This presentation was part of Embody's Safe Healthy Strong 2015 conference on sexuality education (www.ppwi.org/safehealthystrong). Embody is Planned Parenthood of Wisconsin's education and training programs. Learn more: www.ppwi.org/embody DESCRIPTION This workshop will outline the basics of Hepatitis C virus including a brief history, symptoms, and treatment. The majority of the presentation will focus on the ways that HCV can be sexually transmitted. We will also talk about the increased risk of HCV for men who have sex with men (MSM) who are HIV positive, the lack of research around women who have sex with women’s (WSW) risk for HCV transmission, and the general controversy of calling HCV an STI. ABOUT THE PRESENTERS Rachael Cooper currently works as a Prevention Specialist at the AIDS Resource Center of Wisconsin and has worked in HIV/AIDS prevention and education both in Wisconsin and abroad. One of her current projects focuses heavily on educating at-risk populations about Hepatitis C transmission, symptoms, and care. Veronica Shaheen is an Opiate Overdose Prevention Specialist, providing harm reduction services to injection drug users at the AIDS Resource Center of Wisconsin (ARCW) LifePoint program by helping active users remove their personal risk for HIV, HCV, and other STIs. She also dedicates her time to overdose prevention education and Naloxone training to any members of the community willing to help stop overdose deaths.

1. Hepatitis C:
The Controversial STI
Rachael Cooper & Veronica Shaheen
Prevention Specialists
ARCW Prevention

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Who We Are
Rachael Cooper – HIV/AIDS Prevention
Specialist
Veronica Shaheen – Opiate Overdose
Prevention Specialist
Where we work:
ARCW Prevention Department
• Free HIV, HCV, Gonorrhea,
Syphilis & Chlamydia tests
• Counseling, Testing,
Referral
• HIV/STD Education Groups
LifePoint Needle Exchange
• Clean Syringe Access since
1994
• Harm Reduction: Practical risk
reduction strategies for
behavior associated with
negative health
consequences.
• Proven healthcare benefits

3. Key Words
• Parenteral: Administered or occurring elsewhere in the body than
the mouth and alimentary canal.
• Permucosal: By way of, or through, a mucous membrane.
• Seroconversion: When a specific antibody becomes detectable in
the blood, and the corresponding antigen becomes
undetectable.
• MSM: Men who have sex with men.
• PWID: People who inject drugs.
• Harm Reduction: Strategies for reducing the consequences of risky
behavior.
• Fisting: Sex act that involves inserting hand/wrist into vagina or
rectum.

4. Hepatitis C:
what do you know?

5. Hepatitis Basics
All types of Hepatitis: inflammation of the liver

6. Hepatitis Basics
All types of Hepatitis: means inflammation of the liver
Hepatitis A and B have vaccines, Hepatitis C does not

7. Hepatitis Basics
All types of Hepatitis: means inflammation of the liver
Hepatitis A and B have vaccines, Hepatitis C does not
Hepatitis C can eventually lead to cirrhosis, liver cancer, and liver
failure if untreated, but it can be treated and cured, unlike other
forms of Hepatitis- on average, a person with Hepatitis C who does
not get treated lives 22 years less than persons who are not infected.

8. Hepatitis Basics
All types of Hepatitis: means inflammation of the liver
Hepatitis A and B have vaccines, Hepatitis C does not
Hepatitis C can eventually lead to cirrhosis, liver cancer, and liver
failure if untreated, but it can be treated and cured, unlike other
forms of Hepatitis- on average, a person with Hepatitis C who does
not get treated lives 22 years less than persons who are not infected.
The CDC estimates that 3.2 million people are infected with chronic
HCV in the US - & that up to 85% may not know they have it.

9. Hepatitis C Transmission
HCV is only transmitted via blood

10. Hepatitis C Transmission
HCV is only transmitted via blood
Populations at risk for Hepatitis C include injection drug users [IDU],
the baby boomer population, and children born to mothers with
HCV.
Tattoos from an unlicensed facility and accidental needlesticks are also transmission
pathways

11. Hepatitis C Transmission
HCV is only transmitted via blood
Populations at risk for Hepatitis C include injection drug users [IDU],
the baby boomer population, and children born to mothers with
HCV.
Tattoos from an unlicensed facility and accidental needlesticks are also transmission
pathways
Those who have multiple sex partners, already have an STI, engage
in rough sex or other sex practices that may involve blood, or are
infected with HIV are at a higher risk for contracting HCV.

