C Among Drug Users:
Vu all Over Again?
C. Des Jarlais, PhD Anne Schuchat, MD
Journal of Public Health 21
January 2001, Vol.91, No. I
Following HIV / AIDS, hepatitis C virus (Hepatitis C Virus) is the next emerging
infectious disease epidemic to strike persons who inject
psychoactive drugs.' Like HI\.; Hepatitis C Virus is transmitted through the
sharing of needles and syringes, and the majority of new Hepatitis C Virus
infections in the United States are associated with injection
drug use. 1.2 During the HIV epidemic, stigmatization of drug
users has blocked implementation of programs that could have
greatly reduced HIV transmission. The lack of federal funding
for syringe exchange programs in the United States is but one
clear example of this problem.3 The current Hepatitis C Virus epidemic among
injection drug users challenges communities to learn from the
mistakes that have been madeand are still being made-during
the HIV / AIDS epidemic.
Although the antibody test for Hepatitis C Virus has been available for less than a
decade, well-established and disturbing facts are known about
Hepatitis C Virus infection of injection drug users. Approximately 80% of
persons infected with Hepatitis C Virus become chronic carriers, and Hepatitis C Virus is
readily transmitted through sharing of injection equipment.
Hepatitis C Virus is quite common in populations of injection drug users,
with seropreva1ence rates typically from 60% to 80%. Hepatitis C Virus
infection also frequently occurs early in a drug injection
career, usually before the user seeks help for drug problems.4
Lorvick et al. tested serum samples collected from injection drug users
in San Francisco, Calif., in 1987.5 They found an Hepatitis C Virus
seroprevalence rate of 95%. Most of the subjects in that study
had begun injecting drugs in the late 1960s and early 1970s,
and they had probably been infected for 10 years or more in
1987. For the minority of infected persons who develop severe
disease, the estimated period from initial Hepatitis C Virus infection to
the development of end-stage liver disease is 20 to 30 years.6
The findings of Lorvick et al thus warn us that we must
prepare for an epidemic of end-stage
disease among injection drug users who first became infected
with Hepatitis C Virus in the 1960s and 1970s.
At present there is no vaccine for Hepatitis C Virus and the rapid mutation rate of the
virus will make it difficult to develop one. The extent to
which behavior change (or risk reduction) programs can reduce
Hepatitis C Virus transmission among injection drug users is an important
question for continuing research. Hagan and colleagues make a
critical contribution to the potential for controlling Hepatitis C Virus
infection among injection drug users. They are the first to
show that sharing of drug preparation equipment (such as
cotton and cookers) can be an important route of Hepatitis C Virus
transmission. In their study of Seattle injection drug users,
Hagan et al. found that 54% of the incident Hepatitis C Virus infections
among those who did not share syringes were attributable to
the sharing of drug preparation equipment. Programs to reduce
Hepatitis C Virus transmission among injection drug users will need to focus
on preventing the sharing of drug preparation equipment as
well as the sharing of needles and syringes.
In their study of Hepatitis C Virus among the seriously mentally ill, Rosenberg and
colleagues ob- served the expected increased prevalence
associated with use of injection drugs.8 They also found
increased prevalence among persons who did not report
injecting drugs but did report smoking crack cocaine or using
cocaine intra-nasally. Whether Hepatitis C Virus can be transmitted through
the sharing of equipment for cocaine use without injection (
e.g., crack pipes, cocaine spoons) is a question that requires
Hepatitis C Virus infection among drug users also raises important ethical concerns.
Given the current evidence, it is very likely that risk
reduction programs could at least reduce Hepatitis C Virus transmission
among drug users. As a society, however, the United States has
yet to fully implement risk reduction programs that are known
to reduce HlV transmission among drug
Failure to develop and implement programs to reduce Hepatitis C Virus
transmission would be another ethical failure to protect the
health of all members of the society.
There are current treatments for Hepatitis C Virus infection. These treatments are
expensive and uncomfortable, and they are effective in fewer
than half the cases in which they are undertaken. Current
National Institutes of Health guidelines require that drug
users abstain from drugs for 6 months before beginning these
treatments. The exclusion of active drug users as candidates
for therapeutic medications raises ethical questions and
probably serves to further alienate drug users from the health
care system. Individualized assessment of suitability for Hepatitis C Virus
treatment may be preferable9 and may provide an opportunity
for overall improvements in the health of drug users,
including reduction of drug use.
Finally, it is a statistical
certainty that many drug users will reach end-stage liver
disease in the next 5 to 10 years. They will need liver
transplants to survive, and the number of organs available for
transplantation will not equal the number of patients who need
them. The resulting competition for the limited supply of
organs will undoubtedly create opportunities to discriminate
against drug users. Factoring social worthiness into
transplant decisions- granting a higher priority to
celebrities or as- signing a lower priority to marginalized
populations-violates the principles of health care ethics.
Hepatitis C Virus
infection among injection drug users is a continuing public
health disaster in the United States and many other countries.
This situation provides both opportunities for courageous
public health action and opportunities for unethical
activities that would almost certainly exacerbate the problem.
The Hepatitis C Virus epidemic provides a rare second chance for society to
learn from the mistakes made with HIV/AIDS and to implement
are timely, effective, and just and that transcend the
politics of stigmatization.
- Centers for
Disease Control and Prevention. Recommendations for the
prevention and control of hepatitis C virus (Hepatitis C Virus)
infection and Hepatitis C Virus- related chronic disease. MMWR Morb
Morta/ Wk/y Rep 1998;47(RR-19):1-39.
MJ, Moyer LA. The importance of pre- venting hepatitis C
virus infection among injection drug users in the United
States. J Acquir Immune Defic Syndr Hum Retrovirol 1998;
- Normand J,
Vlahov D, Moses LE, eds. Preventing HIV Transmission: 77re
Ro/e of Steri/e Need/es and B/each. Washington, DC:
National Academy Press; 1995.
- Hagan H. Hepatitis C
virus transmission dynamics in injection drug users. Subst
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J, Kral AH, Seal K, Gee L, Edlin BR. Prevalence and
duration of hepatitis C among injection drug users in San
Francisco .,Am J PublicHealth.2001;91.46--47.
The natural history of hepatitis C., Hepatology. 1997;26(suppl
H, Thiede H, Weiss NS, etal. r . Sharing of drug
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incidence. Am J Public Health . 2001;91:42--46.
SO, Goodman LA, Osher FC.Prevalence of HIV, hepatitis B,
and Hepatitis C in people with severe mental illness. Hea/th.
2001 ;91 :31-37.
BR, Lorvick J, Seal KH, et al. Withholding treatment for
hepatitis C injection drug users: is it ethical?
Paper presented at 1Oth International Symposium
on, Viral Hepatitis and Liver Disease; April
9-13,2000 Atlanta, Ga.