The Importance of Hepatitis C Education and Testing in Alcohol and Drug Programs

Victor Pawlak
Arizona Hepatitis C Coalition[1]

 Presented at the 100^th Conference of the International Council on Alcohol and Addictions, Stockholm, Sweden, June 10-15, 2007.

 Introduction

            I am here today to advocate for hepatitis C education and testing in all alcohol and drug treatment programs. This is not just another of many medical complications from heavy drinking and injection drug use. Hepatitis C among these populations is an epidemic.

            My emphasis here will be more aimed at alcohol programs. Most of those working in drug treatment, especially programs for intravenous drug users, have already largely embraced hepatitis C as a major health problem. By far the most detailed meta-analysis of research on hepatitis C and drug use was published in 2004 by EMCDDA, the European Monitoring Center for Drugs and Drug Addiction, in Portugal. It can be downloaded off the internet (Jager, et al).

 Hepatitis C

            Hepatitis C (HCV) is a viral infection of the liver that causes long-term damage to 80-85% of those infected. It is the most common blood-borne disease in the United States (Schiff & Ozden, 2004), and the number one reason for liver transplants. Roughly 15-20% of people infected clear the disease on their own, while the rest go on to sustain some level of  liver damage. About 70% develop chronic liver disease. The word hepatitis means “inflammation of the liver,” and all the hepatitises including A, B and C are unrelated. There are six known genotypes of the hepatitis C virus.

            Hepatitis C is caused by an RNA virus, and was at one time known as non-A, non-B hepatitis. The Hepatitis C Virus was first identified in 1988, though it existed long before then, and a hepatitis C antibody test (anti-HCV) was first made commercially available 1990. By 1992, virtually all donated blood in the U.S. and most industrialized countries was being screened for the virus.

            Hepatitis C has a high mutation rate. This makes it difficult for the body's immune system to fight it off, or to develop a preventive vaccine. Many people who have been vaccinated for hepatitis A and B wrongly believe they are immune to hepatitis C.

            The most recent published global prevalence estimates of hepatitis C are from 1999 (World Health Organization, 2000). (see TABLE 1).

            Globally, the World Health Organization estimates that 169 million had hepatitis C by 1999. However, data was only available from 57 countries. Currently, there are an estimated 4,1 million people with hepatitis C in the U.S.. About 26,000 people are infected each year with this virus, as of 2004, which is down considerably from the 1980s when it was estimated to be 240,000 a year (CDC, 2007). However, because testing has never been conducted on a wide scale nationally, these figures are very tentative. Between 10,000 and 12,000 deaths each year in the U.S. are attributed to hepatitis C (Schiff & Ozden, 2004).

            Although incidence is down considerably in the U.S., this cannot be said for much of the world, especially those poorer nations where syringes are washed and reused even in clinics and hospitals, and areas with large numbers of intravenous drug users.

            The hepatitis C virus can only be transmitted blood-to-blood. When syringes are re-used, trace amounts of blood often remain. Many transmission routes are possible from cuts and open sores, shared razors and even toothbrushes. HCV is much heartier than HIV, and can live for hours outside the body.

            In jails and prisons, tattooing needles and ink are almost always contraband. Tattoo “Ink” is improvised from many sources, and is so precious that what remains after a tattoo is saved, contaminated with blood, for the next person. This is a very efficient way to transmit the virus.

 Risk Populations and Behaviors

            So, having been in jail or prison is itself a major risk factor for hepatitis C. Drunken driving, illicit drug use and other behaviors cause a high rate of incarceration for alcoholics and drug users. Other risky behaviors in prison include injection drug use,  sharing of razors, and bloody wounds from fights.

            In Arizona, 21.6% of prisoners were shown to be HCV-infected before admission (Unpublished epidemiological data, 2006). Limited data from prisons in five other states show a 17% to 41% prevalence rate. Thirty-one percent of those in state prisons are there for drug crimes, and in federal prisons it is 60%. The U.S. Centers for Disease Control (CDC) says about one-third of all those with hepatitis C in the U.S. pass through the prison system each year (Franciscus, 2001; Austin, 2007).

