HIV-AIDS and Injection Drug Use
(Viral Hepatitis Types and Symptoms) "Viral hepatitis is caused by infection with any of at least five distinct viruses: hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis D virus (HDV), and hepatitis E virus (HEV). Most viral hepatitis infections in the United States are attributable to HAV, HBV, and HCV. All three of these unrelated viruses can produce an acute illness characterized by nausea, malaise, abdominal pain and jaundice, although many of these acute infections are asymptomatic or cause only mild disease. Thus, many persons infected with HBV or HCV are unaware they are infected and have clinically silent infections for decades until developing cirrhosis, end-stage liver disease, or hepatocellular carcinoma."Source:"Viral Hepatitis Surveillance - United States, 2013" (Atlanta, GA: US Centers for Disease Control Division of Viral Hepatitis), April 24, 2015, p. 5.
(Growth in Incidence of Hepatitis C Diagnoses in the US and Description of Groups at Risk) "After receiving reports of cases of acute hepatitis C ranging from 781-877 during the years 2006–2010, reported cases of acute HCV infection increased more than 2.5 times from 2010– 2014. Cases of acute HCV infection rose annually, from 850 in 2010 to 1,232 in 2011, 1,778 in 2012, 2,138 in 2013, and 2,194 in 2014. The increase from 2010–2014 is thought to reflect both true increases in incidence and, to a lesser extent, improved case ascertainment. Based on new epidemiologic studies, at least 4.6 million persons are HCV-antibody positive and approximately 3.5 million are currently infected with HCV (13). New cases of HCV infection are predominately among young persons who are white, live in non-urban areas (particularly in Eastern and Midwestern states), have a history of injection-drug use, and previously used opioid agonists such as oxycodone (14). Improved case ascertainment by Florida, Massachusetts, and New York, which were funded by CDC to conduct enhanced surveillance, partially explains the increased incidence of acute HCV infection in these states. In other locations where the number of cases has increased markedly (e.g., Kentucky, Tennessee, Virginia, and West Virginia), increases have occurred without any federal support for investigation or follow-up, reflecting overall increases in incidence (15, 16). After adjusting for under-ascertainment and under-reporting (2), an estimated 30,500 new HCV infections occurred in 2014.
"Mortality among HCV-infected persons—primarily adults aged 55–64 years—is increasing (17, 18). For the first time in the United States (17), in 2007 the number of HCV-related deaths (n=15,106) exceeded the number of HIV/AIDS-related deaths (n=12,734) (17) and has since continued to increase. The number of HCV-related deaths rose to 19,659 in 2014 and more than one-half of deaths occurred among persons aged 55-64 years. A key public health challenge is to increase the proportion of persons tested, and of those who are currently infected, increase the proportion referred for care and treatment (10, 11). To address this challenge the USPSTF joined with CDC in 2013 to recommend one-time testing for HCV infection among adults born during 1945–1965 (19)."Source:"Viral Hepatitis Surveillance - United States, 2014" (Atlanta, GA: US Centers for Disease Control Division of Viral Hepatitis), May 18, 2016, p. 4.
(Hepatitis C Virus and Injection Drug Use) "HCV infection in IDUs [intravenous drug users] is acquired primarily through injecting with an infected needle and syringe, which has been used by someone else who is infected with HCV or possibly has become contaminated through contact with other contaminated injecting paraphernalia. The probability of becoming infected after using an infected syringe ranges from 1.5 to 5 per cent for HCV, in contrast to 0.34 to 1.4 per cent for HIV (Vickerman et al., in press)."Source:Advisory Council on the Misuse of Drugs, "The Primary Prevention of Hepatitis C Among Injecting Drug Users," (London, United Kingdom: February 2009), p. 12.
