ResearchImplementation Brief

HCV infection is highly prevalent among people who inject drugs (PWID) and many injectors who were infected in years past are now becoming ill and require medical care and treatment. There are now more deaths in the US each year from HCV than HIV infection [1]. In addition, outbreaks of HCV infection are emerging in young PWID, fueled by epidemic levels of prescription opioid misuse that have evolved into widespread injection drug use [2]. The CDC reported a 75% increase in new HCV infections nationally 2010-2012 [3]. These recent developments, the discovery of safer and more effective treatments for HCV, and the fact that fewer than 5% of PWID receive HCV care or treatment, compel the development of policy actions to address this urgent and expanding public health problem. Lessons learned about how to control HIV infection in PWID, combined with new knowledge about HCV prevention and treatment, form the basis of the HCV recommendations contained in this CDUHR Research for Implementation Brief.

1. Syringe access programs and medication-assisted substance use treatment must be employed to prevent HCV in PWID

Both syringe access and opiate agonist substitution treatment have been shown to reduce  HIV incidence [4].  However, HCV is more easily transmitted than HIV and there are five to ten times as many infectious carriers of HCV among PWID [5].  For these reasons, syringe access and opioid substitution treatment are effective HCV prevention measures especially when provided in combination and at high levels of coverage. Under these conditions, they may reduce new HCV infections by 75-80% [6].  Scale-up of these interventions to prevent infections will also reduce more costly downstream medical care and treatment services.

2. Interventions to engage and retain HCV infected persons in the Care Continuum must be developed and supported in order for new, highly effective treatments for HCV infection to reduce morbidity and mortality

New HCV treatment regimens can be completed in 8-24 weeks and have been shown to be effective even in patients with advanced disease and those who failed earlier treatments [7]. New treatments have also been shown to be cost-effective, saving public health expenditures that would otherwise be needed to care for those who develop cirrhosis or liver cancer and other HCV-related conditions [8]. Accruing these health benefits and savings will require expanded efforts to diagnose HCV in PWID, and to link those who are infected to care and treatment services [9]. Lessons learned from the HIV Care Continuum for PWID provide useful insights into accomplishing this, including:

a. Supportive services shown to increase retention among PWID in HIV care (e.g., patient readiness, case management, and patient navigation) will be needed to ensure that PWID are appropriately screened, diagnosed and linked and retained in HCV care.

b. The integration of HCV Care Continuum services in settings where PWID currently receive health care and other services will expand access. These include harm reduction programs, substance use treatment programs, correctional facilities, emergency departments, community settings, and primary care and specialty clinics.

c. The number of trained health care providers who can manage and treat HCV infection in PWID will need to be expanded.

d. HCV may be cured in 12-24 weeks. Focusing public health resources on curing a substantial number of HCV-infected patients in the short-term will reap substantial public health benefits in the long-term.

e. Payer systems and insurance coverage will also need to respond to the scope and urgency of the problem.

3. Combine HCV prevention and treatment at sufficient levels of coverage in the near-term in order to eradicate HCV infection in the US

Current recommendations for HIV control center on combining highly effective prevention and treatment interventions to achieve synergistic results. For HIV, these include syringe access, opioid substitution treatment, engagement in HIV care and support for adherence to treatment. Access to these combined interventions has been shown to nearly eliminate HIV incidence in PWID. Similar combinations of prevention and treatment interventions for HCV may eventually eliminate all infectious carriers who serve as a source of new infections.10 Investment of sufficient resources toward eradication will also reduce HCV morbidity and mortality and downstream medical care costs.

The new generation of safer and effective treatments provides hope that implementation of both HCV prevention and treatment modalities will result in the eradication of HCV infection in PWID. Taking advantage of all that has been learned from decades of experience providing harm reduction and HIV care and treatment to PWID will help to achieve the goal of eliminating HCV in the US.

For further information on this brief contact CDUHR@nyu.edu.

CDUHR – cduhr.org
CDC – cdc.gov/hepatitis/hcv/index.htm
WHO – who.int/mediacentre/factsheets/fs164/en/
NYS DOH – health.ny.gov/diseases/communicable/hepatitis/hepatitis_C/

1. K. N. Ly, J. Xing, R. M. Klevens, R. B. Jiles, J. W. Ward, and S. D. Holmberg, ‘The Increasing Burden of Mortality from Viral Hepatitis in the United States between 1999 and 2007’, Ann Intern Med, 156 (2012), 271-8.
2. R. Valdiserri, J. Khalsa, C. Dan, S. Holmberg, J. Zibbell, D. Holtzman, R. Lubran, and W. Compton, ‘Confronting the Emerging Epidemic of Hcv Infection among Young Injection Drug Users’, Am J Public Health, 104 (2014), 816-21.
3. Centers for Disease Control and Prevention, ‘Surveillance for Viral Hepatitis—United States, 2012’, http://www.cdc.gov/
   hepatitis/statistics/2012surveillance/commentary.htm, 01/15/2015.
4. D. C. Des Jarlais, K. Arasteh, C. McKnight, J. Feelemyer, H. Hagan, H. L. Cooper, and D. C. Perlman, ‘Combined HIV Prevention, the New York City Condom Distribution Program, and the Evolution of Safer Sex Behavior among Persons Who Inject Drugs in New York City’, AIDS Behav, 18 (2014), 443-51.
5. H. Hagan, ‘Agent, Host and Environment: Hepatitis C in People Who Inject Drugs.’, J Infect Dis, 204 (2011), 1819-1821.
6. H. Hagan, E. R. Pouget, and D. C. Des Jarlais, ‘A Systematic Review and Meta-Analysis of Interventions to Prevent Hepatitis C Virus Infection in People Who Inject Drugs’, J Infect Dis, 204 (2011), 74-83.
7. A. Kohli, A. Shaffer, A. Sherman, and S. Kottilil, ‘Treatment of Hepatitis C: A Systematic Review’, JAMA, 312 (2014), 631-40.
8. N. K. Martin, P. Vickerman, A. Miners, G. R. Foster, S. J. Hutchinson, D. J. Goldberg, and M. Hickman, ‘Cost-Effectiveness of Hepatitis C Virus Antiviral Treatment for Injection Drug User Populations’, Hepatology, 55 (2012), 49-57.
9. C. L. Masson, K. L. Delucchi, C. McKnight, J. Hettema, M. Khalili, A. Min, A. E. Jordan, N. Pepper, J. Hall, N. S. Hengl, C. Young, M. S. Shopshire, J. K. Manuel, L. Coffin, H. Hammer, B. Shapiro, R. M. Seewald, H. C. Bodenheimer, Jr., J. L. Sorensen, D. C. Des Jarlais, and D. C. Perlman, ‘A Randomized Trial of a Hepatitis Care Coordination Model in Methadone
   Maintenance Treatment’, Am J Public Health, 103 (2013), e81-8.
10. B. R. Edlin, and E. R. Winkelstein, ‘Can Hepatitis C Be Eradicated in the United States?’, Antiviral Res, 110C (2014), 79-93.