hcv and idus: a legacy for the millennium

International Journal of Drug Policy 9 (1998) 63–69

HCV and IDUs: A legacy for the millennium

Paul Wells

Co6entry Community Drug Team, 2 Do6er St., Co6entry CV1 3DB, UK

Abstract

As evidence of the size of the hepatitis C (HCV) epidemic among injecting drug users grows, the response in Britainhas been in marked contrast to the innovative lead that was taken to tackle HIV among drug users. Recent reportshave maintained the position that, though the risk of HCV among injecting drug users (IDUs) is serious, testing isdifficult to justify at present and that instead, services should have suitably trained staff available to offer advice.There is no indication at to what form this advice should take. The implications of failing to follow the lead shownin other countries means that IDUs will continue to be exposed to risk of HCV infection, with the effects becomingincreasingly apparent over the next few decades. © 1998 Elsevier Science B.V. All rights reserved.

The past few years have seen the emergingrecognition of another viral epidemic following onfrom HIV; that of hepatitis C (HCV). However,in this case the response has been muted in theextreme, when compared to the hysteria that ac-companied HIV in the mid 1980s. The one thingthat is clear about the HCV epidemic is thatinjecting drug use is the major mode of transmis-sion in the latter part of the 1990s. A number ofstudies (Crofts et al., 1995; Garfein et al., 1996;Crofts et al., 1997b; Dolan, 1997; Langkham,1997; MacDonald et al., 1997a,b; Sladden et al.,1997; Wodak, 1997) have demonstrated the asso-ciation between injecting drug use and levels ofHCV infection of epidemic proportions world-wide, with periods in prison increasing the risk ofinfection among injecting drug users (IDUs).HCV sero-prevalence levels of 85% among the

populations of injecting drug users studied arecommon.

In Britain, the issue of HCV among IDUs hasbeen publicised by Dr Tom Waller and Holmes(Waller and Holmes, 1993, 1995), who have beenhighlighting the levels of infection among IDUs,past and present. As a result, there has been anincreasing level of awareness and concern amongdrug workers who have had an uphill task ofpersuading others of the seriousness of the issue.The combination of a large number of peoplealready infected with the virus, increasing num-bers using illegal drugs and the continuing popu-larity of injecting could create health andeconomic costs that Wodak and Crofts (1996)estimate may be comparable to (and soon ex-ceed?) those of HIV in developed countries. Therehas been official reluctance to acknowledge this.

0955-3959/98/$19.00 © 1998 Elsevier Science B.V. All rights reserved.

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P. Wells / International Journal of Drug Policy 9 (1998) 63–6964

Injecting in Britain still remains popular, butthe lead that was shown in responding to HIVamong drug users has not been translated intotackling the incidence of HCV amongst the samegroup. In Britain we continue to have a strategythat is HIV led and pays little attention to otherbloodborne viruses. The continuing low levels ofHIV among IDUs nationally seems to have re-sulted in an assumption that no strategic responseto include other blood borne viruses is needed.There seems to be a belief that as HIV has beenkept in check, so have other viruses, such as HBVand HCV, despite evidence to the contrary. TheUnlinked Anonymous HIV Prevalence Monitor-ing Programme—Injecting Drug Users Surveycarried out by PHLS Collindale has found B2%HIV+ , but :22% to be HBV core antibody+ .They are currently unable to test for HCV, al-though the evidence seems to indicate very highlevels of HCV among IDUs.

The advice coming out from government isequivocal, lacking certainty of action and creatingdifficulties for those attempting to get the mattertaken seriously by sceptical public health officialswho are largely unsympathetic to the needs ofIDUs.

