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Emerging Epidemic: Hepatitis C Infection among Young Persons
Who Inject Drugs
Presenter
Jon E. Zibbell, PhD, Health Scientist, Division of Viral Hepatitis,Centers for Disease Control and Prevention
ModeratorJinhee Lee, PharmD, CDR, Senior Public Health Advisor, Division of Pharmacologic Therapies, Center for Substance Abuse Treatment,
SAMSHA, and Member, Rx Summit National Advisory Board
ContributorEmily Winkelstein, MSW, Project Director, Collaborative Hepatitis
Outreach and Integrated Care Evaluation Study, NationalDevelopment and Research Institutes
Disclosures
• Jon E. Zibbell, PhD, and Jinhee Lee, PharmD, CDR, have disclosed no relevant, real, or apparent personal or professional financial relationships with proprietary entities that produce healthcare goods and services.
• Emily Winkelstein, MSW – Consulting fees: ProchiloHealth Inc.
Disclosures
• All planners/managers hereby state that they or their spouse/life partner do not have any financial relationships or relationships to products or devices with any commercial interest related to the content of this activity of any amount during the past 12 months.
• The following planners/managers have the following to disclose:– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center– Carla Saunders – Speaker’s bureau: Abbott Nutrition
Learning Objectives
1. Describe the emerging epidemic of HCV infection among young persons.
2. Explain the association between the emerging epidemic of HCV infections among young persons and the Rx drug epidemic in Appalachia.
3. Identify strategies for HCV prevention, care and treatment for young PWID.
Emerging Epidemic: Hepatitis C Infection among Young Persons Who Inject Drugs
and Misuse Prescription Opioids
Jon E. Zibbell, PhD
Centers for Disease Control and Prevention
Division of Viral Hepatitis
Prevention Research Branch
Learning objectives
• Describe the emerging epidemic of HCV infection among young persons.
• Explain the association between the emerging epidemic of HCV infections among young persons and the Rx drug epidemic in Appalachia.
• Identify strategies for HCV prevention, care and treatment for young PWID.
HCV in the United States
• 4.1 million HCVab infected persons, with 75% of these chronic infections (3.2 million)
• The most common bloodborne infection in the United States
• HCV-related deaths doubled from 1999-2007 to over 16,000/year
• Leading cause of liver transplants and liver cancer [hepatocellular carcinoma (HCC)]
– HCC fasting rising cause of cancer-related death
• Injection drug use (IDU) is the principle “motor” of incidence
Approximately 2.7 million persons chronically infected [CI: 2.4—2.9]
Estimate excludes institutionalized and homeless persons
The most common bloodborne infection in the United States
HCV-related deaths doubled from 1999-2007 to over 17,000/year
Leading cause of liver transplants and liver cancer [hepatocellular carcinoma (HCC)]
HCC fasting rising cause of cancer-related death
Injection drug use (IDU) is the principle driver of incidence
Denniston et al. Ann Intern Med, 2014 ; Armstrong et al. Ann Intern Med, 2006
Age-Adjusted Rates of Mortality: Hepatitis B,
Hepatitis C, and HIV, United States, 1999–2007*
0
1
2
3
4
5
6
7
1999 2000 2001 2002 2003 2004 2005 2006 2007
Rate
per
100,0
00 P
ers
on
s
Year
Hepatitis B
Hepatitis C
HIV
• In 2007, > 70% of registered deaths in HCV-infected were aged
45-64 years old
*Ly et al. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007. Ann Intern
Med. 2012, June 5: 156(4):271-8
HCV Cases from Injection Drug Use
• IDU most reported risk factor for acute infections
• Anti-HCV prevalence among persons who inject drugs (PWID) between 30% and 70%
• Anti-HCV prevalence among younger (<30 yrs) between 10% and 36%
• HCV incidence between 16% and 42% per year
Hagan et al. 2010; Garfein et al. 1998; Armstrong et al. 2006; Amon et al. 2008; Klevens et al. 2013; Daniels et al. 2007
Needles and Syringes Fixed and Detachable
Preparation Equipment
11
Filters Cookers
WaterSurfaces
Increases in New HCV Infections
50% increase in national reporting
200% increase in 17 states
Recent studies show
~70% report IDU
Ages 18 to 29 years
Predominantly white
Equally female and male
Non-urban and urban
Antecedent prescription opioid misuse among PWID
Source: CDC/hepatitis.gov; MMWR 2011; MMWR 2014; CDC unpublished data.
