HIV and hepatitis C among injecting drug users
BMJ 1998; 317 doi: https://doi.org/10.1136/bmj.317.7156.424 (Published 15 August 1998) Cite this as: BMJ 1998;317:424
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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
Competing interests: No competing interests
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
Competing interests: No competing interests