incidence and prevalence of hepatitis C in Australia are far
higher than those of HIV infection. An estimated 130 000
Australians have been infected with hepatitis C virus (HCV) over
the last 20 years, with about 6000 new chronic infections a year
through injecting drug use alone.1 In contrast, an
estimated 15 450 people have been infected with HIV by all
routes of transmission, with about 500 new infections a year
between 1994 and 1996.2 Although a smaller proportion
of individuals infected with HCV experience serious morbidity
and mortality, and only after a longer delay (10%-20% are
estimated -- conservatively -- to develop cirrhosis within 20
years and 5% of these develop hepato cellular carcinoma within
five years),3 the far larger pool of infected people
and longer duration of illness suggest that the total health and
economic burden of hepatitis C in Australia is considerable and
may well surpass HIV before too long.
of bringing hepatitis C under control is daunting. While the
pieces of the hepatitis C jigsaw puzzle are still being
assembled, injecting drug use is undeniably the major mode of
transmission in Australia and other developed countries.
issue of the Journal, Sladden and colleagues found that 85% of
hepatitis C notifications involved IDUs. Their epidemiological
study analysed notifications of hepatitis C from a community
sample and assigned risk factors for a high proportion of
respondents. However, the high non-response rate of 53% and the
statistically significant differences between respondents and
non-respondents qualify their findings. In contrast to Sladden
and colleagues' results, a United States study estimated a much
lower proportion of IDUs among hepatitis C notifications, but
could not assign risk factors for as high a proportion of
respondents.4 As official policy in the US advocates
"zero tolerance" for any illicit drug use, it is hardly
surprising that many American IDUs were apparently intimidated
from revealing their risk behaviour.
national surveillance data (of uncertain quality) accord with
Sladden and colleagues' results -- about 85% of hepatitis C
virus infections involve IDUs.1 Current hepatitis C
incidence in IDUs is now estimated to be about 15 per 100
person-years.1 IDUs entering prison on more than one
occasion are at even greater risk.5 These alarming
figures are consistent with those for other countries.6
Hepatitis C seroprevalence in a large cohort of IDUs in
the United States was 65% for those who had injected for one
year or less and 85% when the cohort was followed up for 49-72
months.7 Indeed, a recent review1 of
published studies of the epidemiology of hepatitis C among
Australian IDUs traces the epidemic back to at least 1971, soon
after injecting drug use became established in this nation.
Clearly, the epidemic will be halted only if it is controlled
harm reduction/public health approach control hepatitis C among
IDUs? Such an approach, which includes needle exchange and
methadone treatment programs, has already been successful in
stabilising the HIV epidemic among IDUs in Australia. In
contrast, the US "War on Drugs", which has resulted from the
official policy of "zero tolerance" for any illicit drug use,
has had catastrophic public health consequences. In 1994, IDUs
accounted for only 2.5% of AIDs cases in Australia,8
compared with 28% in the US in 1993.9 While the
prevalence of AIDS (per million population) in the United States
was 4.3 times that in Australia in 1988, by 1992 this ratio had
increased to 6.4,10
fuelled by an uncontrolled epidemic among IDUs and a
secondary epidemic among heterosexual contacts of HIV-positive
IDUs in the US.
the success of the harm reduction/public health approach in
controlling the HIV epidemic and slowing the spread of hepatitis
B among IDUs in Australia, it appears not to have reduced the
incidence of hepatitis C.1
There is a very real possibility that hepatitis C
transmission among IDUs requires only minimal breaches of
infection control guidelines.1 Hepatitis C virus is
an order of magnitude more infective than HIV,11 and
hepatitis C has a far higher baseline prevalence than HIV
infection. Consequently, while expanding needle exchange and
methadone treatment programs may reduce hepatitis C incidence,
this is unlikely to control the epidemic.
approach of eliminating importation or global production of
injectable drugs continues to enjoy some support, especially
during long election campaigns, but it is increasingly apparent
that this is an expensive fantasy. Even a major architect of
Nixon's "War on Drugs", the former White House adviser John
Erlichman, testified to a US Senate Subcommittee: "the people in
the federal government . . . know darn well that the massive war
they have mounted on narcotics is only going to be effective at
the margins. If they don't know it, they ought to know it."12
Reducing drug supply or demand is seemingly a more
realistic objective, but the evidence of past decades provides
little grounds for optimism.