2007-2012
Injection Behavior and Drugs Used by Persons 18-29 Years of Age with Acute HCV Infection
• 1202 cases of acute HCV investigated
– 52% female
– 85% white
– 77% persons injected drugs
o 57% shared needles/syringes
o 82% shared equipment
• Percent use and mean age of drug use initiation
- Powder cocaine: 71%,: 17.4 yrs.
- Prescription opioids 76% : 17.9 yrs.
- Heroin: 61%: 19.7 yrs.
Suryaprasad et al., CID, 2014
Changing Demographics of HCV Incidence
• During 1990s anti-HCV prevalence was higher among men, Black Americans, urban residents and persons 40-49 years aged.
• New cases largely involve males and females equally; mostly white, rural and suburban residents; persons 18-29 years aged.
• Key difference: prescription opioid misuse
Prescription Opioids Distributed*(kilograms of opioid analgesics prescribed per 10,000 persons)
*Drug Enforcement Agency, 2010, Automation of Reports and Consolidated Orders System (ARCOS)
MMWR, 4 November 2011
0
5
10
15
20
25
30
35
40
2006 2007 2008 2009 2010 2011 2012
Pro
po
rtio
n o
f A
ll A
dm
issi
on
s
Any OpioidAdmissions
Any OpioidAdmissions < 30
Prescription OpioidAdmissions
Prescription OpioidAdmissions < 30
National Drug Treatment Admissions: All ages vs. <30
*SAMHSA, TEDS—A; Preliminary analysis
Opioid deaths, sales, and treatment admissions have increased in lock step
National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS: National Center for Injury Prevention and Control
0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Opioid Sales (kg per 10k)
Opioid Deaths (per 100k)
Opioid Treatment Admissions (per 10k)
0
4
8
12
16
20
2006 2007 2008 2009 2010 2011 2012
Pro
po
rtio
n o
f A
ll A
dm
issi
on
s
Any Opioid Injection
Any Opioid Injection <30
Other Drug Injection
Other Drug Injection <30
National Drug Injection Trends: All ages vs. <30*
*SAMHSA, TEDS—A; Preliminary analysis
National Acute HCV Cases (2006—2013)
Suryaprasad et al., CID, 2014
Multivariate Associations with anti-HCV positivity‡
5.53
3.79
0 2 4 6 8 10 12 14 16
Inject prescription opioid
Share equipment*
† p-value <0.05
1
*Equipment sharing, injecting prescription opiate , fishing for a vein, and using an SEP
are all measured for within the past 12 months. Prescription opiates respondents reported injecting Opana (n=58), Oxycontin (n=21), Dilaudid (n=7), Roxycontin (n=3), Morphine (n=4); Vicodin (n=1), Percocet (n=1) (categories not mutually exclusive)
‡ Zibbell et al., AJPH, 2014
Heroin use and dependence is also increasing
SAMHSA, NSDUH, 2012, National Center for Injury Prevention and Control
0
500
1,000
1,500
2,000
2,500
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Esti
mat
ed #
of
per
son
s 1
2 y
ears
an
d o
lder
rep
ort
ing
abu
se/d
epen
den
ce(i
n t
ho
usa
nd
s)
214K
467K
>2 million
Heroin
Opioids
Special Thanks:
Departments of Health: KY; TN; VA; WVRachel Hart-Malloy, PhD, MPHScott Holmberg, MDDeborah Holtzman, PhDKashif Iqbal, MPHBrian Manns, PHARM-DRajiv Patel, MPHAnil Suryprasad, MD, MPHClaudia Vellozzi, MD, MPH John Ward, MD
Emily Winkelstein, MSWNational Development and Research Institutes (NDRI)
New York, NY
Learning objectives
• Describe the emerging epidemic of HCV infection among young persons.