(Rate and Number of Acute Hepatitis C Infections in the US) "In 2014, a total of 2,194 cases of acute hepatitis C were reported to CDC from 40 states (Table 4.1). The overall incidence rate for 2014 was 0.7 cases per 100,000 population, an increase from 2010–2012. After adjusting for under-ascertainment and under-reporting, an estimated 30,500 acute hepatitis C cases occurred in 2014. (Data for 2014 were unavailable for Alaska, Arizona, Connecticut, Delaware, the District of Columbia, Hawaii, Iowa, Mississippi, New Hampshire, Rhode Island, and Wyoming.)"Source:"Viral Hepatitis Surveillance - United States, 2014" (Atlanta, GA: US Centers for Disease Control Division of Viral Hepatitis), May 18, 2016, p. 42.
(Transmission of Hepatitis C Virus) "HCV is transmitted primarily through percutaneous (parenteral) exposure that can result from injection-drug use, needle stick injuries, and inadequate infection control in health-care settings. Much less often, HCV transmission occurs among HIV-positive persons, especially MSM, as a result of sexual contact with an HCV-infected partner (30, 31), among persons who receive tattoos in unregulated settings (31), and among infants born to HCV-infected mothers (32). After adjustment for populations not sampled in the NHANES household surveys, such as incarcerated and homeless populations, an estimated 3.5 million persons are living with HCV infection in the United States (28)."Source:"Viral Hepatitis Surveillance - United States, 2014" (Atlanta, GA: US Centers for Disease Control Division of Viral Hepatitis), May 18, 2016, p. 6.
(Acute Hepatitis C Infections in the US in 2014, by Transmission Method)
" Of the 2,194 case-reports of acute hepatitis C received by CDC during 2014, 942 (42.9%) did not include a response (i.e., a “yes” or “no” response to any of the questions about risk exposures and behaviors) to enable assessment of risk exposures or behaviors.
" Of 1,252 case-reports that had risk exposure/behavior information, 416 (33.2%) indicated no risk exposure/behavior for hepatitis C and 836 (66.8%) indicated at least one risk exposure/behavior in the 2 weeks to 6 months prior to illness onset. Figure 4.6a presents reported risk exposures/behaviors for hepatitis C during the incubation period, 2 weeks to 6 months prior to onset of symptoms.
" Of the 1,030 case-reports that had information about injection drug use, 68.2% (n=702) indicated use of injection drugs.
" Of the 230 case-reports from males that included information about sexual preferences/practices, 11.7% (n=27) indicated sex with another man.
" Of the 35 case-reports that had information about sexual contact, 8.6% (n=3) reported sexual contact with a person with confirmed or suspected hepatitis C.
" Of the 494 case-reports that had information about number of sex partners, 30.4% (n=150) indicated having ≥2 sex partners."Source:"Viral Hepatitis Surveillance - United States, 2014" (Atlanta, GA: US Centers for Disease Control Division of Viral Hepatitis), May 18, 2016, pp. 50-51.
(Hepatitis C Infections in the US in 2007, by Transmission Methods) "Of the cases reported in 2007 for which information concerning exposures during the incubation period was available, the most common risk factor identified was IDU (48%). During 1998–2007, IDU [intravenous drug use] was reported for an average of 44% of persons (range: 38%–54%). In 2007, 42% reported having multiple sex partners during the incubation period, 10% reported having sexual contact with another known HCV-infected person, and 10% were MSM [men who have sex with men]. Having had surgery was reported for 20% of persons with hepatitis C; the percentage was higher for persons aged >40 years (32%). A total of 2% reported occupational exposure to blood."Source:Centers for Disease Control and Prevention, "Surveillance for Acute Viral Hepatitis -- United States, 2007," Surveillance Summaries, May 22, 2009, MMWR 2009;58(No. SS-3), p. 6.