In Britain, a number of factors have influencedthe continuing low level of official concern aboutHCV. In brief, some of these are: (i) The apparentsuccess of HIV strategies, particularly needle ex-change schemes, which are seen as being effectiveagainst HCV. One Consultant for CommunicableDisease Control has stated that ‘‘If they followthe advice re: HIV, it will protect them. HCV is alow health risk in comparison to HIV’’ (Wells,1996); (ii) the perceived low risk of sexual trans-mission of HCV from IDUs into the generalpopulation did not engender the same level of fearthat HIV had created, with the result that it isseen as a lesser priority. Indeed, some strangeviews are held by communicable disease special-ists. One memorable comment in response to thequestion: ‘‘Why do you think we are seeing higherrates of HCV infection than HIV among IDUs?’’,was ‘‘Are we? If so, it may be due to the numbersof homosexuals who are injecting, drug users notbeing high’’ (Wells, 1996); (iii) changes to theorganisation of the NHS, the introduction of the

internal market, the commissioning role of healthauthorities and the introduction of fundholdingputs decision-making and financial responsibilityfor treatment increasingly into the hands of GPs;and (iv) the absence of an allopathic vaccine oreffective treatment resulted in communicable dis-ease specialists advocating that testing was notnecessary, while others even argued that it wasuneconomic to test.

A review of recent and current guidance con-cerning the needs of IDUs shows continuing am-bivalence to a major health threat that showsevery sign of increasing. The following quotes areextracts of current recent information and adviceon HCV and IDUs taken from various officialand specialist reports.

The Advisory Committee on the Misuse ofDrugs has, over a number of years, producedreports on HIV/AIDS and three reports into drugusers and the prison system. These are someextracts of the advice contained regarding HIVand hepatitis B and C. It is worth noting thathepatitis is mentioned primarily in relation to itsimplications for HIV:

We are concerned that there are very high levelsof hepatitis B and hepatitis C infection amongstinjecting drug users in some parts of the UK,since this may indicate a potential for rapidspread of HIV when the virus is introduced intonetworks of drug injectors. This is particularlytrue of Hepatitis C, as presence of the virus ishighly correlated with sharing of contaminatedinjecting equipment. One study in Glasgow re-ported that 2% of injecting drug users wereHIV positive, while a separate study of injectorsfound that 70% had hepatitis C antibodies intheir blood. Such our findings reinforce theneed for early identification of drug misuse andthe effective delivery of HIV prevention mes-sages (ACMD, 1993).

There is no likelihood of the development of avaccine against Hepatitis C in the immediatefuture and the principal way of controlling thespread of Hepatitis C is therefore to interrupt

P. Wells / International Journal of Drug Policy 9 (1998) 63–69 65

transmission. There is continuing clinical debateabout the effectiveness of treatments and, as inthe early years of the HIV epidemic, there areethical dilemmas as to whether or not someoneshould undergo a test to know whether theyhave contracted the virus… We recommend thatrenewed efforts are made, through continuallyupdated education programmes, to inform staffand prisoners about the risk of transmission ofall blood-borne viruses (ACMD, 1996).

The Centre for Research on Drugs and HealthBehaviour produced this rather non-committalcomment on testing in June 1996.

We need to consider whether any benefit wouldaccrue to individuals or to the wider communityif testing of current or previous IDUs for HCVinfection was offered or promoted in the contextof routine or IDU-related health care. Given theneed for better information concerning the ther-apeutic effectiveness and natural history of HCVinfection, this may be difficult to justify atpresent.

On the other hand, clinicians should be awarethat if people with a history of drug injectionpresent with symptoms, HCV testing may beindicated, and that HCV infection should beincluded in the differential diagnosis as part ofgood clinical practice (The Centre for Researchon Drugs and Health Behaviour, 1996).

The Task Force to Review Services for DrugMisusers reported in 1996 with little mention ofHCV. This is their advice.

In contrast to the low levels of HIV sero-preva-lence, in the region of 50% of UK drug injectorsare infected with Hepatitis B and even more withHepatitis C... The risk of acquiring any of theseviruses depends on the prevalence within theinjecting drug community. For this reason, therisks of acquiring Hepatitis C are probably thelargest.

…The large number of drug misusers infected withHepatitis B and C has treatment implications.There may be thousands of people who areHepatitis C positive, including many who havelong since ceased to inject drugs. The Depart-ment of Health needs to consider how to addressthe needs of these people and of HepatitisC-infected drug misusers (The Task Force toReview Services for Drug Misusers, 1996).

The common thread running through these re-ports is that the need to test drug users for HCVis questionable and that more and better preven-tative advice is needed. The last report, whileacknowledging the gravity of the situation, doesnot make any specific recommendations or sug-gest preferred options.

