Drug Abuse

HCV and IDUs: A legacy for the millennium

Paul Wells

Coventry Community Drug Team, 2 Dover St. Coventry CV1 3DB UK

Abstract

As evidence of the size of the hepatitis C (HCV) epidemic among injecting drug users grows, the response in Britain has been in marked contrast to the innovative lead that was taken to tackle HIV among drug users. Recent reports have maintained the position that, though the risk of HCV among injecting drug users (IDUs) is serious, testing is difficult 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 shown in other countries means that IDUS will continue to be exposed to risk of HCV infection, with the effects becoming increasingly apparent over the next few decades.

The past few years have seen the emerging recognition of another viral epidemic following on from HIV; that of hepatitis C (HCV). However, in this case the response has been muted in the extreme, when compared to the hysteria that accompanied HIV in the mid 1980s. The one thing that is clear about the HCV epidemic is that injecting drug use is the major mode of transmission in the latter part of the 1990s. A number of studies (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 association between injecting drug use and levels of HCV infection of epidemic proportions worldwide, with periods in prison increasing the risk of infection among injecting drug users (IDUs). HCV sero-prevalence levels of 85% among the populations of injecting drug users studied are common.

In Britain, the issue of HCV among IDUs has been publicised by Dr Tom Walter and Holmes (Walter and Holmes, 1993, 1995), who have been highlighting the levels of infection among IDUs, past and present. As a result, there has been an increasing level of awareness and concern among drug workers who have had an uphill task of persuading others of the seriousness of the issue. The combination of a large number of people already infected with the virus, increasing numbers using illegal drugs and the continuing popularity of injecting could create health and economic costs that Wodak and Crofts (1996) estimate may be comparable to (and soon exceed'?) those of HIV in developed countries. There has been official reluctance to acknowledge this.

Injecting in Britain still remains popular, but the lead that was shown in responding to HIV among drug users has riot been translated into tackling the incidence of HCV amongst the same group. In Britain we continue to have a strategy that is HIV led and pays little attention to other bloodborne viruses. The continuing low levels of HIV among IDUs nationally seems to have resulted in an assumption that no strategic response to include other blood borne viruses isneeded. There seems to be a belief that as HIV has been kept in check. so have other viruses such as HBV and HCV, despite evidence to the contrary. The Unlinked Anonymous HIV Prevalence Monitoring Programme - Injecting Drug Users Survey carried out by PHLS Collindale has found <2%HIV +  but = 22%, to be HBV core antibody +.
They are currently unable to test for HCV. although the evidence seems to indicate very high levels of HCV among IDUs.

The advice coming out from government is equivocal, lacking certainty of action and creating difficulties for those attempting to get the matter taken seriously by sceptical public health officials who are largely unsympathetic to the needs of IDU S,

In Britain, a number of factors have influenced the continuing low level of official concern about HCV. In brief, some of thesc are: (i) The. apparent success of' HIV strategies. Particularly needle exchange schemes, which are seen as being effective against HCV. One Consultant for Communicable Disease Control has stated that --If they follow the advice re: HIV, it will protect them. HCV is a low health risk in comparison to HIV--- (Wells, 1996) (ii) the perceived low risk of Sexual transmission of HCV from IDUs into the general population did riot engender the same level of fear that HIV had created, with the result that it is seen as a lesser priority. Indeed, some strange views are held by communicable disease specialists. One memorable comment in response to the question: "Why do you think we are seeing higher rates of' HCV infection than HIV among IDUs, was --- Are we? If so, it may be due to the numbers of' homosexuals who are injecting, drug users riot being high" (Wells. 1996)~ (iii) changes to the organisation of the NHS, the introduction of the internal market, the commissioning role of health authorities and the introduction of fundholding puts decision-making and financial responsibility for treatment increasingly into the hands of GPs, and (iv) the absence of an allopathic vaccine or effective treatment resulted in communicable disease specialists advocating that testing was riot necessary, while others even argued that it was uneconomic to test.

A review of' recent and current guidance concerning the needs of' IDUs shows continuing ambivalence to a major health threat that shows every sign of increasing. The following quotes are extracts of current recent information and advice on HCV and IDUs taken from various official and specialist reports.