12. Progression of HCV
Two stages of HCV: acute & chronic

13. Progression of HCV
Two stages of HCV: acute & chronic
The transition between acute and chronic HCV is poorly
understood, though important viral mutations may occur.
Acute phase: HCV RNA levels fluctuate, cellular responses to HCV peak, wane
and become dysfunctional, and neutralizing antibody responses become
detectable.
Chronic infection is associated with weak cellular immune responses, the
presence of antibodies, and relatively stable HCV RNA levels between 500,000
IU/ml and 50 million IU/ml in 80% of individuals.

14. Hepatitis C Transmission
Risk behaviors

15. Hepatitis C Transmission
Risk behaviors
Presence of co-existing STIs, especially those that cause a sore,
increase the risk for men and women alike.

16. Hepatitis C Transmission
Risk behaviors
Presence of co-existing STIs, especially those that cause a sore,
increase the risk for men and women alike.
Sexual transmission more likely to occur from men → women than
women → men, but the risk increases during menstruation.
Women: more likely to be in a sexual relationship with IDU partner, which can
lead to more risk behaviors for IDU
Higher risk for blood borne illnesses, also may clear acute HCV more easily

17. Hepatitis C Symptoms
During the acute state, many experience general malaise: fever,
fatigue, nausea, abdominal pain, lack of appetite, jaundice.

18. Hepatitis C Symptoms
During the acute state, many experience general malaise: fatigue,
nausea, abdominal pain, lack of appetite, jaundice
Symptoms can develop as early as two weeks after infection, but
many people remain asymptomatic for many years after infection.

19. Hepatitis C Symptoms
During the acute state, many experience general malaise: fatigue,
nausea, abdominal pain, lack of appetite, jaundice
Symptoms can develop as early as two weeks after infection, but
many people remain asymptomatic for many years after infection.
As Hepatitis C settles into the chronic phase, most people do not
exhibit symptoms until their liver is severely damaged.

20. Long Term Effects of Hepatitis C
Chronic HCV is the leading cause for cirrhosis, liver cancer, and is the most
common reason for liver transplants.

21. Long Term Effects of Hepatitis C
Chronic HCV is the leading cause for cirrhosis, liver cancer, and is the most
common reason for liver transplants.
75% – 85% will develop chronic HCV infection, and of those:
60% - 70% will develop chronic liver disease
5% - 20% will develop cirrhosis
1% - 5% will die from cirrhosis or liver cancer

22. Long Term Effects of Hepatitis C
Chronic HCV is the leading cause for cirrhosis, liver cancer, and is the most
common reason for liver transplants.
75% – 85% will develop chronic HCV infection, and of those:
60% - 70% will develop chronic liver disease
5% - 20% will develop cirrhosis
1% - 5% will die from cirrhosis or liver cancer
This means that, at minimum, 32,000 people and, at maximum, 160,000
people who are currently infected with HCV will die from complications.

23. Sexual Transmission of Hepatitis C
Menstruation
Sex with an HCV + person during their period makes it more likely that the virus
will be transmitted.
Sex with a partner who is new, unknown, or doesn’t know their status and who is
menstruating is risky.

24. Sexual Transmission of Hepatitis C
Menstruation
Sex with an HCV + person during their period makes it more likely that the virus
will be transmitted.
Sex with a partner who is new, unknown, or doesn’t know their status and who is
menstruating is risky.
Fisting
Fisting can cause trauma to the sex organs that can lead to rips and tears,
leading to HCV transmission
Especially dangerous if the person has cuts/sores on their hands and/or wrists.