(Hepatitis C Virus and Injection Drug Use) "Hepatitis C virus (HCV) infection is very common among injection drug users. Studies of injection drug users in regions with a longstanding pattern of endemic injection drug use have reported prevalences of HCV antibody in the range of 65% to 90%, even where HIV prevalence is quite low.1-5 The majority of HCV infections become chronic, resulting in a large reservoir of HCV infection among injection drug users. Incidence of HCV infection in previously uninfected injection drug users ranges from 10 to 30 per 100 person-years at risk."Source:Hagan, Holly, PhD, Thiede, Hanne, DVM, MPH, Weiss, Noel S., MD, DrPH, Hopkins, Sharon G., DVM, MPH, Duchin, Jeffrey S., MD, and Alexander, E. Russell, MD, "Sharing of Drug Preparation Equipment as a Risk Factor for Hepatitis C," American Journal of Public Health, Vol. 91, No. 1, Jan. 2001, p. 42.
(Injection Drug Use and Transmission of Hepatitis C) "The potential for blood-borne viral transmission via injection equipment other than syringes was reported in an earlier study of equipment collected in a Miami shooting gallery, where HIV-1 DNA was detected in rinses from cottons and cookers and in water used to clean paraphernalia and to dissolve drugs. A sterile syringe may become contaminated when the tip of the needle is inserted into a contaminated cooker or when the drug is drawn up through contaminated filtration cotton. This type of injection risk behavior appears to be quite common, and fewer injection drug users may recognize the hazard of sharing drug preparation equipment than recognize the hazard of sharing syringes. The present study suggests that HCV may be transmitted via the shared use of drug cookers and filtration cotton even without injection with a contaminated syringe."Source:Hagan, Holly, PhD, Thiede, Hanne, DVM, MPH, Weiss, Noel S., MD, DrPH, Hopkins, Sharon G., DVM, MPH, Duchin, Jeffrey S., MD, and Alexander, E. Russell, MD, "Sharing of Drug Preparation Equipment as a Risk Factor for Hepatitis C," American Journal of Public Health, Vol. 91, No. 1, Jan. 2001, p. 43.
(Global Estimated Prevalence of Injection Drug Use (IDU)-Related Hepatitis C Virus (HCV) Infection) "Another major global public health concern is hepatitis C, which can lead to liver diseases such as cirrhosis and cancer. Infection with the hepatitis C virus (HCV) is highly prevalent among people who inject drugs. UNODC estimates that the global prevalence of HCV among people who inject drugs is 51.0 per cent, meaning that 7.2 million people who inject drugs were living with HCV in 2011.17
"The largest numbers of people who inject drugs and are living with HCV are found in East and South-East Asia, Eastern and South-Eastern Europe and North America. The highest HCV prevalence rates among people who inject drugs in countries with predominantly large numbers of people who inject drugs (more than 100,000 to help ensure that a stable prevalence can be determined) are mostly located in North America and East and South-East Asia: Mexico (96.0 per cent), Viet Nam (74.1 per cent), United States (73.4 per cent), Canada (69.1 per cent), Malaysia (67.1 per cent), China (67.0 per cent) and Ukraine (67.0 per cent)."
(Number of HCV Infections and Deaths Worldwide) "About 150 million people are chronically infected with HCV. More than 350,000 people are estimated to die from HCV-related liver diseases each year. Exposure to blood through injections with non-sterile equipment or transfusion of infected blood products is a common and preventable cause of HBV and HCV infections."Source:"Prevention and Control of Viral Hepatitis Infection: Framework for Global Action" (Geneva, Switzerland: World Health Organization, 2012), WHO/HSE/PED/HIP/GHP 2012.1, p. 7.
(HIV Co-Infection) "HBV/HIV and HCV/HIV coinfections are an increasing problem in countries with HIV epidemics and among injecting drug users. For co-infected persons being treated with HIV antiretroviral medicines, underlying viral hepatitis is becoming a major cause of death."Source:"Prevention and Control of Viral Hepatitis Infection: Framework for Global Action" (Geneva, Switzerland: World Health Organization, 2012), WHO/HSE/PED/HIP/GHP 2012.1, p. 7.
