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The Centers for Disease Control and Prevention (CDC) recently reported that between 2009 and 2018 rates of acute hepatitis C virus (HCV) infection in the US tripled, with the highest rates in people between the ages of 20–39 years old. In that same report, the CDC observed that these increased rates were “concurrent with the nation’s opioid crisis.” The strong association between HCV, a bloodborne virus, and injection drug use is further substantiated by findings from the CDC’s most recent viral hepatitis surveillance report indicating that when risk information is available, nearly three-quarters (72 percent) of people with acute hepatitis C infection report injection drug use. What we have here is a syndemic, one that meets the following defining characteristics: two or more co-occurring population-level health threats; societal-level conditions or circumstances that facilitate the perpetuation of these health threats; and the synergistic interaction of these threats to produce an excess burden of disease at the population level. In this case, the continued spread of hepatitis C among people who inject drugs is a serious, ongoing public health problem. And only by recognizing and confronting it specifically as a syndemic, can we begin to turn the tide.
Geographic data also support the association between HCV infection and the United States’ ongoing epidemic of opioid drug use. Although neither opioid misuse nor HCV infection are confined to a single area of the US, states in the west and in the Appalachian region bear a disproportionate burden of both opioid overdose deaths and HCV infections. These facts illustrate the co-occurrence of substance use disorders involving drug injection and viral hepatitis—in this instance, HCV—although people with a past or current history of injection drug use also have higher rates of hepatitis B virus (HBV), compared to the general population.
And what of the societal circumstances and conditions that facilitate the spread of these two interacting health threats? Syndemics are most likely to emerge “under conditions of health inequality” when social, environmental, and economic factors cluster with the diseases, contributing to a worsening of outcomes. Such is clearly the case when one considers the syndemic of substance use and HCV in Appalachia. A 2019 report issued by the Appalachian Regional Commission and its academic partners cited the following as among the factors contributing to high rates of opioid misuse and overdose deaths in the region: aggressive marketing of prescription pain medication to physicians, limited access to behavioral and public health services—including treatment for substance use disorders—and high rates of poverty. Other researchers have identified distrust of health care providers and fear of stigma as reasons why Appalachian residents may avoid seeking substance use treatment.
Given that HCV is a bloodborne virus, any circumstance that promotes continued drug injection—including failure to prevent or diagnose and adequately treat substance use disorders—can result in persistent transmission of this virus and other bloodborne pathogens, such as HIV and HBV. The synergistic interaction between injection drug use and unchecked hepatitis C transmission is most clearly revealed under the rubric of harm reduction service availability. Simply stated, harm reduction is a practical public health approach that recognizes that people who use drugs may be unwilling or unable to stop and seeks to reduce the negative harms that can accompany continued drug use, including infection and overdose. A key component of harm reduction for people who inject drugs is the importance of using sterile injection equipment to reduce the risk of acquiring or transmitting infections such as HCV. Programs that provide clean needles and syringes, along with other services, reduce the harms of injection drug use and can serve as a gateway to medication-assisted treatment for opioid misuse. Modelers have shown that reducing HCV infections in US settings with low coverage of harm reduction services will require not just the availability of HCV treatment but also expanded syringe service programs and increased access to medication-assisted treatment for opioid misuse. And yet, some of the Appalachian areas hardest hit by HCV and the opioid epidemic are lacking in adequate syringe service programs.
There is no doubt that the circumstances fueling injection drug use, in tandem with the paucity of harm reduction and drug treatment services, facilitate the transmission of hepatitis C virus, thus qualifying as a syndemic. Making matters worse, many facilities that treat substance use disorders don’t offer testing for HCV or HIV. Even among people receiving inpatient or outpatient medical care who have a diagnosis, procedure, or receive medication indicative of injection drug use, fewer than 10 percent have been tested for HCV.