The Advisory Committee on the Misuse of drugs has over a number of' years, produced reports on HIV AIDS and three reports into drug users and the prison system. These are sonic extracts of' the advice contained regarding HIV and hepatitis B and C. It is worth rioting that hepatitis is mentioned primarily in relation to its implications 1'or HIV:

We are concerned that there are very high levels of hepatitis B and hepatitis C' infection amongst injecting drug users in sonic parts of' the UK, since this may indicate a potential 1'or rapid spread of HIV when the virus is introduced into networks of' drug injectors. This is particularly true of' Hepatitis C. as presence of' the virus is highly correlated with sharing of contaminatedinjecting equipment. One study in Glasgow reported that 2% of injecting drug users were HIV positive. while a separate study of injectors found that 70% had hepatitis C antibodies in their blood. Such our findings reinforce the need for early identification of drug misuse and the effective delivery of' HIV prevention messages (ACMD, 1993).

There is no likelihood of' the development of' a vaccine against Hepatitis C in the immediate future and the principal way of' controlling the spread of' Hepatitis C is therefore to interrupt transmission. There is continuing clinical debate about the effectiveness of treatments and, as in the early years of the HIV epidemic, there are ethical dilemmas as to whether or not someone should undergo a test to know whether they have contracted the virus... We recommend that renewed efforts are made, through continually updated education programmes, to inform staff and prisoners about the risk of transmission A all blood-borne viruses (ACMD, 1996).

The Centre for Research on Drugs and Health Behaviour produced this rather non-committal comment on testing in June 1996.

We need to consider whether any benefit would accrue to individuals or to the wider community if  testing of current or previous IDUs for HCV infection was offered or promoted in the context of routine or IDU-related health care. Given the need for better information concerning the therapeutic effectiveness and natural history of HCV infection, this may be difficult to justify at present.

On the other hand, clinicians should be aware that if people with a history of drug injection present with symptoms, HCV testing may be indicated, and that HCV infection should be included in the differential diagnosis as part of good clinical practice (The Centre for Research on Drugs and Health Behaviour, 1996).

The Task Force to Review Services for Drug Misusers reported in 1996 with little mention of HCV. This is their advice.

In contrast to the low levels of HIV sero-prevalence, in the region of 50% of UK drug injectors are infected with Hepatitis B and even more with Hepatitis C... The risk of acquiring any of these viruses depends on the prevalence within the injecting drug community. For this reason, the risks of acquiring Hepatitis C are probably the largest.

The large number of drug misusers infected with Hepatitis B and C has treatment implications. There may be thousands of people who are Hepatitis C positive, including many who have long since ceased to inject drugs. The Department of Health needs to consider how to address the needs of these people and of Hepatitis C-infected drug misusers (The Task Force to Review Services for Drug Misusers, 1996).

The common thread running through these reports is that the need to test drug users for HCV is questionable and that more and better preventative advice is needed. The last report, while acknowledging the gravity of the situation, does not make any specific recommendations or suggest preferred options.

There is now a growing awareness that HCV is going to become an increasingly important matter for health care workers. Since screening of' blood products for HCV, introduced in September 1991, has greatly reduced the risk of infection through contaminated blood products, there has been a need to get recognition that injecting drug users have been, and will continue to be, exposed to increasing risk of HCV infection. This risk will continue to affect ever increasing numbers of individuals unless prompt and effective action is taken.

Needle exchange schemes have dramatically reduced the reported level of sharing injecting equipment from 60 -- 90% pre 1986/7 to < 20'Yo in 1996. This has been interpreted as indicating that IDUs have become more discriminating in their behaviour. However, evidence indicates that while needle/syringe schemes have helped to keep HIV levels to < PYo of IDUs in most British cities, this change in injecting behaviour has not been sufficient to stem HCV. Many studies show that a less than perfect understanding of what is meant by 'sharing' has given rise to continued multiple exposure to HCV infection among IDUs. Given the high numbers now using illegal drugs, combined with continuing injecting, the potential for the spread of viruses such as HBV and HCV is dramatically increased.

The low levels of HIV infection are likely to be seen by new recruits to injecting as a sign that rigid adherence to using clean injecting equipment is not that important. The sharing of' not only injecting equipment (needles and syringes) but also injecting paraphernalia (spoons, water, swabs, tourniquets. etc.) is probably higher than we would like to believe. If this is the case, then the transmission of HCV is likely to be occurring with little effective action being taken to counter it, especially as the evidence suggests that HCV transmission only requires minor lapses in 'infection control' and such lapses are an ongoing, frequent occurrence.

