Rapid Responses to:

EDITORIALS: R A Coutinho HIV and hepatitis C among injecting drug users BMJ 1998; 317: 424-425 [Full text]

Rapid Responses: Submit a response to this article

Rapid Responses published:

Controlling hepatitis C among injecting drug users

Nick Crofts   (9 September 1998)

Hepatitis C virus on drug injecting equipment

Nick Crofts   (29 August 2000)

Controlling hepatitis C among injecting drug users 9 September 1998
Nick Crofts, Deputy Director The Macfarlane Burnet Centre for Medical Research Send response to journal: Re: Controlling hepatitis C among injecting drug users	The Editor British Medical Journal Dear Colleague Epidemics of hepatitis C virus (HCV) infection currently raging among injecting drug users (IDUs) have received far too little attention to date from public health authorities. Thus the editorial by Coutinho[1] is welcome and timely; however, we wish to correct and extend some of the points made in his article. Coutinho suggests some transmission among Australian IDUs may have been due to front and back loading. These behaviours, apparently common in the Netherlands, have not been observed in Australia, where sharing of injecting equipment other than needles and syringes is common. He also suggests that peer education has not been sufficiently explored among IDUs. This is certainly not the case in Australia, where there is extensive, government funded peer education in relation to HCV, often through government funded drug users' groups.[2] And while Coutinho advocates treatment for IDUs with HCV infection, it is the case in Australia as in most of the rest of the world that IDUs are discriminated against in access to treatment for HCV, as in many other areas. Although Coutinho is correct in stating that HCV incidence and prevalence remain high among Australian IDUs, there is some evidence which suggests transmission rates are declining. Declines in incidence of HCV were seen in a cohort study of IDUs, matched by declines in self-reported behavioural risk,[3] and HCV prevalence among first time attenders at a methadone maintenance clinic in Melbourne declined from 75% in 1991 to 50% in 1995.[4] These data match those from the US, of declining incidence of HCV among IDUs[5] and of the effectiveness of needle exchange programs in decreasing HCV risk.[6] Essentially, these data suggest that current strategies for prevention of HIV among IDUs are effective against HCV transmission, but the high prevalence and greater infectiousness of HCV mean our strategies must be applied more broadly and vigorously, particularly in high- risk settings (such as prisons) and among doubly marginalised communities of IDUs. It is relatively easy to stop these epidemics before they start, but very difficult after they have taken off. HCV represents a challenge for governments committed to a harm reduction approach to the consequences of illicit drug use. We can only hope they will meet the challenge. Dr Nick Crofts Dr Campbell Aitken Director Deputy Director The Centre for Harm Reduction The Centre for Harm Reduction References 1. Coutinho RA. HIV and hepatitis C among injecting drug users. BMJ 1998;317:424-5 2. Crofts N, Herkt D. A history of peer-based drug user groups in Australia. J Drug Issues 1995;25:599-616 3. Crofts N, Aitken CK. Incidence of and risk behaviours for blood- borne viruses in a cohort of injecting drug users in Victoria, 1990-1995. Med J Aust 1997;167:17-20 4. Crofts N, Nigro L, Oman K, Stevenson E, Sherman J. Methadone maintenance and hepatitis C virus infection among injecting drug users. Addiction 1997;92:999-1005 5. Alter MJ. Epidemiology of hepatitis C. Hepatology 1997;26(Suppl 1):62S-65S 6. Hagan H, des Jarlais DC, Friedman SR, Purchase D, Alter MJ. Reduced risk of hepatitis B and C among injection drug users in the Tacoma syringe exchange program. Am J Public Health 1995;85:1531-1537
Hepatitis C virus on drug injecting equipment 29 August 2000
Nick Crofts Send response to journal: Re: Hepatitis C virus on drug injecting equipment	To the Editor The hepatitis C virus (HCV) and the human immunodeficiency virus (HIV) are both blood-borne infections of injecting drug users (IDUs), transmitted by sharing contaminated needles and syringes. Despite extensive harm reduction programs (especially needle exchange) in Australia, HCV continues to spread among IDUs where HIV does not, partly because HCV has been at high prevalence among Australian IDUs since at least 1971, whereas HIV, present only from around 1982, has remained at low prevalence.1 HCV also has a higher average transmission efficiency than does HIV, and its transmission may require smaller amounts of blood.2 This raises the possibility that HCV is transmitted between IDUs on equipment other than needles and syringes, consistent with reports of IDUs exposed to HCV with no history of sharing needles and syringes.3 Australian IDUs commonly share other equipment - swabs, spoons, filters, water and tourniquets, for example. To investigate the possibility that this sharing may be responsible for transmission of HCV, we have begun by studying used injecting equipment from ten injecting settings for the presence of HCV RNA. Each setting involved between one and four IDUs, at least one of whom was known to be HCV PCR positive. All used injecting equipment was collected by peer outreach workers and transported immediately to the laboratory. HCV RNA was isolated and purified from equipment using reagents in the QIAGEN QIAamp Viral RNA kit (QIAGEN, Australia). Briefly, needles and syringes were flushed with the QIAGEN lysis buffer, spoons and swabs were rinsed or vortexed in lysis buffer, and water was processed as for serum in the manufacturer's protocol. All samples were tested for HCV RNA by the AMPLICOR HCV test (Roche Diagnostic Systems, Branchburg, NJ). HCV RNA was detected on 70% (14/20) of syringes, 67% (6/9) of swabs, 40% (2/5) of filters, 25% (1/4) of spoons and 33% (1/3) of water samples. These findings suggest that HCV could be transmitted among IDUs on injecting equipment other than needles and syringes; the growing evidence from behavioural studies suggests that such transmission may not be uncommon.3,4 This implies that the public health message used in these groups for control of HIV transmission (basically, do not share needles and syringes) may be inadequate for control of HCV, and that other strategies must be canvassed. These may include encouraging IDUs to use their drugs in ways other than injecting; more intense concentration on hygiene practices including handwashing; and education and support of IDUs to avoid sharing any equipment associated with injecting. Serious commitment to new and expanded harm minimisation strategies will be needed to reduce the continual spread of HCV amongst IDUs, along with the growing toll of illness and cost.5 Dr Nick Crofts Head, Epidemiology and Social Research Macfarlane Burnet Centre for Medical Research Sonia Caruana Research Assistant Walter and Eliza Hall Institute of Medical Research Michael Kerger Outreach Worker Epidemiology and Social Research Macfarlane Burnet Centre for Medical Research Dr Scott Bowden Molecular Microbiology Victorian Infectious Diseases Reference Laboratory References 1. Crofts N, Aitken CK, Kaldor JM. The force of numbers: why hepatitis C is spreading among Australian injecting drug users while HIV is not. Med J Aust 1999;170:220-221. 2. Patz JA, Jodrey D. Occupational Health in surgery: risks extend beyond the operating room. Aust NZ J Surg 1995;65:627-629. 3. van Beek I, Dwyer R, Dore GJ, Luo K, Kaldor JM. Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: retrospective cohort study. BMJ 1998;317:433-437 4. Crofts N, Aitken CK. Incidence of bloodborne virus infection and risk behaviours in a cohort of injecting drug users in Victoria, 1990- 1995. Med J Aust 1997;167:17-20 5. Coutinho. RA. HIV and hepatitis C among injecting drug users - success in preventing HIV has not been mirrored for hepatitis C. BMJ.1998;317:424-425