Practice Pearl 1: Hepatitis C Virus Transmission With Tattoos and Sex

The panel of experts in the management of hepatitis C discuss the syringe exchange programs in different states.

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Christian B. Ramers, MD, MPH, AAHIVS: Bhavesh, are tattoos still a way that people get hepatitis C?

Bhavesh Shah, RPh, BCOP: I was just in Miami recently. I can't believe how many tattoo places there that are open so late. I really got tempted to go and get a tattoo, but then I remembered about hepatitis C. No, but I think that obviously there are nonsterile tattoos, which take place where you're not going to a professional who uses sanitized tools to do tattoos or going to Mexico maybe and getting a tattoo there. I think there are ways of getting it through tattoos where you're using needles from one person to another and can have that exposure.

Christian B. Ramers, MD, MPH, AAHIVS: I think you can tell if a place is using sterile equipment or you can ask. Many people get tattoos either in their friend's basement or in prison. Prison is actually a very common place to be tattooed, and the equipment that's being used is certainly not sterile. We did a focus group in one of our local prisons. One single needle—which is not really a needle, it's just a jerry-built pen—sometimes is used on hundreds of people. That's just really a very efficient way to transmit hepatitis C. I wanted to touch again on sexual transmisison. This is a very common question that we get in the clinic. Is it possible that I could transmit sexually? What do you use in terms of a counseling piece to your patients who ask that?

Christopher Hulstein, PharmD, CSP: Yes, it is possible. What I typically tell patients is, "It's up to you." If you do want to engage, then practicing safe-sex using condoms or barrier protectives tends to be recommended. Certain patients don't want to take the risk, now that therapy is reduced to 8 weeks. In many cases they will just abstain for the entire period.

Christian B. Ramers, MD, MPH, AAHIVS: Caroline?

Caroline Derrick, PharmD, BCPS: I'm an advocate for if you're on treatment and monitoring your viral load, taking a look at that, and if you're undetectable, then there is no active virus that we could quantify or measure at that time. I think using safe-sex practices in important and providing that education. Because the risk if there; however, it's quite low. Transmission from mucous membranes, being so low, sexual transmission falls around that 1% risk, much lower even than, say, vertical transmission. It's something to just keep in mind. It's present, but counseling about abstaining or safe sex is important.

Christian B. Ramers, MD, MPH, AAHIVS: Bhavesh, any other comments?

Bhavesh Shah, RPh, BCOP: No, I think the same thing. I think counseling is the most important aspect. I think we're worried about not just hepatitis C but also probably other things, especially with a lot of patients who are coinfected or have substance abuse. I think it's better to just counsel about safe sex and safe practice.

Christopher Hulstein, PharmD, CSP: I also recommend, when we do have that conversation, if they have an active partner, they should get tested for hepatitis C as well, simply because it is very, very low risk. But that’s 1 more area that if that patient has it, they should know and can be treated moving forward.

Christian B. Ramers, MD, MPH, AAHIVS: Bring a friend. That’s a good strategy. Just to summarize, this is a very confusing area for some people. Sexual transmission does occur. It’s generally rare. It was first described in HIV-positive men who have sex with men. It’s been described in HIV-negative men who have sex with men on PrEP [pre-exposure prophylaxis]. Probably less common in heterosexual transmission, but also still does occur. Let’s just put this in perspective. It is way less common than needle and blood exposure.