"• Infection control precautions in health care and community settings can prevent transmission of viral hepatitis as well as many other diseases.
"• Safe injection practices can protect against HBV and HCV transmission.
"• Safer sex practices, including minimizing the number of partners and using barrier protective measures (condoms), protect against HBV and possibly against HCV transmission.
"• Harm reduction practices for injecting drug users prevent HAV, HBV and HCV transmission."Source:"Prevention and Control of Viral Hepatitis Infection: Framework for Global Action" (Geneva, Switzerland: World Health Organization, 2012), WHO/HSE/PED/HIP/GHP 2012.1, p. 11.
(HCV Drugs and Treatment) "Antiviral agents against HBV and HCV exist. However, drugs active against HBV or HCV are not widely accessible. Currently, three antiretrovirals (TDF, 3TC, FTC) are effective for treatment of both HIV and HBV, so co-infected patients can take fewer drugs to treat the two diseases.
"Although HCV can be treated, access to treatment remains an issue in many countries. Therapeutic advances and intense research have led to the development of many new oral antiviral drugs for HCV infection. A number of HCV-specific oral drugs are in the late stage of development and some have been recently registered."Source:"Prevention and Control of Viral Hepatitis Infection: Framework for Global Action" (Geneva, Switzerland: World Health Organization, 2012), WHO/HSE/PED/HIP/GHP 2012.1, p. 12.
(Progression from Acute to Chronic HCV Infection) "No laboratory distinction can be made between acute and chronic (past or present) HCV infection. Diagnosis of chronic infection is made on the basis of anti-HCV positive results upon repeat testing. Approximately 75%-85% of newly infected persons develop chronic infection (14).
"Because of the high burden of chronic HCV infection in the United States and because no vaccine is available for preventing infection, national recommendations (15) emphasize other primary prevention activities, including screening and testing blood donors, inactivating HCV in plasma-derived products, testing persons at risk for HCV infection and providing them with risk-reduction counseling, and consistently implementing and practicing infection control in health-care settings."Source:"Viral Hepatitis Surveillance - United States, 2010" (Atlanta, GA: US Centers for Disease Control Division of Viral Hepatitis), August 2012, p. 3.
(Risks and Treatment Success) "Chronic HCV infection can lead to severe liver disease, liver cancer and death. Rates of progression, though initially slow, increase over time. For example, after 20 to 40 years approximately 20 per cent of those infected will develop cirrhosis of whom approximately three per cent annually will die from decompensated cirrhosis or liver cancer. Chronic HCV can be successfully cleared in at least half of patients that are treated (Department of Health, 2002; Irving, presentation to ACMD, 2008)."Source:Advisory Council on the Misuse of Drugs, "The Primary Prevention of Hepatitis C Among Injecting Drug Users," (London, United Kingdom: February 2009), p. 7.
(HCV Testing and Treatment) Researchers mailed a survey to 1,200 randomly selected active members of the American Academy of Family Physicians. Here are some of the results:
"Identification of Persons at Risk. Respondents were asked what strategies they use to identify persons at risk for hepatitis C to offer blood testing for the virus, and their responses are listed in Table 2. Relatively few respondents reported using standardized history sheets to assess for hepatitis C risk factors (17%), though a larger percent reported screening (method not specified) all new patients (32%) or asking patients about risk factors (63%). Most (85%) offer hepatitis C testing to patients with elevated liver function tests and to patients they consider to be at high risk for hepatitis C (70%)."
"Hepatitis C Screening Blood Tests. The most common blood test used to screen patients for hepatitis C was hepatitis C antibody testing (91%), followed by liver function testing (59%). Only a few respondents indicated using only liver function tests for hepatitis C screening (2%)."
"Counseling. After a diagnosis of hepatitis C is made, most respondents said they counsel their patients with hepatitis C not to use alcohol (94%), not to use acetaminophen (88%), to get tested for and vaccinated against hepatitis B (86%) and hepatitis A (68%), and to get tested for HIV (81%)."
