The Changing Face of HCV: Role of the Opioid Epidemic

Despite knowledge that the United States has an opioid epidemic, opioid prescribing remains high. In 2014, >240 million prescriptions were written for opioids, down only approximately 19 million from the >259 million prescriptions reported in 2012.^1,2 Opioid overprescribing has fueled drug addiction, with opioid medications often serving as a gateway to illicit drug use. 

It has been reported that 4 out of every 5 heroin users started out taking prescription opioids.² The prevalence of opioid abuse has not only resulted in a substantial increase in drug-related deaths and HIV transmissions, but has also led to a substantial increase in the number of people infected with hepatitis C virus (HCV). Between 2010 and 2015, HCV incidence rates increased 167%, from 0.3 cases to 0.8 cases per 100,000 US population, with the highest risk among people who inject drugs (PWID).³

Because HCV can remain asymptomatic for decades until it manifests as severe liver disease, many people, including high-risk groups such as PWID, may be unaware they are infected, contributing to unchecked disease spread. Some may not realize that HCV is even a risk, preventing them from taking proper precautions or from being tested. “You hear about AIDS. You never hear about hepatitis C,” a patient who contracted HCV from a shared heroin needle stated in an article in The Washington Post.⁴ Education, HCV testing, and treatment of high-risk groups are critically important, but many barriers impeding the care of these patients remain.

The New Patient With HCV

Before the start of the opioid epidemic in the late 1990s, those with HCV were generally middle aged or older. Examination of the National Health and Nutrition Examination Survey between 1999 and 2002 reported that most people with HCV were born between 1945 and 1964, with the peak prevalence of those with antibodies to HCV observed among those age 40 to 49 years.⁵ The older demographic was largely attributed to transmission following medical procedures more prevalent among older persons, such as organ transplantation or transfusion of blood products or clotting factor concentrates, particularly before routine screening for HCV and more strict infection control practices were implemented in the early 1990s.⁶ HCV was also attributed to intravenous drug use, particularly in urban areas, with heroin often being the first opioid tried.²

Today, most new HCV cases are attributed to injection drug use, particularly heroin, among younger (aged <30 years) persons in suburban or rural settings whose path to drug addiction started with prescription opioids.^7,8 This is not surprising given that prescribing rates for prescription opioids among adolescents and young adults nearly doubled between 1994 and 2007.⁹ In 2015, 122,000 adolescents were addicted to prescription pain killers, with 21,000 having used heroin in the past year.⁹ Nonmedical users of opioid pain medications are 19 times more likely to use heroin, making this a major risk factor.²

Because more of those with HCV are now of reproductive age, there has been a sharp rise in HCV among pregnant women. Between 2009 and 2014, maternal HCV infections nearly doubled.¹⁰ Subsequently, there is an increased risk for perinatal transmission, which can go undetected and untreated, particularly if maternal HCV status is unknown. Unfortunately, poor follow-up of infants with known HCV exposure has also been reported.¹⁰  

Although there are HCV testing recommendations for high-risk groups,¹¹ they are not always carried out, and resources for people who screen positive are often lacking. A recently published study examined the prevalence of self-reported HCV screening and testing of 196 young adults (mean age, 24 years) who used prescription opioids nonmedically. All study participants were recruited from the Rhode Island Young Adults Prescription Drug Study (RAPiDS) between January 2015 and February 2016. The authors found that although 3 in 4 had been screened for HCV, screening was less likely among the youngest participants (age 18-23 years).¹² Additionally, even when patients screened positive for HCV, they often received inadequate follow-up care, such as confirmatory diagnostic testing, referral for specialty HCV care, and education about living with HCV and preventing transmission to others.

