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Hepatitis C virus (HCV) infection is a leading cause of liver disease and mortality around the world; 3.4 to 5 million people are currently infected in the United States alone. HCV-related deaths reached an all-time high in 2014, surpassing the total number of deaths from 60 infectious diseases combined—including HIV and tuberculosis.
Injection drug use (IDU) is a primary mode of HCV transmission; therefore, HCV infection rates have risen in recent years in conjunction with the opioid crisis. Although HCV infection rates fell from 1989 through 2003, infection rates have more than doubled from 2010 to 2014, with many of these new infections occurring among young people who inject drugs (PWID) in non-urban areas.
Given the link between IDU and HCV transmission, evidence suggests that harm reduction strategies like syringe service programs (SSPs) and medication-assisted treatment (MAT) for opioid use disorder can decrease HCV transmission by 50%–80% via reductions in needle sharing.
A study first published in 2017 looked at the use of SSPs and MAT in conjunction with HCV treatment to improve treatment outcomes. Implementing SSPs and MAT concurrently with HCV treatment, by increasing the number of people cured and decreasing rates of re-infection, can reduce the number of individuals who contract HCV and require treatment. The study used data from an HIV outbreak in Scott County, Indiana, among people injecting prescription opioids; the data were used to create a model estimating the percent change in HCV incidence and prevalence given differing levels of SSP and MAT program coverage.
The projections indicate that a 90% decrease in HCV infection prevalence and incidence can be achieved by 2030; with no scale-up of SSPs and MAT, nearly 25% of all HCV infections treated in the first year would need to receive HCV treatment annually to reach that goal. Yet, if SSPs and MAT are both scaled-up to 50% coverage, the number of people needing treatment annually is nearly cut in half.
SSPs and MAT programs have been more widely established in urban areas and these places have experienced substantial decreases in HIV transmission over time. And although these successes in urban areas demonstrate the utility of similar programs in rural areas, no modeling had been conducted prior to this study.
The study is an important step in filling the knowledge gap by calculating the required scale-up necessary to achieve reductions in HCV prevalence and incidence in rural settings. It demonstrates that an achievable scale-up of HCV treatment can dramatically reduce the infection burden among PWID in rural settings when paired with SSPs and MAT. As many other rural areas in the United States are experiencing the dual epidemic of HCV and IDU, the findings from this study can be used not only to justify the effectiveness of MAT and SSPs in other regions of the country, but to also address inequities in the provision of these kind of programs.