• Explain the association between the emerging epidemic of HCV infections among young persons and the Rx drug epidemic in Appalachia.
• Identify strategies for HCV prevention, care and treatment for young PWID.
Overview
• Offer insight from personal practice experience
• Share feedback given from younger clients and peers
• Provide context within a harm reduction framework
• Explore the role of drug-related stigma
What is Harm Reduction?
• A philosophy
• A service delivery model
• A proven effective public health strategy that reduces harm to people who use drugs and struggle with related issues– Includes and embraces abstinence, but does not
assume or require cessation of use
• A social justice and human rights movement
Harm Reduction Coalition, harmreduction.org
Basic Principles of Harm Reduction
• Sometimes people engage in behaviors that are harmful to themselves or others.
• People may engage in these behaviors even if they know they’re harmful, illegal, unhealthy, or cause harm to others.
• However, people may be willing and able to make some changes to decrease the risk of harm to themselves and their community.
• “Any positive change”
Harm Reduction
• Harm reduction doesn’t promote, encourage or require active drug use
• Drug use can be very harmful – and – we have to be cautious in assuming or defining harm.
• We do not have control over outcomes or behaviors – but we can influence process and provide education
• People may still make unhealthy choices
The Problem
• Prescription opioid misuse among youth is high
– white, young adults, non-urban
• Non-medical use of prescription opioids increases likelihood of transition to injection/heroin use
– Sequelae: increased ER visits, dependence, overdose, infectious disease; endocarditis; abscesses
• Several recent HCV outbreaks reported
– MA, NY, KY, WI, VA, PA, FL and IN (w/HIV)
• Supply-side strategies alone are insufficient
CDC; DHHS; Cicero 2014; Jones 2013; Hagan 2008; Keyes 2014; Page 2013; Peavy 2012; Arman 2008
Differences between HIV and HCV
• HCV is currently more prevalent than HIV– More people test HCV AB positive
– HCV causing more deaths than HIV
• HCV replicates faster and thus more infectious than HIV – HCV remains viable for long periods of time outside of the
host, increasing number of transmission fomites
– Results in high viral loads (i.e. there is a lot of virus in per measure of blood)
• HCV is less likely to be sexually transmitted
• SEPs not as effective reducing HCV incidence compared to HIV
CDC; Ly 2012; Wicker 2008
Lessons from HIV
• HIV rates have fallen dramatically – PWID account for 8% of new HIV infections v. 55%
in 1990
• Syringe access programs were incredibly valuable in this effort
• Early HIV messages failed to include information about risk from ancillary injection equipment
• Education was widespread, specific, targeted
CDC; Des Jarlais 2005
Urban vs. Non-Urban (Rural, Suburban)
• Higher rates of prescription opioid injection• Transition to injection may happen earlier• Less access to harm reduction resources• Less access to primary and specialized medical care• Less access to drug treatment, including methadone
and buprenorphine• Confidentiality and disclosure issues (small, insular
communities)• High poverty/unemployment rates, lower education • Less research on effective prevention and treatment
strategies in rural areas
Christian et al 2010; Keyes 2014; Havens et al, 2011; Young et al 2012
Influences on Injection-related Risk
• Who– Number of injection partners; Control over injection; Control
over drug preparation; Power dynamics
• What– Drug of choice; Formulation; Injection equipment
• Where– Injection spaces; Privacy; Proximity to services/equipment; Vein
health and location
• When– Adequate time; Frequency of injection
• Why– Recreation v. dependence; Trauma; Boredom; Fatalistic
Worldview; Lack of hope for future
Why Engage Youth?
