November 30, 2013

Hepatitis C prevention and treatment for substance users in the UnitedStates: acknowledging the elephant in the room

International Journal of Drug Policy 15 (2004) 81–91


Brian R. Edlin

Center for the Study of Hepatitis C, Weill Medical College of Cornell University, New York, NY, USA

Received 20 March 2002; received in revised form 3 October 2003; accepted 9 October 2003

Like many countries, the United States faces a major epi-demic of hepatitis C virus (HCV) infection. Nearly 3 millionAmericans are estimated to be infected with HCV (Alteret al., 1999),and some 35,000 new infections are believed tooccur annually (Williams, 1999).The virus causes chronicinfection in about 85% of those infected, and among thosechronically infected, cirrhosis may eventually develop infrom 5 to 20% (Freeman et al., 2001;Liang, Rehermann,Seeff, & Hoofnagle, 2000).HCV infection is thought to re-sult in 8000–10,000 deaths annually. It is already the mostcommon cause of chronic liver disease and the most com-mon reason for liver transplantation in the United States,and morbidity and mortality from HCV infection are risingand are expected to continue rising in the coming decades(Armstrong, Alter, McQuillan, & Margolis, 2000).

In the United States, as in many other developed coun-tries, injection drug users (IDUs) constitute the largest groupof persons infected with HCV, and most new infectionsoccur in IDUs. Injection drug use predominates as a modeof transmission in most countries where the endemicity of HCV is low. There are probably a million or more currentIDUs with HCV infection in the U.S.; of the estimated1.2–1.3 million current IDUs in the U.S. (Normand, Vlahov,& Moses, 1995), some 80–90% have been infected withHCV (Lorvick, Kral, Seal, Gee, & Edlin, 2001;Thomaset al., 1995),although recent studies have shown that preva-lence rates in young IDUs and recent initiates are now muchlower (Garfein et al., 1998;Hahn, Page-Shafer, Lum, Ochoa,& Moss, 2001;Thorpe, Ouellet, Levy, Williams,&Monterroso, 2000).The incidence of new infections amongIDUs is also quite high, however, generally ranging from10 to 20% per year in the U.S. (Garfein et al., 1998; Haganet al., 1999, 2001; Hahn et al., 2001; Thorpe et al., 2000).

The situation is similar in other developed countries (Crofts,Jolley, Kaldor, van Beek, & Wodak, 1997;Patrick et al.,2001;Van Ameijden, Van den Hoek, Mientjes, & Coutinho,1993;van Beek, Dwyer, Dore, Luo, & Kaldor, 1998).Moreover, initiation of heroin use and injection drug use isincreasing among young people (CDC, 2001a).Controllingthe HCV epidemic, therefore, will require developing, test-ing, and implementing prevention and treatment strategiesthat will be effective for persons who inject drugs. Fortu-nately, substantial research and clinical experience exists inthe prevention and management of chronic viral infectionsamong IDUs, particularly because of the HIV epidemic.Learning from this experience will be critical for efforts tocontrol HCV

The public health response to the HCV epidemic in theU.S. to date has, unfortunately, fallen short of what is neededto stop the epidemic. Until recently, official documents pro-duced by the U.S. Public Health Service about its responseto the HCV epidemic were silent on most of the interven-tions described in this article (CDC, 1998; CDC, 2001b;NIH, 1997a).In 2002, NIH issued an updated ConsensusStatement on the Management of Hepatitis C that took asubstantially more comprehensive approach to the problem(NIH, 2002).This statement challenges the medical, scien-tific, and public health communities to address numerousproblems that remain unsolved and continue to contribute tothe HCV epidemic.

Preventing morbidity and mortality from HCV can bedivided into primary, secondary, and tertiary prevention(Table 1).This paper summarises recommendations for ef-fective prevention in each of these categories, and discussessome of the barriers that have hampered their implementa-tion.

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