"Risk Factors. Nearly all respondents indicated they offer blood testing for hepatitis C in patients with known risk factors (98%) that, as listed in Table 2, were identified as including elevated liver enzymes, history of intravenous drug use, hepatitis B infection sex partner with hepatitis C, HIV infection, and blood transfusion before 1992. A high percent also reported offering blood testing to patients with tattoos (75%), all pregnant women (40%), and patients with blood transfusions after 1992 (47%), even though the CDC does not recommend blood testing for any of these factors.1"
"Antiviral Efficacy and Side Effects. Almost half (46%) of all respondents thought that the current multi-drug regimens “cure” hepatitis C less than 50% of the time, while 21% thought the cure rate was 50% to 69%. Most respondents thought the side effects of drug therapy were bothersome (33%) or very bothersome (34%)."Source:Clark, Elizabeth C.; Yawn, Barbara P.; Galliher, James M.; Temte, Jonathan L.; and Hickner, John, "Hepatitis C Identification and Management by Family Physicians," Family Medicine (Leawood, KS: Society of Teachers of Family Medicine, October, 2005) Volume 37, Issue 9, p. 645-647.
(Global Estimated Drug-Related Mortality, 2011) "UNODC estimates that there were between 102,000 and 247,000 drug-related deaths in 2011, corresponding to a mortality rate of between 22.3 and 54.0 deaths per million population aged 15-64. This represents between 0.54 per cent and 1.3 per cent of mortality from all causes globally among those aged 15-64.20 The extent of drug-related deaths has essentially remained unchanged globally and within regions."
(HCV Mortality and Costs, 1998) "In the United States, chronic HCV infection accounts for 8,000 to 10,000 related deaths annually.1,3 It has become the leading cause of liver transplantation, accounting for 30% of all liver transplants. The Centers for Disease Control and Prevention (CDC) conservatively estimates expenditures devoted to HCV to be more than $600 million annually."Source:Wong, John B., MD, McQuillan, Geraldine M., PhD, McHutchison, John G., MD, and Poynard, Thierry, MD, "Estimating Future Hepatitis C Morbidity, Mortality, and Costs in the United States," American Journal of Public Health, Vol. 90, No. 10, Oct. 2000, p. 1562.
(HCV Prevalence) "Hepatitis C is the most common blood-borne pathogen in humans and the most common cause of liver failure and reason for liver transplantation in the United States.1 In a large population-based study, 1.8% (3.9 million) of a large household-based sample was positive for anti-hepatitis C virus antibody.2 Of these, 74% (2.7 million) had viremia, an indicator of chronic infection. As many as half of these persons were unaware they were infected.3,4"Source:Clark, Elizabeth C.; Yawn, Barbara P.; Galliher, James M.; Temte, Jonathan L.; and Hickner, John, "Hepatitis C Identification and Management by Family Physicians," Family Medicine (Leawood, KS: Society of Teachers of Family Medicine, October, 2005) Volume 37, Issue 9, p.
(Recommendation of British Advisory Council on Misuse of Drugs) "Recommendation 1. Local service planners need to review local needle and syringe services (and be supported in this work) in order to take steps to increase access and availability to sterile injecting equipment and to increase the proportion of injectors who receive 100 per cent coverage of sterile injecting equipment in relation to their injecting frequency."Source:Advisory Council on the Misuse of Drugs, "The Primary Prevention of Hepatitis C Among Injecting Drug Users," (London, United Kingdom: February 2009), p. 28.
(Cannabis and HCV Viral Load) "Short-term use of smoked cannabis did not affect viral load in 15 HIV-positive patients and also is associated with adherence to therapy and reduced viral loads in 16 patients with hepatitis C infections."Source:American Medical Association, Council on Science and Public Health, "Report 3 of the Council on Science and Public Health: Use of Cannabis for Medicinal Purposes" (December 2009), p. 15.