You Can Get it From Sex, and 10 Other Things to Know About Hep C


Did you know that there are about 3.5 million people in the U.S. with hepatitis C—and about half don’t know they’re infected? In San Francisco, it’s estimated that between 5% and 8% of men who have sex with men have hep C.

At a recent Positive Force event, I invited my colleague Lisa Capaldini, MD, to speak to our group about what gay men should know about hepatitis C. Dr. Capaldini is an HIV and hep C specialist who’s been practicing in the Castro since 1989. Below is a summary of the no-nonsense, practical info she gave our guys about what hep C is, how people get it and how to treat it.

  1. It’s possible to get hep C during unprotected anal sex

I was taught in medical school—during the 70s and 80s—that hep C is not sexually transmitted. I learned that most often, it’s transmitted through contact with an infected person’s blood by sharing injection drug use needles. But, we now are seeing instances when men who have sex with men got hep C through sex.

If you have anal receptive sex—if a guy sticks his penis in your butt without wearing a condom—it’s possible to get hep C if your partner is infected. This has happened in situations where, as far as both guys know, there’s no blood involved. And at a scientific meeting in 2015, researchers presented evidence that hepatitis C can be found in the rectal fluid and rectal mucosa at levels high enough to be transmissible.

Something is different between anal sex and vaginal sex where people with vaginas don’t get hep C from vaginal sex. The thinking is that the cellular connections in the rectum [the butt] are more fragile than in the vagina which may account for the fact that it’s easier to get hep C through anal sex than through vaginal sex.

  1. Your body might get rid of hepatitis C on its own, but it’s rare

A small percentage of people are able to clear a hepatitis C infection without treatment. Out of 100 HIV-negative people with hepatitis C, maybe 20% to 25% of them will clear the infection on their own, and 75% to 80% will have it chronically. People with HIV who get hep C are less likely to naturally clear the infection: Maybe 10% to 15% will clear the infection, and 85% to 90% will get chronically infected.

But, there’s no way for us to predict who is going to be lucky and not need treatment, and who is going to get complications. So it’s best to get tested and treated for hep C if you can.

  1. If you are cured of hep C, you can get infected again

Hepatitis C is different from other kinds of hepatitis. Once you have hepatitis A or B, only with rare exceptions will you get it again. But if you get hepatitis C, and either clear it naturally or cure it with treatment, you can be re-infected if you’re exposed to hep C again. That’s why it’s important to get tested on a regular basis, even if you’ve had hep C in the past.

  1. Hep C can damage your liver, but sometimes it’s hard to know how much

Over the long term, hepatitis C damages your liver, causing inflammation and scarring. We do tests, such as blood tests that measure liver enzymes, an ultrasound or a special type of ultrasound called a FibroScan, or a FibroSure biomarker test to try to figure out how much damage is being caused.

But you can get the same type of scarring, called cirrhosis, from drinking too much alcohol. Liver function tests might be normal even if hep C has already severely damaged your liver. So it’s a mistake to conclude that hep C isn’t causing problems even if your liver function tests are normal. The measure of fibrosis that you get from a FibroSure test is probably thrown off a bit by HIV—so it can be difficult to figure out if the test is accurate for people who are coinfected with HIV and hep C. The old fashioned test is to do a liver biopsy—which isn’t as scary as it sounds. With this test, we’re able to see under the microscope, how much scarring, fibrosis and inflammation is there. However, it’s rare that we need to do liver biopsies anymore because our non invasive tests are very good.

  1. Having hep C antibodies does not mean that you have chronic hep C

It’s confusing, because it’s different than HIV. But people who are cured from hep C, because they were treated with medication successfully or because they cleared the infection on their own will still test positive for hep C antibodies. The way to know if you have chronic hep C—and know if you should be treated—is to do a viral load test. If you are antibody positive, but viral load negative (or undetectable) you don’t need treatment. If you are antibody positive, and also have hep C virus, then you need treatment.

  1. Newer hep C treatments are effective, but expensive

We used to treat hepatitis C with interferon, which was not that effective and came with a lot of side effects. Now, we have newer drugs that—when prescribed correctly—have a hep C cure rate of 95% after 12 weeks of treatment. And these medications work as well even when people are coinfected with HIV. And they are well tolerated—I’ve never had to have a patient stop taking them because of side effects.

But, these new medications are very expensive, so oftentimes I have to puzzle over how to get my patients coverage. The good news is that people with HIV and hepatitis C are usually approved by insurance companies to receive treatment, because insurance companies know that people with HIV are more likely to develop problems caused by hep C.

  1. Half of infections go undiagnosed

There are estimated to be about 3.5 million people in the U.S. with hepatitis C. About half of those people don’t know that they’re infected. In San Francisco, it’s estimated that between 5% and 8% of men who have sex with men are infected. If you look at people who use injection drugs, the percentage is higher.

  1. Hep C testing should be part of your sexual health screening

How often you might want to get tested depends on your sexual activity and other risk factors. The CDC made a recommendation that all baby boomers get checked once and that people who are sexually active or use injection drugs get checked regularly. People who have higher risk sex—with multiple partners, or without using condoms—should get tested on a regular basis. It’s a blood test that can be done with your HIV viral load test.

  1. HIV affects how quickly you get symptoms from hep C

In general, hep C doesn’t affect HIV much—it’s not going to make your HIV progression worse. But, the flip of that is true. HIV does affect the progression of hepatitis C. People with HIV who get hep C get liver scarring earlier and will have a higher risk of liver cancer than people who get hep C who are HIV-negative. People who are HIV-negative might not get symptoms of hep C for 15 to 30 years, while people with HIV might experience hep C symptoms after five years.

  1. PrEP does not prevent hep C

If you don’t have HIV and are taking PrEP properly, you’re not going to get HIV. But, there’s still a risk of getting hep C through sex. Condoms can act as a barrier to help prevent hep C.

  1. Getting your HIV under control may also help your hep C infection

Having an immune system that functions well may help you clear a hep C infection. But if untreated HIV has damaged your immune system, you might be less likely to clear a hep C infection. I saw a patient once who was coinfected with both HIV and hep C. He wasn’t on HIV medications yet and didn’t want to treat his hep C infection because he’d been on interferon before and he experienced a lot of side effects. So I treated him for HIV. His CD4 cell count went from 250 cells/mm3 to 800 cells/mm3, and this improvement in his immune system helped him clear his hep C infection. This doesn’t happen all the time, but it can happen.

Joanna Eveland, MD, is an HIV treatment specialist in San Francisco. She oversees HIV and homeless services as the Clinical Chief for Special Populations at the Mission Neighborhood Health Center, is a faculty member at the University of California, San Francisco Clinician Consultation Center, and leads a bi-monthly health education group for HIV-positive men through San Francisco AIDS Foundation. Dr. Eveland received her M.S. and M.D. at the University of California, Berkeley-UCSF Joint Medical Program and completed her residency at the Contra Costa Family Medicine Residency Program.