• Large numbers of youth are using Rx opioids & heroin– Enforcement and supply-side strategies alone will not work
for everyone
– Harm reduction and engagement are necessary to reduce negative consequences of the epidemic
• Youth can and will engage in healthier behaviors when offered information/tools and treated with respect
• There is a finite window of opportunity to prevent HCV transmission– 32% PWID become HCV-infected within 1 year of injecting
– 53% become infected within 5 years
– New injectors develop routines/rituals/patterns
Hagan et al. 2008; Paterson 2008; Raymond 2015
Youth
• Isolation from services and medical care; fear and mistrust
• Invincibility; Haven’t “hit bottom”
• Lack of specific education and knowledge
• Lack of historical memory (e.g. AIDS epidemic)
• Social network issues – Injection patterns, serosorting, partner roles
• Engagement: Living at home vs. street involved
The Players• Young people (>12 years of age)• People who use drugs
– Anyone who experiences an accidental, non-fatal drug overdose
• Family, friends and partners• Educators• Pharmacists• Healthcare providers• Community-based organizations• Houses of worship • Law enforcement• Drug sellers
Strategies for Engaging Youth
• Meet people where they are – literally and figuratively
• Keep access low-threshold
• Offer things that people need
• Provide information and tools – not directives, ultimatums, demands
• Recruit ambassadors/peers
• Be consistent
• Be respectful
• Honor autonomy
Meeting People Where They Are
• Schools• Hangouts (bars, parks, local spots, etc.)• Medical centers (testing sites, free clinics, VA)• Pharmacies• Community-based organizations• Jails and other state institutions• Drug treatment facilities• Mental health centers• Trauma centers• Social media
Engagement
• Every interaction has the potential to build trust or diminish it
• Every interaction has the potential reinforce stigma or challenge it
• Every interaction has the potential to increase dialogue or shut it down
• Every interaction has the potential to increase health – baby steps are important
Role of Stigma in Perpetuating Risk
• Often decreases willingness to access care and services
• Erodes relationships and trust
• Can increase patient risk and make healthy choices less likely
– Fear of disclosure, increased isolation
• Can decrease patient sense of self-worth
– Guilt, shame, self-blame, weakness
Syringe Access
• Syringe access programs are critical to engagement of PWID– Cost effective, link people to treatment and prevention
services, promote public safety, and reduce health disparities
– Insufficient access, especially in non-urban areas
– Federal ban on funding of syringe access programs
• Secondary and peer distribution
• Over-the-counter pharmacy access
• Physician prescribing (e.g. buprenorphine docs)
amfAR, 2013
Drug Treatment
• Abstinence-based and medicated-assisted therapy
• Young people may not know their options– More options are needed
– Learn what options are available in your area
• Youth-centered drug treatment is important
• Managed or moderated use are important options– Alternate routes of use; taking breaks; order of use
• Opioid agonist therapy is highly effective, but not widely available in non-urban areas– Methadone, buprenorphine (Suboxone®)
• Confidentiality is needed; parental and family involvement adds complications
Nolan, 2014
Linkage to HCV Testing and Care
• Increased testing is needed; reflex testing – Testing is a link to engagement, education and
behavioral change
• Offer at Community Health Centers, STI clinics, syringe access programs, methadone clinics, buprenorphine docs, correctional facilities
• Increase testing in areas where prescription opioid misuse is endemic
• Offer incentives for testing in resource-deprived areas
• Co-localize HCV treatment with drug treatment settings (SAMHSA and DVH)
Role of HCV Treatment
• Traditionally, PWID have had limited access to HCV treatment
• Treatment restrictions/abstinence requirements for illicit drug use in most states
• Recent advances in HCV antiviral therapy– Easy to tolerate– 95-100% effective, simpler monitoring– Short duration (8-12 weeks)
• Treatment as prevention– Minimize transmission within networks
• Treatment as an opportunity for engagement and ongoing prevention education
Trending Topics Track
Emerging Epidemic: Hepatitis C Infection among Young Persons
Who Inject Drugs
Presenter
Jon E. Zibbell, PhD, Health Scientist, Division of Viral Hepatitis,Centers for Disease Control and Prevention
ModeratorJinhee Lee, PharmD, CDR, Senior Public Health Advisor, Division of Pharmacologic Therapies, Center for Substance Abuse Treatment,
SAMSHA, and Member, Rx Summit National Advisory Board
With Appreciation ToEmily Winkelstein, MSW, Project Director, Collaborative Hepatitis
Outreach and Integrated Care Evaluation Study, NationalDevelopment and Research Institutes
