American Journal of Medicine, internal medicine, medicine, health, healthy lifestyles, cancer, heart disease, drugs

Hepatitis C Infection Screening and Management in Opioid Use Epidemics in the United States

Time trends of acute hepatitis C incidence by age groups: 2003-2016.

Acute hepatitis C infection is on the rise in the United States, with a more than twofold increase in incidence rate from 2003 to 2016 overall and a threefold increase among young adults1, 2 (Figure). In 2016, a total of 2967 cases were reported from 42 states, and the Centers for Disease Control and Prevention estimates the actual case number to be 41,200.2 This national increase in acute hepatitis C infection has mirrored reports of escalating injection drug use.2 Heroin injection is known to be a major route of hepatitis C transmission, and young adults are increasingly shifting from other opiates to heroin due to its lower price and easier accessibility as prescription opioids become more difficult to acquire amid concern for an epidemic of opiate addiction.3, 4 The cumulative incidence rate of hepatitis C virus was reported to be 28% at 1 year of drug injection.5 In 2016, nearly 1 million Americans reported using heroin.6 Groups at high risk for hepatitis C infection include young adults, males, and whites, the same groups at risk for heroin use.2 Although decreases in prescription opioids correspond to national, state, and local initiatives that target opioid prescribing, public health stakeholders are alarmed at rising trends in heroin-associated hospital and emergency department utilizations.7, 8 Nationally representative face-to-face interviews provide further evidence for increasing use of heroin, with greater increases among white individuals.9

Unequal Access to Cost-Effective Direct-Acting Antiviral Therapy in the United States

Direct-acting antiviral (DAA) therapy to eradicate hepatitis C virus is highly cost-effective, with an excellent tolerability profile.10 Even so, considerable heterogeneity remains across state Medicaid programs in the criteria for approving DAA therapy.11 DAA therapy is accessible mainly through state Medicaid programs among low-income and nonelderly populations that are at high risk for injection drug use and acute hepatitis C.11 There are remarkable, unmet needs for DAA therapy among prison inmates with hepatitis C; less than 1% of state inmates are reported to receive DAA therapy, even though the prevalence of hepatitis C is estimated to be more than 10 times greater in inmates than in noninstitutionalized US populations.12, 13 Because many inmates will eventually return to public life, coordinated strategies for affordable and accessible DAA therapy are needed in this high-risk population.

Hepatitis C Screening Strategies in the United States

The current hepatitis C screening strategy is a 1-time testing of the baby boomer cohort born between 1945 and 1965, as recommended by the US Centers for Disease Control and Prevention in 2012 and endorsed by the US Preventative Services Task Force in 2013.14, 15, 16 As seen in the Figure, part of the increase in acute hepatitis infection rate is attributable to the newly expanded screening guidelines. However, increases in the 0-29–year age group are not explained by that window.

A recent comparative effectiveness analysis suggests that screening the entire US population would be more cost-effective than the current birth cohort strategy, given the high risk of injection drug users.17 However, this analysis has limitations and does not reflect secular opioid epidemic trends.17

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-Xibei Liu, MD, Jay Shen, PhD, Pearl Kim, PhDc, Seong-min Park, PhD, Sungyoun Chun, PhD, Jen-Jung Pan, MD, PhD, Mohamed Azab, MD, Haneul Choi, Hyeyoung Yeom, MD, Yong-Jae Lee, MD, Ji Won Yoo, MD

This article originally appeared in the November issue of The American Journal of Medicine.

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