“Screening for HCV is free in many parts of Rhode Island, but financial and other barriers exist for youth who test positive and need additional resources and hepatitis C care,” said Brandon Marshall, PhD, senior author of the RAPiDS study, in an email exchange with Infectious Disease Advisor. Rhode Island has a comprehensive needle and syringe program, which provides free HCV screening to PWID. This may be why HCV screening rates were high in the RAPiDS study. However, access to treatment remains largely limited to people with more advanced liver disease and those who are abstinent from alcohol and drug use. “We need to work on improving access to hepatitis C treatment programs for young people, particularly those who are using drugs, as they are the population most likely to transmit the virus to others,” said Professor Marshall.

Barriers to Care

Numerous barriers to proper testing and care of people who are at high risk for HCV and those who have HCV have been identified, even in settings that appear ideally suited to provide targeted strategies to improve HCV testing and access to care and educational resources. The international C-SCOPE study examined perceived barriers in one such setting: clinics providing opioid agonist therapy to PWID.¹³ In the study, physicians practicing at such clinics completed a self-administered survey designed to measure response to barriers for HCV testing, evaluation, and treatment across health system, clinic, and patient domains.

Major reported health system barriers included lack of funding for noninvasive liver testing and new direct-acting antivirals, long wait times to see HCV specialists, and reimbursement restrictions based on drug and/or alcohol use.¹³ In the United States, reimbursement policies for HCV treatment can be particularly problematic. In 2015, 24 states had restrictive Medicaid treatment policies that required a period of sobriety to receive HCV treatment, with 11 of these states having the least comprehensive laws related to HCV prevention.¹⁴ Only 3 states — Massachusetts, New Mexico, and Washington — had permissive Medicaid treatment policies and a comprehensive set of laws regarding HCV prevention, although no state has yet met all 6 of the National Safety Council indicators designed to strengthen regulations regarding opioid medications.^2,14

“Despite clear guidance from Centers for Medicare and Medicaid Services, many states continue to limit access to life-saving HCV treatment due to restrictions based on inappropriate requirements of sobriety, disease severity, and/or prescriber type. These restrictions are not in line with guideline recommendations from the American Association for the Study of Liver Diseases and Infectious Diseases Society of America,” noted Alain H. Litwin, MD, a C-SCOPE study investigator and professor at Albert Einstein College of Medicine, in an email to Infectious Disease Advisor. “All restrictions must be urgently lifted. Specifically, people with low-stage disease and those actively using drugs and alcohol must have access to HCV medications, and all providers including primary care and addiction treatment providers should be able to prescribe these medications,” he added.

In addition to health system barriers, C-SCOPE identified several major clinic and patient barriers.¹⁴ Clinic barriers included a lack of case managers or link-to-care coordinators for HCV treatment, need for off-site referral for liver disease assessment and treatment, and lack of peer support programs for testing. Patient barriers included missing referral appointments for testing, difficulty navigating the health system, fear of adverse effects, and lack of motivation for HCV treatment.¹⁴

Summary

Barriers across multiple domains can impede both prevention of HCV among PWID and timely diagnosis, treatment, and follow-up care of those who become infected. Future research on ways to remove barriers to HCV care will need to account for a variety of variables when developing interventions, including physicians’ perceived beliefs about patient readiness for HCV treatment. 

References

1. US Department of Health and Human Services (HHS). The Opioid Epidemic: By the Numbers. Updated June 2016. Accessed November 24, 2017.
2. National Safety Council. Prescription Nation 2016. Addressing America’s Drug Epidemic. 2016. Accessed November 24, 2017.
3. Campbell CA, Canary L, Smith N, Teshale E, Ryerson AB, Ward JW. State HCV incidence and policies related to HCV preventive and treatment services for persons who inject drugs — United States, 2015-2016 [published correction appears in MMWR Morb Mortal Wkly Rep. 2017;66(29):795]. MMWR Morb Mortal Wkly Rep. 2017;66:465-469.
4. Zezima K. Another outbreak related to the nation’s opioid crisis: hepatitis C. The Washington Post. October 17, 2017. Accessed November 28, 2017.
5. Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144(10):705-714.