The ongoing opioid epidemic in the United States continues to take an alarming toll on communities across the country. In addition to the more visible and devastating health consequence of accidental overdose death, there are other serious adverse health outcomes of this scourge that may be less immediately apparent, including increased transmission of blood-borne viruses such as HIV and hepatitis C virus (HCV) through the use of shared needles and drug preparation equipment.
According to data from the US Centers for Disease Control and Prevention, incidence of acute HCV infection among adults remained stable from 2001 to 2005, followed by increases from 2005 to 2016, with the steepest inclines beginning in 2010.1 Although rates increased for all age groups, the largest increases occurred among adults aged 20-29 years (more than 6-fold increase) and adults aged 30-39 years (5.5-fold increase). The rise in HCV incidence shows a clear association with increased rates of injection drug use during the past decade, and studies have shown that the majority of new HCV infections occurs in nonurban areas among young, white individuals who inject drugs.
Recent studies evaluating rates of HCV screening, linkage to care, and treatment confirmed the increasing burden of HCV among young adults in the United States and further identified age-related disparities in linkage to HCV care and treatment provision. In an analysis of patients with a positive HCV RNA test who were linked to care, HCV treatment initiation rates were lower for younger adults vs baby boomers (22.6% vs 32.0%, respectively, if linked to a specialist provider and 4.5% vs 8.1%, respectively, if linked to a primary care provider).2
Because the vast majority of HCV infections among young adults occur through injection drug use, HCV screening, treatment, and cure in this group are essential not only to improve individual health but also when considered from a public health perspective—persons who inject drugs are at high risk of transmitting HCV to others. Yet, there are multiple barriers that impede access to HCV treatment for persons who inject drugs, including sobriety restrictions established by payers in some regions and reluctance on the part of healthcare providers who may fear that the patient will not be able to adhere to daily therapy. The results of clinical trials have demonstrated this fear to be unfounded. Current all-oral HCV therapies are highly effective among patients receiving opioid substitution therapy as well as those with ongoing or recent injection drug use. A recent study has also shown that HCV treatment remains effective even with imperfect adherence. An emerging paradigm that may prove to be the most beneficial to patients who inject drugs is coadministration of opioid substitution therapy and HCV therapy through colocalized addiction and hepatitis C service provision.
The shift in focus within the HCV field in recent years toward the goal of eradicating HCV as a public health threat through expanded case-finding and delivery of curative treatment to all infected individuals requires that healthcare providers understand the close association between the opioid epidemic and ongoing HCV transmission. A universal recognition of the multiple individual and community health benefits of curing HCV among persons who inject drugs could go a long way to achieving national HCV elimination goals.
Reference 1. Centers for Disease Control and Prevention. Surveillance for Viral Hepatitis – United States, 2016. Available at: https://www.cdc.gov/hepatitis/statistics/2016surveillance/commentary.htm. Accessed January 7, 2019. 2. Reau N, Marx S, Manthena S, et al. National examination of HCV linkage to care in the United States (2013-2016) based on large real-world dataset. Program and abstracts of the 2018 Annual Meeting of the American Association for the Study of Liver Diseases; November 9-13, 2018; San Francisco, California. Abstract 1567.