Education + Advocacy = Change

Click a topic below for an index of articles:

New Material



Alternative Treatments

Financial or Socio-Economic Issues


Health Insurance



Institutional Issues

International Reports

Legal Concerns

Math Models or Methods to Predict Trends

Medical Issues

Our Sponsors

Occupational Concerns

Our Board


Religion and infectious diseases

State Governments

Stigma or Discrimination Issues


If you would like to submit an article to this website, email us at for a review of this paper

any words all words
Results per page:

“The only thing necessary for these diseases to the triumph is for good people and governments to do nothing.”

Hepatitis C: waiting for the Grim Reaper

Encouraging drug users to adopt non-injecting routes of administration may be the most effective way of controlling the hepatitis C epidemic


MJA 1997; 166: 284

Until the controversial Grim Reaper campaign alerted Australians to the seriousness of its newly recognised AIDS epidemic, citizens of the Lucky Country were complacent about infections. Fortunately, the HIV epidemic has been stabilised among injecting drug users (IDUs) in Australia by a harm reduction/public health approach to intravenous drug use. Now we have evidence of another important viral epidemic -- hepatitis C. Despite it being arguably the commonest life-threatening infection in Australia, alarm bells have not yet been rung for hepatitis C.

The 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.

The task 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.

In this 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.

Australian 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 among IDUs.

Could a 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.

Despite 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.

The 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.

While 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.

We are 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.

Alex Wodak
Director, Alcohol and Drug Service,
St Vincent's Hospital, Sydney, NSW.

  1. Crofts 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.
  2. National 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.
  3. Albertis 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.
  4. Alter 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: 2231-2235.
  5. Crofts N, Stewart T, Hearne P, et al. Spread of blood borne viruses among Australian prison entrants. BMJ 1995; 310: 285-288.
  6. MacDonald M, Crofts N, Kaldor J. Transmission of hepatitis C virus: rates, routes and cofactors. Epidemiol Rev. In press.
  7. Garfein 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.
  8. National Research Council and Institute of Medicine. Preventing HIV transmission. The role of sterile needles and bleach. Washington DC: National Academy Press. 1995.
  9. National Centre For Epidemiology And Clinical Research. Australian HIV surveillance report. 11: 14. April. 1995.
  10. Feachem 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.
  11. Gerberding JL. Management of occupational exposure to blood-borne viruses. N Engl J Med 1995; 332: 444-451.
  12. Baum D. Smoke and mirrors. The war on drugs and the politics of failure. Boston: Little Brown and Company, 1996.
  13. Wodak A, Crofts N. Once more unto the breach: controlling hepatitis C in injecting drug users. Addiction 1996; 91: 181-184.