Historically, most HIV positive people with hepatitis C—often life- threatening, worsened by HIV and only sometimes curable—got it from tattoo or IV-drug tools, not sex. Now, U.S. and European docs are seeing a rise in sexually spread hep C among gay men with HIV—and positive heteros may also be vulnerable.

A London Royal Free Hospital study linked noninjection drug use, multiple sex partners and unprotected rough anal sex (fisting, using toys) to sexual transmission of C among HIV positive gay men. Meanwhile, New York City’s Callen-Lorde clinic has seen hep C cases rise from virtually none to between 4% and 8% among their gay male HIV positive clients, with more expected: “That’s the tip of the iceberg,” says medical director Gal Mayer, MD.

Is the surge a result of rough sex—with blood-to-blood contact (unlike HIV, hep C isn’t easily transmitted in sexual fluids)—or of sharing equipment to inject or snort cocaine and crystal meth? In the London study, those with hep C were more likely to have engaged in street-drug use as well as fisting. But at Callen-Lorde, Mayer says, most new cases report only sexual risk factors. Callen-Lorde director Jay Laudato adds that crystal can aid hep C transmission even without shared gear: “It’s an anesthetic,” he says, “so men are less likely to feel rectal pain and may have more forceful sex.”

Either way, it’s preventable. Use condoms and water-based lube for vaginal or anal intercourse and latex gloves with oil-based lube for fisting. Don’t share sex toys or equipment to snort or shoot drugs. Grab safety details at www.harmreduction- .org; 22 W. 27th St., Fifth Floor, NY, NY 10001.

Get tested regularly for hep C. If it doesn’t clear naturally in 90 days, consider treatment. Taken for six months early in infection, meds can often eradicate C, even in those with HIV. So don’t make C a passing grade.