaccination is recommended in many countries within the European Union. Herein, we draw attention to the increasing risk of HAV in the MSM population, especially in France.

From January to March 2017, 5 cases of acute hepatitis A in unvaccinated MSM were diagnosed in our hospital: the median age of patients was 30 years (range 23 to 41 years). All patients presented with jaundice, liver enzyme elevation >1000 IU/L, and positive immunoglobulin M against HAV. Two were infected with human immunodeficiency virus (HIV) and were being followed in our clinic. The 3 other patients had been admitted to the emergency department. One was HIV-negative taking preexposure prophylaxis (PrEP) with tenofovir disoproxil fumarate (TDF) and emtricitabine (FTC). The 5 patients did not know each other. Genotypic analysis showed the presence of 2 epidemic strains: RVM16-090 in 4 patients and VRD_521_2016 in 1 patient.

Since the early 2000s, unprotected sex in MSM is increasing in many countries. Large-scale PrEP with TDF and FTC has been implemented in France since January 2016 and there are now >3000 MSM taking PrEP. The initial prescription of PrEP was restricted to specialized physicians; however, prescription for maintenance treatment is now available from general practitioners since 1 March 2017.

There has been a large increase in sexually transmitted infections in MSM infected with HIV over the past years, and STIs are also a major problem in MSM taking PrEP.

Our findings and those from other countries suggest that further outbreaks of HAV are likely to occur in MSM. Sustained transmission and outbreaks could be prevented with a level of immunity >70% [7]. Seroprevalence of HAV antibody in MSM in Europe is unknown, but in the adult general population it has been estimated between 20% and 30% in the United States [8] and Europe [9]. In our cohort of MSM with HIV infection (257 patients), HAV antibodies have been found in 76%, with one-quarter of cases secondary to HAV vaccination. HAV immunization is far lower in HIV-negative MSM. For example, in MSM taking PrEP in our hospital (24 patients), 62.5% are seronegative for HAV antibodies.

The availability of the HAV vaccine has been greatly reduced in France and many countries over the past few months due to production issues [10]. This vaccine is no longer available in most French pharmacies and can only be found in scarce pretravel consultations.

Based on our data, because access to the HAV vaccine is so limited, around 24% of MSM infected with HIV and 62% of HIV-negative MSM taking PrEP are likely to be at risk of HAV infection. In this context, avoiding oral anal sex should be recommended for HAV-seronegative MSM. However, no specific health-promotion program has been released to target this issue. There is an urgent need for French health authorities and the pharmaceutical industry to improve access to the HAV vaccine.

Notes

Acknowledgments. The authors gratefully acknowledge the National Reference Laboratory of Enteric Hepatitis for genotyping hepatitis A virus.

Potential conflicts of interest. All authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

References