In recent years, there has been an emerging epidemic of hepatitis C virus (HCV) infection among young injection drug users (IDU) in rural and suburban settings. Early this spring, the U.S. Department of Health and Human Services convened a multidisciplinary technical consultation to discuss the existing evidence and to identify and define priorities for the development of a public health response. Already working together to implement the Action Plan for the Prevention, Care, and Treatment of Viral Hepatitis—which includes among its priorities “reducing viral hepatitis caused by drug use behaviors”—the Office of HIV/AIDS and Infectious Disease Policy, the National Institutes of Health, the Centers for Disease Control and Prevention, the Substance Abuse and Mental Health Services Administration organized the consultation which brought together representatives of federal agencies, state health department officials, researchers, care providers, staff of community-based organizations, and other experts in the field. Over two days the participants explored factors fueling this epidemic and recommended priorities around epidemiology and surveillance initiatives, prevention and linkages to care interventions, and research questions designed to curb the rising rate of HCV among young persons who inject drugs (PWID) in the United States.
Injection drug use is known to play a major role in HCV transmission. Surveillance data shared by Massachusetts in 2010 put a spotlight on an emerging HCV infection trend among young PWID. That year, the Massachusetts Department of Public Health analyzed chronic hepatitis C infection data and observed an increase of HCV among persons aged 15–24 between 2002 and 2009. The young people being reported were from all over the state, almost all outside of metropolitan Boston, primarily White, and equally male and female. In-depth interviews with a number of these HCV-positive young people uncovered that most were IDUs who had started opioid use by first misusing oral oxycodone around 1–1.5 years before transitioning to injecting heroin.
After the Massachusetts findings were published, other jurisdictions across the country, began to report similar findings: rising rates of hepatitis C infection among young injectors, both male and female, primarily White, found in suburban and rural settings, who started misusing prescription opioids (e.g., oxycodone) before transitioning to heroin injection.
Participants in the consultation shared that HCV transmission among young IDUs is highly efficient, with young injectors frequently acquiring HCV soon after they first begin to inject opioids. This indicates that the window for HCV prevention interventions targeting this population is narrow. In addition to drug use behaviors, other risk factors influence their risk of acquiring or transmitting HCV including homelessness and a lack of understanding about their risk of infection with HCV and how to prevent it.
The size of this population is significant. An analysis of data from the National Household Survey on Drug Abuse between 1979-2002 (now the National Survey on Drug Use and Health) estimated that 590,000 young adults aged 18–29 had ever injected drugs. As the surveys do not include institutionalized or homeless individuals, it is likely that these figures are underestimates. Among these young injectors, it is estimated that as many as 45% (265,000) are infected with HCV.
There is growing concern that these increases could begin to reverse the declines in overall HCV incidence and prevalence observed by the CDC over the past decade. It is clear that federal, state local and community partners need to take action if we are to mount a sound public health response.
During the consultation, researchers, federal agency representatives, providers, and community leaders shared presentations on key facts about the epidemiology of HCV infection among this population, the state of current research, and examples of innovative community responses. The consultants engaged in robust, highly interactive discussions identifying successes, challenges, and gaps and proposing strategies to address the issues that emerged. A summary of the presentations and the groups’ recommendations are presented in a meeting summary report [PDF 4MB].
The consultation participants recommended several key public health actions including:
Create community-led education and messaging strategies on hepatitis C risks, injection transmission risks (e.g., sharing drug preparation equipment in addition to sharing drug injection equipment), and HCV testing resources.
Improve and increase infrastructure for HCV surveillance and data collection.
Create age-appropriate (e.g., young adult) substance use and hepatitis C interventions and prevention strategies that are evidence based and effective.
Expand both community-based and basic science research activities to better understand how to effectively address the emerging crisis of hepatitis C infection among young IDUs.
Discussions about this issue are ongoing among the participants and other federal and non-federal partners as we collaborate on ways to stem the tide of new HCV infections among young PWID and connect those already living with HCV to care and treatment for their infection and underlying drug use. With heightened awareness of this evolving epidemic and the attention and engagement of partners from across all sectors of society– including the voices of young people– we can make a positive difference in the lives of these young men and women.