            Such statistics vary widely globally. One survey of eight prisons in England and Wales showed a 7% rate of hepatitis C antibodies. An estimated one-quarter of prisoners had used intravenous drugs at some time, and 6% had injected drugs in prison (Yamey, 2000). This is nearly six times the general public rate. In Canada, an estimated one-quarter of all inmates are infected with hepatitis C, and about 45% participate in tattooing.

            The news is not all bad. Unprotected sex is normally not a major risk unless it somehow involves sharing of blood (estimates are that 1-5% of HCV is sexually transmitted). Homelessness and poverty elevate risk. Among the young, unsterile piercings and amateur tattoos may elevate risk. So does inhaling powder cocaine, since shared straws often used for this collect blood from inside the nose. Pipes used to smoke crack cocaine burn very hot, and users often may have blood on lips.

            All of the mechanisms for alcoholics acquiring hepatitis C are not known, but the infection rate is still many times that of the general public. Prior drug use among those in alcohol treatment may be a greater factor than many admit. The co-founder of Alcoholics Anonymous, Bill W., acknowledged from the outset that many if its members had been through addictions to pills and needle drugs (Bill W., 1958). Substitute intoxicants are often used by those who cannot get alcohol. Those in the U.S., born between the late 1940s and early 1960s have the highest rate of ever injecting drugs,, and could be among the reasons for high infection among middle-age alcoholics today (Armstrong, 2007).

            Alcoholics and and drug dependent people have a double stigma to fight: their dependence and hepatitis C. If they are reluctant to talk about the latter, it is understandable. HCV Anonymous.Com http://www.hcvanonymous.com/ is one group that, interestingly enough, has combined 12-step principles with information on the virus and living healthy. It is not necessarily for those dependent on alcohol or drugs, however..

            Heavy alcohol consumption appears to accelerate progression from hepatitis C to cirrhosis and liver cancer. Even moderate consumption of alcohol may increase liver fibrosis and cirrhosis in HCV-positive patients. Younger heavy drinkers with HCV are more likely to develop liver cancer at a younger age, (Schiff & Ozden, 2004). (See TABLE 2)

 Prevalence Among Alcoholics

            Studies of how many alcoholics have hepatitis C are limited, but show anywhere from 14% to 43% infection rate. One study of nearly 600 homeless veterans  showed a 41% HCV infection rate. Even worse, 72% of those with HIV had hepatitis C coinfection, and those with hepatitis B had 57% coinfection (Cheung, et al, 2002). Alcohol and drug use, homelessness, and most likely blood transfusions and wounds in military service, all may have worked together to create these high numbers.

            In another study, 150 currently drinking alcoholics admitted to a detoxification center showed a 35% infection rate, and there was a significant association with prior IV drug use. However, alcoholics with no risk factors had a significantly higher rate of hepatitis C than the non-alcoholic general public control group (10 vs 0%, p >0.01). Researchers suggest that alcoholism itself, in some way, is a predisposing factor for HCV infection (Rosman, et al, 1996). Once infected, alcohol may accelerate liver damage, probably causing an “increase in viral replication; rapid mutation of HCV, leading to greater viral complexity; increased liver-cell death and inflammatory response; suppression of immune responses; accumulation of fat in the liver; and accumulation of excess iron in body tissues” (Schiff & Ozden, 2004).

            Still another study of 6354 hospital patients with diagnoses related to alcohol dependence or abuse found that 15% of these were also hepatitis C-positive. Researchers found that alcoholics with hepatitis C were nearly twice as likely to die (4.4 vs. 2.4%), and this trend towards increased mortality was true “even after adjustment for demographics, medical service, homelessness and comorbidities” (Tsui, et al, 2006) Nearly one-third of alcoholics with symptoms of liver disease have HCV (Schiff & Ozden, 2004).