There is now a growing awareness that HCV isgoing to become an increasingly important matterfor health care workers. Since screening of bloodproducts for HCV, introduced in September 1991,has greatly reduced the risk of infection throughcontaminated blood products, there has been aneed to get recognition that injecting drug usershave been, and will continue to be, exposed toincreasing risk of HCV infection. This risk willcontinue to affect ever increasing numbers ofindividuals unless prompt and effective action istaken.

Needle exchange schemes have dramatically re-duced the reported level of sharing injectingequipment from 60–90% pre 1986/7 to B20% in1996. This has been interpreted as indicating thatIDUs have become more discriminating in theirbehaviour. However, evidence indicates that whileneedle/syringe schemes have helped to keep HIVlevels to B1% of IDUs in most British cities, thischange in injecting behaviour has not been suffi-cient to stem HCV. Many studies show that a lessthan perfect understanding of what is meant by‘sharing’ has given rise to continued multiple ex-posure to HCV infection among IDUs. Given thehigh numbers now using illegal drugs, combinedwith continuing injecting, the potential for thespread of viruses such as HBV and HCV is dra-matically increased.

The low levels of HIV infection are likely to beseen by new recruits to injecting as a sign that


rigid adherence to using clean injecting equipmentis not that important. The sharing of not onlyinjecting equipment (needles and syringes) butalso injecting paraphernalia (spoons, water,swabs, tourniquets, etc.) is probably higher thanwe would like to believe. If this is the case, thenthe transmission of HCV is likely to be occurringwith little effective action being taken to counterit, especially as the evidence suggests that HCVtransmission only requires minor lapses in ‘infec-tion control’ and such lapses are an ongoing,frequent occurrence.

In contrast to British ambivalence, an Aus-tralian report has noted that—‘‘The extremelyhigh prevalence and incidence of HCV amonginjecting drug users clearly indicates efficient andcontinuing transmission within this group, inwhom HIV is not spreading at an appreciablerate. This and circumstantial evidence implicatingenvironmental contamination as well as thesharing of injecting equipment in the transmissionof HCV between users indicates the potentialdifficulties facing attempts to control the epidemicamong users (NHMRC, 1996)’’.

The executive summary of a piece of research(West Midlands NHS Executive, 1997) into thedrug injecting end sexual risk behaviour of 302injecting drug users in the West Midlands, indi-cates that there is great cause for concern. Thelevel of sharing various elements of injectingequipment is worringly high. A third of the re-spondents had, in the past 6 months, used inject-ing equipment previously used by others. Therewere even higher rates for sharing paraphernalia,85% in the previous 6 months and 69% in theprevious 4 weeks, indicating that the messageregarding the sharing of injecting equipment andparaphernalia, is still not being heeded or fullyunderstood by users. Lenton (1997) found similarlevels of sharing injecting equipment at 25.3%,and paraphernalia at 56.2%, among 511 ‘hiddendrug injectors’ in Western Australia.

In the West Midlands research, stimulant userswere the largest group not using needle exchangefacilities. There has been a level of concern thatthe use of stimulants might be a factor in in-creased levels of sharing, with elated mood negat-ing concerns over health risks. The latest

Department of Health Statistical Bulletin: DrugMisuse Statistics (No 7) Department of Health,1997b indicates that the West Midlands RegionalOffice area has, at 17%, the highest level of am-phetamine use in England, with local areas suchas Coventry and North Worcestershire reporting31% using amphetamines as their main drug,three times the national average of 10%.

Improving information is still seen as the main,if not only, response to reducing the risk of futureexposure to HCV. Current injecting drug usersand ex-users are not being encouraged to gettested. As long as the official advice remainsequivocal and public health officials continue toregard HCV as a low health priority, serviceswishing to introduce testing will continue to facean uphill struggle persuading health commission-ers of the need.

