This document discusses the emerging epidemic of hepatitis C virus (HCV) infection among young injection drug users. Rates of HCV have increased significantly in recent years, particularly among young white adults in non-urban areas who misuse prescription opioids and transition to injecting drugs like heroin. The prescription opioid epidemic has contributed to rising HCV cases by fueling non-medical opioid use and a subsequent rise in injection drug use. Effective prevention strategies include expanding access to syringe services programs and reducing the stigma around drug use to engage more young people in harm reduction.

1. Trending Topics Track
Emerging Epidemic: Hepatitis C
Infection among Young Persons
Who Inject Drugs
Presenter
Jon E. Zibbell, PhD, Health Scientist, Division of Viral Hepatitis,
Centers for Disease Control and Prevention
Moderator
Jinhee Lee, PharmD, CDR, Senior Public Health Advisor, Division of
Pharmacologic Therapies, Center for Substance Abuse Treatment,
SAMSHA, and Member, Rx Summit National Advisory Board
Contributor
Emily Winkelstein, MSW, Project Director, Collaborative Hepatitis
Outreach and Integrated Care Evaluation Study, National
Development and Research Institutes

2. Disclosures
• Jon E. Zibbell, PhD, and Jinhee Lee, PharmD, CDR,
have disclosed no relevant, real, or apparent
personal or professional financial relationships with
proprietary entities that produce healthcare goods
and services.
• Emily Winkelstein, MSW – Consulting fees: Prochilo
Health Inc.

3. Disclosures
• All planners/managers hereby state that they or their
spouse/life partner do not have any financial
relationships or relationships to products or devices
with any commercial interest related to the content of
this activity of any amount during the past 12 months.
• The following planners/managers have the following to
disclose:
– Kelly Clark – Employment: Publicis Touchpoint Solutions;
Consultant: Grunenthal US
– Robert DuPont – Employment: Bensinger, DuPont &
Associates-Prescription Drug Research Center
– Carla Saunders – Speaker’s bureau: Abbott Nutrition

4. Learning Objectives
1. Describe the emerging epidemic of HCV
infection among young persons.
2. Explain the association between the
emerging epidemic of HCV infections among
young persons and the Rx drug epidemic in
Appalachia.
3. Identify strategies for HCV prevention, care
and treatment for young PWID.

5. Emerging Epidemic: Hepatitis C Infection
among Young Persons Who Inject Drugs
and Misuse Prescription Opioids
Jon E. Zibbell, PhD
Centers for Disease Control and Prevention
Division of Viral Hepatitis
Prevention Research Branch

6. Learning objectives
• Describe the emerging epidemic of HCV infection
among young persons.
• Explain the association between the emerging
epidemic of HCV infections among young persons
and the Rx drug epidemic in Appalachia.
• Identify strategies for HCV prevention, care and
treatment for young PWID.

7. HCV in the United States
• 4.1 million HCVab infected persons, with 75% of these chronic infections
(3.2 million)
• The most common bloodborne infection in the United States
• HCV-related deaths doubled from 1999-2007 to over 16,000/year
• Leading cause of liver transplants and liver cancer [hepatocellular
carcinoma (HCC)]
– HCC fasting rising cause of cancer-related death
• Injection drug use (IDU) is the principle “motor” of incidence
 Approximately 2.7 million persons chronically infected [CI: 2.4—2.9]
 Estimate excludes institutionalized and homeless persons
 The most common bloodborne infection in the United States
 HCV-related deaths doubled from 1999-2007 to over 17,000/year
 Leading cause of liver transplants and liver cancer [hepatocellular
carcinoma (HCC)]
 HCC fasting rising cause of cancer-related death
 Injection drug use (IDU) is the principle driver of incidence
Denniston et al. Ann Intern Med, 2014 ; Armstrong et al. Ann Intern Med, 2006

8. Age-Adjusted Rates of Mortality: Hepatitis B,
Hepatitis C, and HIV, United States, 1999–2007*
0
1
2
3
4
5
6
7
1999 2000 2001 2002 2003 2004 2005 2006 2007
Rateper100,000Persons
Year
Hepatitis B
Hepatitis C
HIV
• In 2007, > 70% of registered deaths in HCV-infected were aged
45-64 years old
*Ly et al. The increasing burden of mortality from viral hepatitis in the United States between 1999 and 2007. Ann Intern
Med. 2012, June 5: 156(4):271-8

9. HCV Cases from Injection Drug Use
• IDU most reported risk factor for acute infections
• Anti-HCV prevalence among persons who inject
drugs (PWID) between 30% and 70%
• Anti-HCV prevalence among younger (<30 yrs)
between 10% and 36%
• HCV incidence between 16% and 42% per year
Hagan et al. 2010; Garfein et al. 1998; Armstrong et al. 2006; Amon et al. 2008; Klevens et al. 2013; Daniels et al. 2007

10. Needles and Syringes
Fixed and Detachable

11. Preparation Equipment
11
Filters Cookers
Water
Surfaces

12. Increases in New HCV Infections
 50% increase in national reporting
 200% increase in 17 states
 Recent studies show
 ~70% report IDU
 Ages 18 to 29 years
 Predominantly white
 Equally female and male
 Non-urban and urban
Antecedent prescription opioid
misuse among PWID
Source: CDC/hepatitis.gov; MMWR 2011; MMWR 2014; CDC unpublished data.
2007-2012

