Full length articleHepatitis C virus prevalence and estimated incidence among new injectors during the opioid epidemic in New York City, 2000–2017: Protective effects of non-injecting drug use
Introduction
The US is currently experiencing an opioid epidemic that has officially been declared a “public health emergency” (Gostin et al., 2017). There are multiple components to this epidemic, including excessive marketing, over-prescription and diversion of opioid analgesics, transitions from opioid analgesic use to heroin use, and transitions from oral and intranasal drug use to injecting drug use. The increase in overdose deaths, from 17,415 in 2000 to 63,632 in 2016 (Centers for Disease Control and Prevention, 2018; Hedegaard et al., 2017) may be the most dramatic indicator of the seriousness of this epidemic. Concomitant with transitions to injecting drug use, large increases in hepatitis C virus (HCV) infection have also occurred during the opioid epidemic (Des Jarlais et al., 2018; Zibbell et al., 2018). There has been considerable attention given to the opioid epidemic in suburban and rural areas of the US (Cerdá et al., 2017), but marked increases have also occurred in large urban centers.
Both HIV and HCV are transmitted through multi-person use (“sharing”) of needles and syringes for injecting illicit drugs. Syringe service programs (SSPs, primarily syringe exchange and legal over the counter sales of sterile needles and syringes), medication assisted treatment for opioid use disorders (MAT, primarily methadone and buprenorphine maintenance treatment) and anti-retroviral treatment (ART) for HIV infection have dramatically reduced HIV transmission in many areas (Des Jarlais et al., 2016a,b), but these programs have been much less effective in reducing HCV infection (Platt et al., 2017).
New York City has implemented public-health scale “combined prevention and care for HIV” among PWID and HIV incidence has been reduced to 0.01/100 PY. (Des Jarlais et al., 2016a, b) Large-scale implementation of syringe programs in New York was followed by a substantial reduction in HCV prevalence—from a near saturation level of 90% to a high but clearly less than saturation level of 70%, with an estimated HCV incidence of 18/100 person-years among persons who had begun injecting within the previous 5 years (Des Jarlais et al., 2010, 2005). Additionally, New York implemented a “Stop Hep C” program in 2004. This program included public education efforts to increase awareness of HCV, increased provision of HCV testing at programs that serve PWID, and increased referrals of HCV seropositive individuals for further evaluation and HCV treatment with the new “direct acting antivirals.” The increase in persons who have received treatment for HCV infection, however, has not been sufficient to generate a “treatment as prevention” effect for HCV. Recently, in conjunction with the NY State program to “End the HIV Epidemic,” the governor and Commissioner of Health have announced a program to “End the HCV Epidemic,” with increased funding for access to Hepatitis C medications and expanded prevention, screenings and treatment services for high risk communities (New York Governor’s Office, 2018).
Concurrent with these positive public health initiatives, New York City has been experiencing an “opioid epidemic,” with overprescribing and diversion of opioid analgesics, transitions from use of opioid analgesics to use of heroin, increased fatal opioid overdoses and transitions from non-injecting to injecting drug use (New York State Department of Health, 2018). Together these factors create conditions conducive to increased transmission of HCV.
In this report, we examine HCV seroprevalence and estimated HCV incidence among persons who began injecting drugs during the course of the “opioid epidemic” (2000–2017) in New York City. We are particularly interested in whether there have been any reductions in HCV infection, suggesting possible cumulative effects of the new interventions or increases in HCV infection, suggesting possible acceleration of the HCV/opioid injecting epidemic. We are also interested in identifying any factors that may be protective against acquiring HCV. Finally, we also consider the implications of the New York City data for addressing HCV in the opioid epidemic in other areas of the US.
Section snippets
Materials and methods
The data presented here were collected between January 2007 and December 2017 as part of a long-running study of persons entering Mount Sinai Beth Israel drug detoxification and methadone maintenance programs in New York City. The methods for this “Risk Factors” study have been previously described (Des Jarlais et al., 2009, 1989) so only a summary will be presented here. The programs serve New York City as a whole and there were no changes in the requirements for entrance into the program over
Results
Between January 2007 and December 2017, we recruited a total of 846 study participants among entrants to the Mount Sinai Beth Israel drug use treatment programs who reported beginning to inject in 2000 or later. These represented 32% of the 2687 participants who participated in our study during the data collection period and reported a history of injecting drug use. The percentage of study participants who first injected in 2000 or later among all study participants with a history of injecting
Discussion
As noted in the introduction, the Governor of New York State has recently called for an “End to HCV” in the state. Given the success of combined prevention and care controlling HIV in the state, extending public health efforts to address HCV is a laudable goal. However, this effort is being undertaken during the current opioid epidemic, which includes many persons who transition from non-injecting to injecting drug use, and who are at very high risk for acquiring HCV. The estimated incidence of
Limitations
Several limitations of this study should be noted. First, the participants were recruited from entrants into a single set system of substance use programs and are not a random sample of people who use drugs in New York City. HIV and HCV infection among participants in the Risk Factors study has tracked consistently with HIV infection data from other sources in New York City (Des Jarlais et al., 2016a,b, 2000a,b; Des Jarlais et al., 1998; Murrill et al., 2001; Thomas, 2001). We did compare our
Conclusions
Like many other areas in the US, New York City has experienced large numbers of persons beginning to inject drugs and becoming infected with HCV. Multiple interventions will be needed to control HCV infection among persons who have begun injecting during the current opioid epidemic. The New York City data suggest possible additional harm reduction strategies for reducing HCV transmission among PWID. These could include supporting “reverse transitions” from injecting back to exclusively
Role of funding sources
This work was supported through grants R01DA003574 and 5-DP1-DA039542 from the US National Institute on Drug Abuse The funding agency had no role in the design, conduct, data analysis or report preparation for the study.
Contributors
Don Des Jarlais conceived the study; Courtney McKnight managed data collection; Kamyar
Arasteh performed statistical analysis; Jonathan Feelemyer worked with data analysis and managed final editing of manuscript; Hannah Cooper, David Perlman, Susan Tross, David Barnes and Anneli Uuskula contributed to editing of the manuscript. All authors reviewed the full study and results prior to submission to the journal. All co-authors have approved the final manuscript and the revisions that are being
Conflict of interest
No conflict declared.
Acknowledgments
We would like to thank the staff at Mount Sinai Beth Israel treatment programs for their diligent work in interviewing and collecting the relevant data for this study.
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