In contrast to British ambivalence, an Australian report has noted that- "The extremely high prevalence and incidence of HCV among injecting drug users clearly indicates efficient and continuing transmission within this group, in whom HIV is not spreading at an appreciable rate. This and circumstantial evidence implicating environmental contamination as well as the sharing of' injecting equipment in the transmission of HCV between users indicates the potential difficulties facing attempts to control the epidemic among users (NHMRC, 1996)",

The executive summary of a piece of research (West Midlands NFIS Executive, 1997) into the drug injecting end sexual risk behaviour of' 302 injecting drug users in the West Midlands, indicates that there is great cause for concern. The level of' sharing various elements of' injecting equipment is worringly high. A third of' the respondents had, in the past 6 months, used injecting equipment previously used by others. There were even higher rates for sharing paraphernalia, 85'Y,) in the previous 6 months and 69% in the previous 4 weeks, indicating that the message regarding the sharing of injecting equipment and paraphernalia, is still not being heeded or fully understood by users. Lenton (1997) found similar levels of sharing injecting equipment at 25.3%, and paraphernalia at 56.2%, among 511 'hidden drug injectors' in Western Australia.

In the West Midlands research, stimulant users were the largest group not using needle exchange facilities. There has been a level of concern that the use of stimulants might be a factor in increased levels of sharing, with elated mood negating concerns over health risks. The latest Department of Health Statistical Bulletin: Drug Misuse Statistics (No 7) Department of Health, 1997b indicates that the West Midlands Regional Office area has, at 17%, the highest level of amphetamine use in England, with local areas such as Coventry and North Worcestershire reporting 31% 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 future exposure to HCV. Current injecting drug users and ex-users are not being encouraged to get tested. As long as the official advice remains equivocal and public health officials continue to regard HCV as a low health priority, services wishing to introduce testing will continue to face an uphill struggle persuading health commissioners of the need.

It is now time to refocus the strategy to include all blood-borne viruses with an emphasis on HCV, as this appears to be most prevalent. By attempting to reduce the transmission of' HCV we should be able to continue to keep the prevalence of the other viruses to low levels. Testing for HCV should be made easily available 1rom drug services. This would have two benefits: (i) by identifying those who are infected we can give advice on reducing the damage to their liver; (ii) through PCR, identify those current injectors who carry the virus, in order to target specific information and advice so that they do not unwittingly infect others. The risk of HCV transmission appears to be very low from those who are HCV antibody positive but have undetectable viraernia (Dore et al., 1997).

Research being carried out in Perth, Australia (Carruthers, 1997) and Sacramento, CA (Flynn et al., 1996) which involves filming drug users injecting in their usual/normal setting, has identified 1'requent opportunities for contamination and the spread of infection. This has shown that repeated exposure to low level contamination is the norm, with environmental factors such as the communal use of water, spoons, swabs, tourniquets, etc., in social injection settings being an identifiable source of potential infection.

The official advice on services for drug users at present either ignores HCV completely or plays down its significance. The latest advice on HBV and HCV, contained in the publication- Purchasing Effective Treatment and Care for Drug Misusers -mentions the risk of infection and recommends that 'purchasers should ensure that suitably trained staff are available to advise these patients' (Department of Health, 1997a). Unfortunately. there is no indication in the guidance as to what form this advice on HCV should take. HBV is more clearly thought out with recommendations for vaccinations for those at risk. However. even here, the level of completed H13V vaccination among drug users still remains very low.

Given the poor level of' understanding of HCV by health professionals and the prejudice against drug users and without there being some strategic framework in place, it is unlikely that any effective advice will be offered if those most at risk and who need to be given appropriate information cannot be identified. The view of some health care professionals is that as there is no cure we should not test for HCV. This ignores the opportunities that exist for reducing the future incidence of HCV, which given the existing high levels of infection among IDUs and the anticipated growth in injecting among new injectors should be our priority. Current injectors with detectable levels of HCV viraemia need to be given targeted information in order to reduce the risk of them transmitting the virus to others through poor infection control practices when injecting.

The assumptions underlying the current official inaction seem to be that:

1. to test would be costly

2. in the absence of a vaccine testing is not necessary

3. to know would only be another problem for drug users to contend with

4. drug users are unlikely to change their drug taking habits as a result of knowing a test outcome

5. drug users are incapable of changing so, in the prioritisation of resources, treatment would not be offered

These assumptions can and should be challenged for the following reasons:

The cost of testing for HCV is not that dissimilar from HIV tests. An HIV screen costs £8.50, while a HCV antibody test is £6.70. HIV confirmation tests are £19.30 and the HCV PCR test is £30.00. HCV tests are only £8.90 more than those for HIV.

The absence of a vaccine did not prevent the promotion of testing for HIV among drug users and the establishment of alternative testing sites. On the contrary, both were encouraged in order that "an infected person may benefit clinically from prophylactic treatments". (Department of Health, 1992). HCV has been found to respond to alternative and complementary therapies, such as traditional Chinese medicine, but as these are not reliant on an allopathic vaccine to be effective, this has not been pursued. Neither has another of the rationales for testing for HIV; that ---a subsidiary epidemiological benefit is that the results may give a more accurate picture of local seroprevalence which is helpful in planning services and targeting local educational initiatives more effectively" (DoH, 1992) been promoted with HCV. It is more a question of attitude than vaccine.

