Advocacy

Hepatitis C (with Physician Supplement)

Adoption Date:
May 1, 2003

Public Policy Statement on Hepatitis C

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Background

Injection drug users (IDUs) account for the majority of persons infected with hepatitis C virus (HCV) in the United States. Most new HCV infections are acquired through sharing of injection equipment, and approximately 80% of IDUs are HCV-infected. Users of non-injected illicit drugs are at risk as well, though HCV is less easily transmitted by sexual contact. An estimated 76% of persons enrolled in methadone maintenance treatment in the United States have hepatitis C infection, in stark contrast with the estimated prevalence of 1.8% among the US population overall.

Acute hepatitis C is usually asymptomatic. Once infection occurs, it becomes chronic in 85% of persons. Of these, approximately 20% develop hepatic cirrhosis over the ensuing 20-30 years, and of those, approximately 25% will develop liver failure, liver cancer, or both. In the US, an estimated 10,000 deaths per year are presently attributed to HCV infection, and a 3-4 fold increase in HCV-related deaths is anticipated over the next 20 years.

Many patients with HCV are not candidates for currently available treatment, but many are. The decision to treat is based primarily on the degree to which the virus has resulted in liver damage. Effective treatments exist and should be offered to patients for whom treatment is considered appropriate based on patient selection criteria. Screening for depression before and during treatment for HCV infection, and access to psychiatric backup services, are important elements of treatment programs for drug users who have HCV, given the potential for depression to arise as a side-effect of current treatments.

The NIH HCV Consensus Conference Statement of 2002 stated that “HCV therapy has been successful even when patients have not abstained from continued drug or alcohol use or are on daily methadone.” Treatment, therefore, provides the public health benefit of reducing the number of HCV carriers.

Several important interventions are very likely to maintain or improve the health of HCV-infected drug users. Preventing further liver damage is an important aspect of managing chronic hepatitis. Alcohol consumption can accelerate development of liver disease among persons with HCV infection, so infected persons should be counseled regarding its use and to seriously consider the salutary effects of complete alcohol abstinence. Screening for and vaccination against infection with other hepatitis viruses (hepatitis A and B) are also important interventions for HCV-infected drug users. Infection with HIV can also accelerate the progression of HCV-related liver disease, so prevention and treatment of co-occurring HIV infection are important to consider. Behavioral interventions to decrease the frequency of high-risk behaviors, and ready access to addiction treatment services, as well as to HCV education, counseling and testing, are essential elements of the public health response to the epidemic of HCV infection among drug users. Widespread access to sterile injection equipment needle is an important objective in this regard. Drug users both in and out of formal treatment programs must be engaged in such efforts.

Recommendations

1. Persons with a history of drug use, particularly those with a history of injection drug use, should be offered voluntary serologic testing for hepatitis C virus (HCV) infection.

2. HCV-infected persons with active injection drug use should be offered ready access to addiction treatment services, including methadone and buprenorphine maintenance.

3. Clinical staff working with current or former drug users should receive education regarding the prevention, transmission, clinical course and treatment options for HCV infection.

4. Addicted patients with HIV infection should be offered voluntary serologic testing for co-infection with hepatitis C virus.

5. Addicted patients with HCV infection should be offered testing for immunity to hepatitis A and hepatitis B virus infection. Those testing negative should be advised of the benefits of vaccination against hepatitis A and hepatitis B virus infection.

6. Addicted patients with HCV infection should be counseled to eliminate alcohol use. All patients with HCV infection who fulfill diagnostic criteria for abuse or dependence on alcohol and/or other drugs should receive treatment for these disorders.

7. State of the art medical treatment for HCV should be accessible and available to HCV-infected current and former drug users. Active drug or alcohol use should not in itself exclude any person from receiving treatment for their HCV infection. The decision to initiate treatment for HCV infection in any patient should be made by the doctor and patient following careful consideration of the benefits and risks of therapy.

8. All persons undergoing HCV treatment should have access to psychiatric assessment and treatment before and during treatment.

9. Addiction treatment programs are well situated to provide or coordinate HCV counseling, screening, and treatment for their patients; interventions such as supervised therapy to enhance adherence to HCV treatment may be integrated effectively with addiction treatment services. Co-location of medical, psychiatric and addiction treatment services fosters integration of the diverse elements of patients’ treatment, optimizing communication and minimizing fragmentation of care, and thus such integration of service delivery is strongly encouraged.

10. Third party health insurance coverage (public and private) should cover HCV treatment, including costs of the viral load and genotype tests that are essential to HCV treatment.

11. Public sector addiction treatment programs should be provided whatever additional resources may be required to provide necessary infectious disease and psychiatric services for their patients.

[For further detailed policy recommendations, physicians and others should consult the document Policy Statement on Hepatitis C: Supplemental Information for Physicians.]

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