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


Hepatitis C Among Drug Users: 

De’ja’ Vu all Over Again?

Don C. Des Jarlais, PhD Anne Schuchat, MD

American 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 made—and 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

liver 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 additional research.

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

users. 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 strategies that are timely, effective, and just and that transcend the politics of stigmatization.


  1. 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.
  2. Alter 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; 18: S6-SIO.
  3. 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.
  4. Hagan H. Hepatitis C virus transmission dynamics in injection drug users. Subst Use Mis- use.I998;33:1197-1212.
  5. Lorvick 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.
  6. SeelfLB. The natural history of hepatitis C., Hepatology. 1997;26(suppl Ir21S-28s.
  7. Hagan H, Thiede H, Weiss NS, etal. r . Sharing of drug preparation equipment as a risk hepatitis C virus incidence. Am J Public Health . 2001;91:42--46.
  8. Rosenberg 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.
  9. Edlin 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.