 Prevalence Among Drug Users

            The infection rate among intravenous drug users is extremely high in the U.S. and much of the world. Estimates vary widely from 60% to 85% infection among all IDUs in the United States. Because of a normally long asymptomatic period for those infected, those who shared a syringe only once or twice as teenagers may not show symptoms of liver damage until their 30s or 40s – long after drug experimentation has been forgotten.

            As one researcher stated so aptly, "Anyone who has ever used injection drugs, no matter how infrequently or how remotely in the past, should be appropriately counseled and offered testing for HIV, hepatitis B, and hepatitis C” (Armstrong, 2007).

 Testing

            Considerable variation exists in the availability of hepatitis C testing, even in the United States. Those in alcohol and drug treatment and rehabilitation programs, self-help groups, therapeutic communities, detoxification centers and halfway houses constitute a special high-risk group for which hepatitis C testing is warranted.

            Currently, this test involves drawing blood, and a waiting period

for results. Many tested do not report back to learn the outcome. Fortunately, hepatitis C testing will soon become easier and faster, without need to draw blood. The new method, OraSure, makes it possible to test in remote locations outside clinics. Rapid results will help ensure that those tested remain there for the results and counseling.

            Integrating testing, counseling and referral for hepatitis C into treatment programs often cannot be accomplished overnight. Funds must be found for testing, and often administrators and funders must be convinced of the importance of this disease. For those in poorer countries, there are not yet any large international funding sources such as the Global Fund to Fight AIDS, Tuberculosis and Malaria.

 Treatment Availability

            It is very difficult to make any general statement about availability of hepatitis C treatment globally. It is quite expensive, and largely unaffordable by those in poorer countries with no universal health care. In the United States, even those who are insured are often not fully covered and may end up paying many thousands of dollars for treatment.  With AIDS drugs, public pressure and negotiation have brought down drug prices for poorer countries. Hepatitis C, however, is not yet seen as a global emergency, and there is little pressure to reduce drug prices.

            Treatment for hepatitis C is not always advisable because of different genotypes and comorbidity with other conditions. For example, people with HIV usually have to stabilize this disease, then temporarily stop using HIV drugs to start on interferon or ribavirin. The very high cost of these drugs, plus the uncertainty of treatment effectiveness, are both major obstacles. Another complicating factor in treatment is its uncertain outcome. Only an estimated 40-50% of those treated respond positively.

            One much more affordable treatment recommended for those with hepatitis C, or at high risk, is vaccination for hepatitis A and B. Health consequences from co-infections can be very serious. Hepatitis C can be especially devastating in some Asian countries where hepatitis B infection  is endemic.

 Treatment Outcomes

            Knowledge of a hepatitis C infection may itself be a strong motivator towards cessation of drinking, and intake of other drugs known to cause liver damage. However, education about treatment, causes of disease progression, and maintaining relative liver health are essential. Otherwise, many will interpret hepatitis C as a death sentence and try to drown their sorrows in alcohol, which accelerates the disease. Loguercio, et al, found that less than half of 245 alcoholics studied stopped drinking after being diagnosed with liver disease, so counseling and support for this group is vital. Alcohol adversely affects response to interferon therapy for hepatitis C by interfering with the drug’s antiviral actions, worsens liver damage and increases HCV RNA levels (Loguercio,2000; Schiff & Ozden, 2004). Alcohol appears to also adversely affect long-term response when interferon therapy is successful (Schiff & Ozden, 2004).

            Depression, fatigue and inability to tolerate injections of medications are common reasons cited for discontinuing anti-HCV drugs. Depression, irritability and anxiety appear in 20-30% of those taking interferon (Schiff & Ozden, 2004). Some decide that living with the untreated virus is preferable to severe medication side effects. This was also true in the early days of AIDS drugs, which often ravaged bodies of those already sick. To counter depression from hepatitis C medications, anti-depressant drugs are recommended to begin a month prior to interferon administration.