It is now time to refocus the strategy to includeall blood-borne viruses with an emphasis onHCV, as this appears to be most prevalent. Byattempting to reduce the transmission of HCV weshould be able to continue to keep the prevalenceof the other viruses to low levels. Testing for HCVshould be made easily available from drug ser-vices. This would have two benefits: (i) by identi-fying those who are infected we can give adviceon reducing the damage to their liver; (ii) throughPCR, identify those current injectors who carrythe virus, in order to target specific informationand advice so that they do not unwittingly infectothers. The risk of HCV transmission appears tobe very low from those who are HCV antibodypositive but have undetectable viraemia (Dore etal., 1997).

Research being carried out in Perth, Australia(Carruthers, 1997) and Sacramento, CA (Flynn etal., 1996) which involves filming drug users inject-ing in their usual/normal setting, has identifiedfrequent opportunities for contamination and thespread of infection. This has shown that repeatedexposure to low level contamination is the norm,with environmental factors such as the communaluse of water, spoons, swabs, tourniquets, etc., insocial injection settings being an identifiablesource of potential infection.

The official advice on services for drug users atpresent either ignores HCV completely or plays


down its significance. The latest advice on HBVand HCV, contained in the publication—Pur-chasing Effective Treatment and Care for DrugMisusers—mentions the risk of infection and rec-ommends that ‘purchasers should ensure that suit-ably trained staff are available to advise thesepatients’ (Department of Health, 1997a). Unfortu-nately, there is no indication in the guidance as towhat form this advice on HCV should take. HBVis more clearly thought out with recommenda-tions for vaccinations for those at risk. However,even here, the level of completed HBV vaccina-tion among drug users still remains very low.

Given the poor level of understanding of HCVby health professionals and the prejudice againstdrug users and without there being some strategicframework in place, it is unlikely that any effec-tive advice will be offered if those most at risk andwho need to be given appropriate informationcannot be identified. The view of some health careprofessionals is that as there is no cure we shouldnot test for HCV. This ignores the opportunitiesthat exist for reducing the future incidence ofHCV, which given the existing high levels ofinfection among IDUs and the anticipated growthin injecting among new injectors should be ourpriority. Current injectors with detectable levels ofHCV viraemia need to be given targeted informa-tion in order to reduce the risk of them transmit-ting the virus to others through poor infectioncontrol practices when injecting.

The assumptions underlying the current officialinaction seem to be that:1. to test would be costly2. in the absence of a vaccine testing is not

necessary3. to know would only be another problem for

drug users to contend with4. drug users are unlikely to change their drug

taking habits as a result of knowing a testoutcome

5. drug users are incapable of changing so, in theprioritisation of resources, treatment wouldnot be offered

These assumptions can and should be chal-lenged for the following reasons:

The cost of testing for HCV is not that dissim-ilar from HIV tests. An HIV screen costs £8.50,

while a HCV antibody test is £6.70. HIV confir-mation tests are £19.30 and the HCV PCR test is£30.00. HCV tests are only £8.90 more than thosefor HIV.

The absence of a vaccine did not prevent thepromotion of testing for HIV among drug usersand the establishment of alternative testing sites.On the contrary, both were encouraged in orderthat ‘‘an infected person may benefit clinicallyfrom prophylactic treatments’’. (Department ofHealth, 1992). HCV has been found to respond toalternative and complementary therapies, such astraditional Chinese medicine, but as these are notreliant on an allopathic vaccine to be effective,this has not been pursued. Neither has another ofthe rationales for testing for HIV; that ‘‘a sub-sidiary epidemiological benefit is that the resultsmay give a more accurate picture of local sero-prevalence which is helpful in planning servicesand targeting local educational initiatives moreeffectively’’ (DoH, 1992) been promoted withHCV. It is more a question of attitude thanvaccine.

A frequent justification for not testing is thatwithout a cure it would be yet another problemfor the user. The encouragement to test for HIV,but not HCV, despite the fact that HIV would beanother problem to contend with, has also to beseen in the context of which of the two viruseswould you prefer to test positive for? Given theoption, most would prefer to test positive forHCV, not HIV. An important element in theearlier thinking was to ‘prevent the spread of HIVamong and from drug misusers’ (Department ofHealth, 1988). The apparent minimal risk of sex-ual transmission of HCV into the wider commu-nity is key to this differing response. HCV cantherefore be regarded by some as being self-con-tained. It now mainly affects drug users who areseen to have brought it on themselves; and HCVposes a lesser risk than HIV, to the general popu-lation who do not require the same degree ofprotection ‘from drug misusers’.

