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Little Change in Hepatitis C Risk among Injection Drug Users

SUMMARY: Hepatitis C virus (HCV) infection remains common among injection drug users, despite prevention programs and behavior changes that have reduced new HIV infections, according to research published in the March 2011 Journal of Infectious Diseases. The researchers recommended that prevention efforts must be intensified to further lower the rate of HCV infection.

By Liz Highleyman

The advent of HIV epidemic in the early 1980s led to widespread establishment of prevention programs for IDUs, including harm reduction efforts such as needle exchanges. Prior studies have shown that such efforts have significantly reduced HIV incidence (new infections), but they have had less impact on hepatitis C. In part this may be because HCV is much easier to transmit than HIV and more likely to spread through occasional risky behavior.

Shruti Mehta from Johns Hopkins Bloomberg School of Public Health and colleagues characterized trends in incidence of HCV and HIV infection among injection drug users (IDUs) in Baltimore recruited during 4 periods: 1988-1989, 1994-1995, 1998, and 2005-2008.

The researchers calculated incidence of both infections within the first year of follow-up among 373 IDUs whose initial HCV test results were negative, and 2061 IDUs who were HIV negative at baseline.


The average age of IDUs increased during the study (from 34 to 43 years), as did duration of drug use (from 13 to 19 years).
HIV incidence declined significantly over time:
1988-1989: 5.5 cases per 100 person-years (PY);
1994-1995: 2.0 cases per 100 PY;
1998: 0 cases per 100 PY;
2005-2008: 0 cases per 100 PY.
HCV incidence declined somewhat, but remained relatively high; the decrease did not reach statistical significance:
1988-1989: 22.0 cases per 100 person-years (PY);
1994-1995: 17.2 cases per 100 PY;
1998: 17.9 cases per 100 PY;
2005-2008: 7.8 cases per 100 PY.
HCV prevalence (all cases, new plus existing) declined, but mostly among younger IDUs.
Among people younger than 39 years, HCV prevalence decreased significantly relative to 1988-1989 (adjusted prevalence ratio [PR] 0.73 for the 2005-2008 cohort).
For people age 39 or older, however, a decrease was observed only for the 2005-2008 cohort (adjusted PR 0.87).

Based on these findings, the study authors wrote, "Although efforts to reduce blood-borne infection incidence have had impact, this work will need to be intensified for the most transmissible viruses, such as HCV."

"Large-scale expansion of [needle exchange programs] and opiate substitution treatment programs appear to have reduced HIV transmission among IDUs," they elaborated in their discussion. "In this analysis, we also detected a decline in HCV infection incidence as well as HCV infection prevalence among those who were younger or had recently started injection. Importantly, we observed that HCV acquisition may be delayed by up to 10 years among IDUs compared with that in the late 1980s when the epidemic was at peak."

"[A]dditional, more intensive strategies, particularly those that target new initiates into drug injection, are needed to significantly impact community-level drug-related risk," they concluded.

In an accompanying editorial, Jason Grebeley and Gregory Dore from the University of New South Wales in Sydney concurred that existing harm reduction measures in most settings are inadequate.

"The development and implementation of national harm-reduction strategies including broader coverage, enhanced early access, and intensification and combination of interventions are probably all needed," they recommended. "Furthermore, peer-based education, support, and community participation will be essential for the successful delivery and uptake of intervention strategies."

Investigator affiliations; Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health and Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine, University of California San Diego School of Medicine, San Diego, CA; Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, NY.



SH Mehta, J Astemborski, GD Kirk, and others. Changes in Blood-borne Infection Risk Among Injection Drug Users. Journal of Infectious Diseases 203(5): 587-594 (free full text). March 2011.

J Grebely and GJ Dore. Prevention of hepatitis C virus in injecting drug users: a narrow window of opportunity. Journal of Infectious Diseases 203(5): 571-574 (free full text). March 2011.

Other Source
Journal of Infectious Diseases. Study Finds Little Decline in Hepatitis C Infections Among Injection Drug Users. News release. January 31, 2011.























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