            Treatment adherence may suffer for those who continue drinking during hepatitis C treatment. Abstaining at least six months before, and during treatment also appears to better treatment outcomes (Schiff & Ozden, 2004). Abstaining from alcohol is a stated prerequisite of most treatment providers, though little is known about light drinking during treatment. For an alcoholic, there is no such thing as an occasional drink. With the scarcity of donated livers for transplant, non-abstainers are virtually always considered an unacceptable risk for surgery.

            It is difficult to make broad statements about the effects of various illicit drugs on those with hepatitis C. We do not have a large body of published research on this. Logically, it may be assumed that the pharmacological action of some drugs, including cannabis and opiates would have little negative effect, while drugs like methamphetamine and cocaine, used in high or frequent amounts, would heighten damage.

            The mechanisms of drug delivery, however, are another matter.  Unsterile syringes, which may have transmitted the HCV virus in the first place, may later transmit HIV or a second HCV genotype, which can greatly complicate treatment.

 
References

            Armstrong, G.L. (2007) “Injection Drug Users in the United States,
1979_2002.” Archives of Internal Medicine, 167(2):166-73

            Austin, P. (17 Mar 2007). "Prisoners' Hepatitis Threatens Public"
Press Enterprise (Riverside, CA)

            Bill W., “Problems other than alcohol.” (1958) Alcoholics Anonymous World Services.

            CBC News. (29 Mar 2004). “Tattoo parlours to open in Canadian prisons”

            Centers for Disease Control (CDC). (2007), “Viral hepatitis C fact sheet.” www.cdc.gov

            Cheung R.C., et al. (2002) Hanson AK. Maganti K. Keeffe EB. Matsui SM. Viral hepatitis and other infectious diseases in a homeless population. [Journal Article. Research Support, U.S. Gov't, Non-P.H.S.] Journal of Clinical Gastroenterology. 34(4):476-80

            Franciscus, A. (2001) “Centers for Disease Control (CDC) – Consulting Meeting on Prevention and Control of Viral Hepatitis in Prisons.” www.hcvadvocate.org/

            HCV Anonymous.Com (Web Resource)

http://www.hcvanonymous.com/

            Jager, J., et al, Hepatitis C and Injecting Drug Use: Impact, Costs and Policy Options. (2004). Lisbon: European Monitoring Center for Drugs and Drug Addiction (EMCDDA) www.emcdda.eu.int

            Loguercio, C., et al. (2000) “Drinking habits of subjects with hepatitis C virus-related chronic liver disease: prevalence and effect on clinical, virological and pathological aspects,” Alcohol & Alcoholism, 35(3):296-301

            Rosman, A.S. et al, (1996). "Alcohol is associated with hepatitis C but not hepatitis B in an urban population." American Journal of Gastroenterology, 91(3):498-505

            Schiff, E.R. & Ozden, N., “Hepatitis C and Alcohol.” (2004). National Institute on Alcohol Abuse and Alcoholism (NIAAA), Bethesda, MD. http://pubs.niaaa.nih.gov/publications/arh27_3/232_239.htm

            Wiley, T..E.; et al (1998).. “Impact of alcohol on the histological and clinical progression of hepatitis C infection.”.Hepatology 28(3):805-809.

            World Health Organization (2000), “Hepatitis C,” Fact sheet no. 164. http://www.who.int/mediacentre/factsheets/fs164/en/

            Yamey, G. (2000) “Prisoners in England and Wales are at risk of bloodborne viruses” British Medical Journal (320)1493

TABLE 1: Global HCV Prevalence 

Source: Weekly Epidemiological Record. N° 49, 10 December 1999, WHO

TABLE 2: How Drinking Accelerates Fibrosis