25. Sexual Transmission of Hepatitis C
Menstruation
Sex with an HCV + person during their period makes it more likely that the virus
will be transmitted.
Sex with a partner who is new, unknown, or doesn’t know their status and who is
menstruating is risky.
Fisting
Fisting can cause trauma to the sex organs that can lead to rips and tears,
leading to HCV transmission
Especially dangerous if the person has cuts/sores on their hands and/or wrists.
Multiple Sex Partners
As with all STIs, multiple sex partners makes it more probable that an individual will
come into contact with infections and viruses.

26. Sexual Transmission of Hepatitis C
Group Sex
Repeated insertion can cause tears & rips in the anus, vagina, rectum, and other
sex organs.

27. Sexual Transmission of Hepatitis C
Group Sex
Repeated insertion can cause tears & rips in the anus, vagina, rectum, and other
sex organs.
Sex Toys
Repeated insertion can lead to cuts & tears in sex organs
If sex toys are shared, HCV can be transmitted.
HCV can live on any surface for at least four days – including sex toys.
Soap, rubbing alcohol, and other disinfectants are not 100% at killing the virus.

28. Sexual Transmission of Hepatitis C
Drugs and alcohol can impair a person’s decision making ability as
well as cause them to forget prevention methods or use them
incorrectly [condoms, dental dams, etc.].
Ketamine: numbs the body so that a person may not realize how much
trauma they are experiencing. This makes it more likely that broken skin
may result.
Poppers: increase blood flow and therefore the likelihood that there will
be blood to blood contact.

29. Who is most at risk of contracting HCV
via sexual contact?
HIV + MSM
People with multiple partners

30. Monogamous Partners and Sex Acts
with Very Low Risk
Specialists have no risk reduction recommendations for sero-
discordant partners who are in monogamous relationships, as
studies show that transmission rates are extremely low.
Deep kissing: no known cases, though theoretically possible.
Oral sex [no menstruation]: no known cases, though theoretically
possible.

31. HCV and other STIs
Increased level of susceptibility with any infection that creates a
sore [HPV, syphilis, herpes, etc.].
Sexual transmission is primarily permucosal – exposure to an infected liquid via a
disrupted membrane.

32. HCV and other STIs
Increased level of susceptibility with any infection that creates a
sore [HPV, syphilis, herpes, etc.].
Sexual transmission is primarily permucosal – exposure to an infected liquid via a
disrupted membrane.
Syphilis and HCV: outside of HIV, highest risk for seroconversion.
Men with recent syphilis infection 2 X more likely to acquire HCV

33. The CDC supports that HCV can be
transmitted sexually: where’s the
controversy?
In order for an HCV transmission to be ruled a result of sexual
contact:
Viral strains must match from partner to partner
All other transmission routes must be ruled out
New infection must chronologically follow sexual contact with a person who is
positive
Many experts believe that due to these difficulties, the number of
sexually transmitted HCV cases could be drastically over or under
estimated.

34. The CDC supports that HCV can be
transmitted sexually: where’s the
controversy?
In order for an HCV transmission to be ruled a result of sexual
contact:
Viral strains must match from partner to partner
All other transmission routes must be ruled out
New infection must chronologically follow sexual contact with a person who is
positive
Many experts believe that due to these difficulties, the number of
sexually transmitted HCV cases could be drastically over or under
estimated.
Once a new HCV case has been proved to be a result of sexual contact, it is still very
difficult to determine which specific sex act caused the transmission.

35. HIV & HCV: similarities and differences
Both can be transmitted via blood
HCV is 10 X more concentrated in the blood than HIV
HCV lives outside the body for much longer than HIV [up to 63 days in certain
environments]

36. HIV & HCV: similarities and differences
Both can be transmitted via blood
HCV is 10 X more concentrated in the blood than HIV
HCV lives outside the body for much longer than HIV [up to 63 days in certain
environments]
Viral Load
HIV: correlates to progression of disease [high VL 5,000 – 10,000 copies/mL]
HCV: does NOT correlate to progression of disease [high VL anything greater
than 800,000, can reach up to 50 million copies/mL]
HCV: does correlate to an increase in vertical transmission

37. HIV & Hepatitis C
HCV is categorized as an opportunist infection.

38. HIV & Hepatitis C
HCV is categorized as an opportunist infection.
As many as 30% of people with HIV may also be co-infected with
HCV [30,000].
HIV +/IDU: could be up to 90%

39. HIV & Hepatitis C
HCV is categorized as an opportunist infection.
As many as 30% of people with HIV may also be co-infected with
HCV [30,000].
HIV +/IDU: could be up to 90%
HIV triples the risk of severe HCV disease progression, is associated
with high viral loads and infectiousness, and a higher risk of
developing liver damage and cancer.
Lower T- cell counts may increase risk of HCV acquisition.