That syndemics are complex and unlikely to be successfully addressed by a single strategy or intervention is evident when we consider the challenges of eliminating hepatitis C among people who inject drugs. But difficult does not mean impossible. There are specific actions that policy makers can take to achieve viral hepatitis elimination in the United States. However, we must begin by recognizing and embracing the tenet that hepatitis C cannot be eliminated among people who inject drugs without addressing their needs vis-à-vis their substance use. Furthermore, we must be willing to accept individuals “where they are,” actively supporting harm reduction services for people who aren’t able or willing to achieve complete and consistent abstinence from drug use. The following actions will be critical in achieving the elimination of hepatitis C in Appalachia and elsewhere in the United Sates.
Although syringe service programs have expanded in the US in recent years, substantial legal barriers to syringe service programs and participant syringe possession are still present in more than 20 percent of US states. State-level legal reforms are necessary to enable the optimal use of this proven public health prevention strategy. That includes, for example, updating state drug paraphernalia laws so that it is no longer a crime to possess or distribute sterile syringes.
Advocacy and litigation have resulted in the removal of some Medicaid HCV treatment restrictions, especially those requiring a patient to have severe liver disease before initiating hepatitis C curative treatment. But a number of state Medicaid programs still require a documented minimum period of sobriety (for example, abstinence from drug and alcohol use) prior to starting HCV treatment. These patient sobriety restrictions continue to create barriers to curative HCV treatment among drug users. This despite the fact that research has shown that HCV treatment outcomes among people who inject drugs and those on opioid substitution therapy are similar to outcomes in patients without a history of injection drug use.
A 2018 audit survey found that in six states with the highest burden of opioid overdose mortality, 36–48 percent of callers—research assistants posing as current heroin users—were denied an appointment with clinicians who were listed on a public website as buprenorphine providers. A recent discussion paper from the National Academy of Medicine lists specific strategies to overcome access barriers to medication-assisted treatment for opioid use disorders. Among other recommendations, they include expanding the training and scope of practice of nurse practitioners to provide medication-assisted treatment and developing federally funded loan repayment programs for addiction specialists willing to work in underserved areas of the country.
Stigma associated with substance misuse, and other mental health conditions, is not a new phenomenon. It can act as a potent deterrent to seeking care for the underlying drug dependence as well as associated medical complications, such as injection site abscesses. Stigma can also affect providers, influencing their attitudes about the “reliability” of people who use drugs in terms of their ability to remain adherent to HCV treatment. There’s no easy solution to eliminating the pervasive misperceptions about drug dependence, but available research can help to inform both public- and private-sector communication and education campaigns that aim to destigmatize these serious health issues.
Because syndemics are fueled by societal circumstances that promote health inequities, solutions must be more than strictly biomedical. Yes, expanding the availability of services to diagnose and treat hepatitis C along with harm reduction services and evidence-based addiction treatment will be necessary to eliminate HCV among people who inject drugs. But equally important are actions that will address the underlying socioeconomic circumstances exacerbating the syndemic of injection drug use and hepatitis C. Case in point: Listening sessions conducted by the Appalachian Regional Council (ARC) revealed that a comprehensive “recovery ecosystem” must span multiple sectors and address not just physical and mental health, but also housing, income support, and employment services. In response to these findings, the ARC launched the INSPIRE initiative to support workforce entry and reentry for individuals in recovery from substance use disorders.
It’s not a small thing to ask legislators and other policy makers to take actions to combat the syndemic of HCV and injection drug use at a time when our nation is dealing with so many negative health, economic, and social consequences of the COVID-19 pandemic. But ignoring the problem won’t make it go away. In fact, evidence suggests that the effects of the COVID-19 pandemic are hindering national efforts to eliminate viral hepatitis with the potential to result in even more disease and death. While funding for hepatitis elimination, substance use prevention and treatment, and COVID-19 may appear on different lines in a budget, they are not isolated from one another in the daily lives of people who inject drugs. Understanding their deadly synergy is the first, necessary, step to ending their destructive consequences.
What's A Syndemic? Hepatitis C Among Injection Drug Users Is An Urgent Example – Health Affairs
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