A frequent justification for not testing is that without a cure it would be yet another problem for the user. The encouragement to test for HIV, but not HCV, despite the fact that HIV would be another problem to contend with, has also to be seen in the context of which of the two viruses would you prefer to test positive for'? Given the option, most would prefer to test positive for HCV, not HIV. An important element in the earlier thinking was to 'prevent the spread of HIV among and from drug misusers' (Department of Health, 1988). The apparent minimal risk of sexual transmission of HCV into the wider community is key to this differing response. HCV can therefore be regarded by some as being self-contained. It now mainly affects drug users who are seen to have brought it on themselves; and HCV poses a lesser risk than HIV, to the general population who do not require the same degree of protection 'from drug misusers'.

It is questionable whether or not changes in injecting drugtaking behaviour will be sufficient in themselves to stem the HCV epidemic. As long as injecting continues as a preferred route of administration, then so will opportunities exist for infection. Some (Wodak, 1997) have promoted non-injecting routes of administration (NIROA) as the only effective means of stemming future infection. This in itself is questionable as it was the emergence of heroin chasing in the early to mid 1980s that introduced large numbers of British drug users to heroin and in turn led onto increased injecting. To be successful a NIROA strategy depends on a number of factors including price, purity and suitability of drugs available which, given the illicit nature of the market, will be hard to ensure over any period of time.

HCV has a higher prevalence among IDUs and is more infectious than HIV. However, maintitining the continuing focus on HIV only serves to enable the spread of HCV among new recruits into injecting, with research (MacDonald et al. , 1997a,b) showing 32'Y,) of IDUs infected within I year of commencing injecting and other studies finding 70--851Y, of IDUs infected within 6 years. Targeting information and awareness of HCV as an issue that affects the majority of IDUs in Britain is more likely to bring about behaviour change than continuing to concentrate on HIV which, while only affecting a minority, can seem increasingly remote in the experience of most drug users.

Drug users do change their habits und many drug users are only involved in injecting for relatively short periods, but by then the damage is done. Not being able to identify those with HCV also means that advice regarding the impact of alcohol cannot be given to reduce the risk of liver damage. Change in drug using behaviour which includes a reduction in alcohol will potentially have long-term benefits for those with HCV, including reducing the need for treatment later on. The ability to test improves the outcome and can potentially reduce the effect of HCV when drug use is not replaced by alcohol use in someone infected with HCV. The effects of alcohol on disease progression are unclear with one study showing that alcohol did not appear to alter clinical outcomes of those with chronic HCV (Khan et al., 1997) while Crofts (1994) and Duscheiko et al. (1996) have indicated that alcohol aggravates the onset of hepatic injury.

Relying on stereotypes of drug users as 'junkies' as a justification for not offering treatment does little to address their health needs or those of whom do not conform to the stereotype, such as steroid users. In a time of increasing rationing of medical treatment, this blanket approach means that a deserving versus undeserving ethos develops, reinforced by relying on stereotypes, to justify drug users lack of priority for treatment. Protocols can and should be developed to identify suitable cases for treatment on the basis of clinical need, that take account of drug use but do not use it to deny treatment.

The implications of not addressing the issues around injecting drug use and sharing of injecting equipment are that increasingly large numbers of' users are going to be exposed to viral infections, the most common of which is HCV. The West Midlands report, and a recommendation from the First Australasian Conference on Hepatitis C, that testing for HCV among injecting drug users should be available; support the argument that it is now time to refocus our strategy to include all blood-borne viruses with a particular focus on HCV.

1. Summary

Drug users in Britain still remain largely unaware of HCV. Those who are aware are frequently poorly informed or confused about the differing types of hepatitis, transmission routes, risk factors, etc. Official interest is muted and the medical profession appear not to have recognised the significance of the epidemic. Approaching your GP is unlikely to help as the British Liver Trust, a charity covering all liver diseases, now receives between 30-501X~ of all calls to its telephone information service relating to HCV. Many of these callers have HCV and have been referred to the Trust by their GP as they do not have the information, do not think HCV is serious or do not know how to treat it.

In conclusion, the British situation can best be described as being too little, too late, while HCV numbers continue to increase against a background of increasing drug use; inadequate resources, publicity and awareness; and support for all with HCV. In the absence of a national strategy to prevent further infection among IDUs we are leaving a legacy for the millennium.

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