40. HIV & Hepatitis C
Impaired liver function can result in slower processing of drugs in the
body
Some HIV drugs are especially hard on the liver

41. HIV & Hepatitis C
Impaired liver function can result in slower processing of drugs in the
body
Some HIV drugs are especially hard on the liver
HCV can affect HIV treatment by increasing the frequency of liver
toxicity related to the processing of HIV drugs

42. HIV & Hepatitis C
Impaired liver function can result in slower processing of drugs in the
body
Some HIV drugs are especially hard on the liver
HCV can affect HIV treatment by increasing the frequency of liver
toxicity related to the processing of HIV drugs
Beginning HIV treatment first is best if possible – HCV treatments
work better for people with stronger immune systems.
Some experts believe that controlling HIV can help slow HCV progression

43. Prevention Methods
Thoughts?

44. Prevention Methods
Condoms and other barriers
Even with sex toys
Abstain from sex during outbreaks (herpes, syphilis, genital warts)
Abstain from sex during menstruation if currently HCV positive
Use gloves during fisting
Sex toys
Important to clean, but may not be effective to kill HCV.
Do not share sex toys.
Use condoms.

45. Prevention Methods
Limit partners
Lube
HCV can live in lube
Less likely condom will break, less likely friction will cause abrasions.
Ask their status
Getting tested (not prevention, but essential.
Abstinence

46. HCV Treatment Options
Interferon
Harvoni [+ other drug cocktail options]
Genotype 1
Insurance/expense issues

47. Questions??

48. Sources
Burchell, Ann N., et al. "Hepatitis C virus seroconversion among HIV-positive men who have sex with
men with no history of injection drug use: Results from a clinical HIV cohort." The Canadian Journal
of Infectious Diseases & Medical Microbiology 26.1 (2015): 17.
Centers for Disease Control and Prevention. "Sexual transmission of hepatitis C virus among HIV-
infected men who have sex with men--New York City, 2005-2010." MMWR. Morbidity and mortality
weekly report 60.28 (2011): 945.
Fethers, Katherine, et al. "Sexually transmitted infections and risk behaviours in women who have sex
with women." Sexually Transmitted Infections 76.5 (2000): 345-349.
HCV Advocate. Hepatitis C Support Project, 2015. Web. May 2015.
Kouyos, Roger D., et al. "Clustering of HCV coinfections on HIV phylogeny indicates domestic and
sexual transmission of HCV." International journal of epidemiology (2014): dyt276.
Project Inform. Sexual transmission of hepatitis C: A guide for HIV-positive gay men, 2015. PDF file.
Reynolds, Andrew. “Can Hepatitis C be Sexually Transmitted?” Positively Aware. May 2015.

49. Sources
Tahan, Veysel, et al. "Sexual transmission of HCV between spouses." The American journal of
gastroenterology 100.4 (2005): 821-824.
Terrault, Norah A., et al. "Sexual transmission of hepatitis C virus among monogamous heterosexual
couples: the HCV partners study." Hepatology 57.3 (2013): 881-889.
Tohme, Rania A., and Scott D. Holmberg. "Is sexual contact a major mode of hepatitis C virus
transmission?." Hepatology 52.4 (2010): 1497-1505.
Tracy, Daniel, et al. "Higher risk of incident hepatitis C virus among young women who inject drugs
compared with young men in association with sexual relationships: a prospective analysis from
the UFO Study cohort." BMJ open 4.5 (2014): e004988.
Viral Hepatitis – Hepatitis C Information. Centers for Disease Control and Prevention, 2015. Web. May
2015.