An Emerging Epidemic: The Public Health Response to Hepatitis C Infection among Young People who Inject Drugs

By Oscar Mairena April 24, 2014

Last year, the Viral Hepatitis Prevention Coordinator (VHPC) in Massachusetts, Dan Church, wrote a post about the increasing rate of acute hepatitis C (HCV) infection among young persons who inject drugs in Massachusetts and the health department’s efforts to prevent new infections, identify existing cases, educate individuals vulnerable to acquisition, and enhance surveillance and data collection to better address the epidemic. Since then, more health departments have reported this trend, especially among young persons who begin using prescription opioids and transition to injecting heroin. Earlier this week, NASTAD partnered with the Harm Reduction Coalition to host a Congressional Briefing, An Emerging Epidemic: The Public Health Response to Hepatitis C Infection among Young People who Use Drugs, to bring this issue to light, educate Congressional staff and reinforce the role of public health in addressing emerging health concerns.

In recent years, health departments have seen an alarming increase in new HCV cases among people under the age of 30 in states like Alabama, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Maryland, Massachusetts, Montana, New Mexico, North Carolina, Oregon, Tennessee, Washington and West Virginia. Unlike historical trends of HCV infections in most jurisdictions (i.e., concentration in larger, urban city centers), new HCV infections are increasingly found in suburban and rural settings, especially in Appalachia. However, new infections continue to occur in urban areas, as well.

While much of the viral hepatitis response in the United States currently is focused on identification of existing cases of chronic HCV among the baby boomer cohort, new HCV infections are on the rise – marking a need for enhanced primary prevention efforts for HCV, especially among young people who inject drugs. The updated Viral Hepatitis Action Plan, however, does establish “Reducing Viral Hepatitis Caused by Drug Use Behaviors” as its fifth priority area.

Here’s what we know:

  • The majority of new HCV infections occur among people who inject drugs
  • Increases in HCV infection among adolescent and young people who inject drugs have been reported in several US regions, within rural, suburban and urban settings
  • In a recent study of young people who inject drugs, 72% of those living with HCV were unaware of their infection
  • Young people living with HCV and injecting drugs are at risk of transmitting HCV to others but can successfully be treated and even cured

These facts illustrate the need for increased comprehensive education and prevention services for young people who inject drugs, including access to sterile injection equipment, safer injection education, culturally competent and age appropriate drug treatment programs, as well as testing for HIV, hepatitis B (HBV) and HCV.

Over the past two decades, prescription drug misuse – the intentional use of a medication with intoxicating properties outside a physician’s prescription – has increased among youth and young adults in the U.S. Research suggests that prescription opioid misuse is a key factor in the transition to injection drug use for both urban and rural people who inject drugs. Yet adolescents and young adults who misuse prescription opioids underutilize treatment services because of a fear of stigma associated with substance use treatment or a lack of available, adequate services – particularly in more rural areas.

There is a need to expand access to age-appropriate drug use prevention and treatment services for adolescents and young adults, including opiate agonist therapy and evidence-based models of care that meet the needs of this age group. Programs and interventions used for adults may not be as successful when applied to youth. Innovative strategies such as social media outreach to engage young people who inject drugs should be considered.

However, young persons’ use of drug treatment or syringe services programs is associated with increased awareness of HCV status, underscoring the importance of substance use treatment in reducing the impact of the HCV epidemic among youth. Early detection of HCV infection and treatment of acute infection can lead to better health outcomes, cure and prevention of new HCV infections among others in their networks. Moreover, the best strategies to prevent new HCV infections among young people who inject drugs will require combination prevention, including scaling up syringe access, treatment that includes methadone and buprenorphine, HCV testing, linkage to care and treatment. Congress and our federal partners must scale up prevention efforts for this vulnerable population and invest in public health infrastructure to identify, link, treat and cure young people living with HCV who use or inject drugs in order to truly curb this syndemic. For more recommendations and information, refer to our fact sheet on HCV among young people who inject drugs.

A special thank you to the Congressional Hepatitis Caucus, Senator Elizabeth Warren, Congresswoman Barbara Lee and Congressmen Mike Honda and Hank Johnson for co-sponsoring this event. We would also like to thank Michael Botticelli from the White House Office of National Drug Control Policy, Dr. Wilson Compton from the National Institutes of Health (NIH) National Institute on Drug Abuse (NIDA), Dr. Jennifer Havens from the University of Kentucky College of Medicine, Sheila Guilfoyle, VHPC in Wisconsin, and Rachel McLean for their contributions and presentations at the briefing.