It is questionable whether or not changes ininjecting drug-taking behaviour will be sufficientin themselves to stem the HCV epidemic. As longas injecting continues as a preferred route ofadministration, then so will opportunities exist for


infection. Some (Wodak, 1997) have promotednon-injecting routes of administration (NIROA)as the only effective means of stemming futureinfection. This in itself is questionable as it wasthe emergence of heroin chasing in the early tomid 1980s that introduced large numbers ofBritish drug users to heroin and in turn led ontoincreased injecting. To be successful a NIROAstrategy depends on a number of factors includingprice, purity and suitability of drugs availablewhich, given the illicit nature of the market, willbe hard to ensure over any period of time.

HCV has a higher prevalence among IDUs andis more infectious than HIV. However, maintain-ing the continuing focus on HIV only serves toenable the spread of HCV among new recruitsinto injecting, with research (MacDonald et al.,1997a,b) showing 32% of IDUs infected within 1year of commencing injecting and other studiesfinding 70–85% of IDUs infected within 6 years.Targeting information and awareness of HCV asan issue that affects the majority of IDUs inBritain is more likely to bring about behaviourchange than continuing to concentrate on HIVwhich, while only affecting a minority, can seemincreasingly remote in the experience of most drugusers.

Drug users do change their habits and manydrug users are only involved in injecting for rela-tively short periods, but by then the damage isdone. Not being able to identify those with HCValso means that advice regarding the impact ofalcohol cannot be given to reduce the risk of liverdamage. Change in drug using behaviour whichincludes a reduction in alcohol will potentiallyhave long-term benefits for those with HCV, in-cluding reducing the need for treatment later on.The ability to test improves the outcome and canpotentially reduce the effect of HCV when druguse is not replaced by alcohol use in someoneinfected with HCV. The effects of alcohol ondisease progression are unclear with one studyshowing that alcohol did not appear to alterclinical outcomes of those with chronic HCV(Khan et al., 1997) while Crofts (1994) andDuscheiko et al. (1996) have indicated that alco-hol aggravates the onset of hepatic injury.

Relying on stereotypes of drug users as ‘junkies’as a justification for not offering treatment doeslittle to address their health needs or those ofwhom do not conform to the stereotype, such assteroid users. In a time of increasing rationing ofmedical treatment, this blanket approach meansthat a deserving versus undeserving ethos devel-ops, reinforced by relying on stereotypes, to jus-tify drug users lack of priority for treatment.Protocols can and should be developed to identifysuitable cases for treatment on the basis of clinicalneed, that take account of drug use but do not useit to deny treatment.

The implications of not addressing the issuesaround injecting drug use and sharing of injectingequipment are that increasingly large numbers ofusers are going to be exposed to viral infections,the most common of which is HCV. The WestMidlands report, and a recommendation from theFirst Australasian Conference on Hepatitis C;that testing for HCV among injecting drug usersshould be available; support the argument that itis now time to refocus our strategy to include allblood-borne viruses with a particular focus onHCV.

1. Summary

Drug users in Britain still remain largely un-aware of HCV. Those who are aware are fre-quently poorly informed or confused about thediffering types of hepatitis, transmission routes,risk factors, etc. Official interest is muted and themedical profession appear not to have recognisedthe significance of the epidemic. Approachingyour GP is unlikely to help as the British LiverTrust, a charity covering all liver diseases, nowreceives between 30–50% of all calls to its tele-phone information service relating to HCV. Manyof these callers have HCV and have been referredto the Trust by their GP as they do not have theinformation, do not think HCV is serious or donot know how to treat it.

In conclusion, the British situation can best bedescribed as being too little, too late, while HCVnumbers continue to increase against a back-ground of increasing drug use; inadequate re-


sources, publicity and awareness; and support forall with HCV. In the absence of a national strat-egy to prevent further infection among IDUs weare leaving a legacy for the millennium.

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hcv and idus: a legacy for the millennium

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