attempts to eliminate harm from illicit drugs almost
universally fail, efforts to reduce harm generally
succeed. Therefore, encouraging drug users to adopt
non-injecting routes of administration (sniffing, smoking,
snorting or swallowing) appears to offer our best hope for
achieving hepatitis C control among IDUs. Smoking of heroin has
overtaken injecting in popularity in many parts of the United
States, the United Kingdom and the Netherlands.13
Reasons differ between these countries but are thought to
include, in the US, the scarcity of sterile injecting equipment,
coupled with drug users' fear of contracting HIV infection
through needle sharing, and (most importantly) the recent drop
in price and increase in purity of available heroin. In other
countries, the increased availability of heroin base, which has
a lower melting point than heroin hydrochloride and is thus more
suitable for smoking, has played a part. A strategy of promoting
non-injecting routes of administration also offers the hope of
reducing the growing epidemic of drug overdoses, which claim
about 500 young Australian lives each year.
beginning to recognise hepatitis C as a public health problem
comparable in magnitude with HIV. The recent inclusion of
hepatitis C in the Third National HIV/AIDS Strategy means that
it will at least be included in a national policymaking
apparatus, which delivered splendid, internationally recognised
results for HIV/AIDS. Only when there is a national commitment
to raise levels of awareness about the seriousness of this
epidemic will Australia stand a chance of controlling hepatitis
C. Until Australia embarks on a major national awareness-raising
exercise, such as a "Grim Reaper"-style public education
campaign, the band will continue to play on for hepatitis C as
it once did for HIV.
Director, Alcohol and Drug Service,
St Vincent's Hospital, Sydney, NSW.
N, Jolley D, Kaldor J, et al. The epidemiology of hepatitis
C virus infection among injecting drug users in Australia.
J Epi Comm Health. In press.
Centre in HIV Epidemiology And Clinical Research. An
epidemiological assessment of the HIV epidemic in Australia.
Technical Appendix 1. Evaluation of the HIV/AIDS Strategy
1993-4 to 1995-6. Canberra: AGPS, 1996: 9-16.
A, Realdi G. Parenterally acquired non-A, non-B (type C)
hepatitis. In: McIntyre N, Benhamou J-P, Bircher J, et al.,
editors. Oxford textbook of clinical hepatology. Oxford:
Oxford University Press, 1991: 605-617.
MJ, Hadler SC, Judson FN et al. Risk factors for acute
non-A, non-B hepatitis in the United States and association
with hepatitis C virus infection. JAMA 1990; 264:
N, Stewart T, Hearne P, et al. Spread of blood borne viruses
among Australian prison entrants. BMJ 1995; 310:
MacDonald M, Crofts N, Kaldor J. Transmission of hepatitis C
virus: rates, routes and cofactors. Epidemiol Rev. In
RS, Vlahov D, Galai N, et al. Viral infections in short-term
injection drug users: the prevalence of the hepatitis C, B
human immunodeficiency and human T-lymphotropic viruses.
Am J Pub Health 1996; 86: 655-661.
Research Council and Institute of Medicine. Preventing HIV
transmission. The role of sterile needles and bleach.
Washington DC: National Academy Press. 1995.
Centre For Epidemiology And Clinical Research. Australian
HIV surveillance report. 11: 14. April. 1995.
RGA. Valuing the past -- investing in the future. Evaluation
of the national HIV/AIDS strategy 1993-94 to 1995-96.
Canberra: Commonwealth Department of Human Services and
Health, AGPS, 1995.
Gerberding JL. Management of occupational exposure to
blood-borne viruses. N Engl J Med 1995; 332: 444-451.
Smoke and mirrors. The war on drugs and the politics of
failure. Boston: Little Brown and Company, 1996.
Wodak A, Crofts N. Once more unto the breach: controlling
hepatitis C in injecting drug users. Addiction 1996;