14. Injection Behavior and Drugs Used by Persons 18-29
Years of Age with Acute HCV Infection
• 1202 cases of acute HCV investigated
– 52% female
– 85% white
– 77% persons injected drugs
o 57% shared needles/syringes
o 82% shared equipment
• Percent use and mean age of drug use initiation
- Powder cocaine: 71%,: 17.4 yrs.
- Prescription opioids 76% : 17.9 yrs.
- Heroin: 61%: 19.7 yrs.
Suryaprasad et al., CID, 2014

15. Changing Demographics of HCV Incidence
• During 1990s anti-HCV prevalence was higher among men,
Black Americans, urban residents and persons 40-49 years
aged.
• New cases largely involve males and females equally; mostly
white, rural and suburban residents; persons 18-29 years
aged.
• Key difference: prescription opioid misuse

16. Prescription Opioids Distributed*
(kilograms of opioid analgesics prescribed per 10,000 persons)
*Drug Enforcement Agency, 2010, Automation of Reports and Consolidated Orders System (ARCOS)

18. MMWR, 4 November 2011

19. 0
5
10
15
20
25
30
35
40
2006 2007 2008 2009 2010 2011 2012
ProportionofAllAdmissions
Any Opioid
Admissions
Any Opioid
Admissions < 30
Prescription Opioid
Admissions
Prescription Opioid
Admissions < 30
National Drug Treatment Admissions: All ages vs. <30
*SAMHSA, TEDS—A; Preliminary analysis

20. Opioid deaths, sales, and treatment admissions have increased
in lock step
National Vital Statistics System, DEA’s Automation of Reports and Consolidated Orders System, SAMHSA’s TEDS: National Center for Injury Prevention and Control
0
1
2
3
4
5
6
7
8
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Opioid Sales (kg per 10k)
Opioid Deaths (per 100k)
Opioid Treatment Admissions (per 10k)

21. 0
4
8
12
16
20
2006 2007 2008 2009 2010 2011 2012
ProportionofAllAdmissions
Any Opioid Injection
Any Opioid Injection <30
Other Drug Injection
Other Drug Injection <30
National Drug Injection Trends: All ages vs. <30*
*SAMHSA, TEDS—A; Preliminary analysis

22. National Acute HCV Cases (2006—2013)
Suryaprasad et al., CID, 2014

23. Multivariate Associations with anti-HCV positivity‡
5.53
3.79
0 2 4 6 8 10 12 14 16
Inject prescription opioid
Share equipment*
† p-value <0.05
1
*Equipment sharing, injecting prescription opiate , fishing for a vein, and using an SEP
are all measured for within the past 12 months. Prescription opiates respondents reported injecting Opana (n=58), Oxycontin
(n=21), Dilaudid (n=7), Roxycontin (n=3), Morphine (n=4); Vicodin (n=1), Percocet (n=1) (categories not mutually exclusive)
‡ Zibbell et al., AJPH, 2014

24. Heroin use and dependence
is also increasing
SAMHSA, NSDUH, 2012, National Center for Injury Prevention and Control
0
500
1,000
1,500
2,000
2,500
2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Estimated#ofpersons12yearsandolderreporting
abuse/dependence
(inthousands)
214K
467K
>2 million
Heroin
Opioids

25. Special Thanks:
Departments of Health: KY; TN; VA; WV
Rachel Hart-Malloy, PhD, MPH
Scott Holmberg, MD
Deborah Holtzman, PhD
Kashif Iqbal, MPH
Brian Manns, PHARM-D
Rajiv Patel, MPH
Anil Suryprasad, MD, MPH
Claudia Vellozzi, MD, MPH
John Ward, MD

26. Emily Winkelstein, MSW
National Development and Research Institutes (NDRI)
New York, NY

27. Learning objectives
• Describe the emerging epidemic of HCV
infection among young persons.
• Explain the association between the emerging
epidemic of HCV infections among young
persons and the Rx drug epidemic in
Appalachia.
• Identify strategies for HCV prevention, care
and treatment for young PWID.

28. Overview
• Offer insight from personal practice
experience
• Share feedback given from younger clients
and peers
• Provide context within a harm reduction
framework
• Explore the role of drug-related stigma

29. What is Harm Reduction?
• A philosophy
• A service delivery model
• A proven effective public health strategy that
reduces harm to people who use drugs and
struggle with related issues
– Includes and embraces abstinence, but does not
assume or require cessation of use
• A social justice and human rights movement
Harm Reduction Coalition, harmreduction.org

30. Basic Principles of Harm Reduction
• Sometimes people engage in behaviors that are
harmful to themselves or others.
• People may engage in these behaviors even if
they know they’re harmful, illegal, unhealthy, or
cause harm to others.
• However, people may be willing and able to
make some changes to decrease the risk of harm
to themselves and their community.
• “Any positive change”

31. Harm Reduction
• Harm reduction doesn’t promote, encourage
or require active drug use
• Drug use can be very harmful – and – we have
to be cautious in assuming or defining harm.
• We do not have control over outcomes or
behaviors – but we can influence process and
provide education
• People may still make unhealthy choices

32. The Problem
• Prescription opioid misuse among youth is high
– white, young adults, non-urban
• Non-medical use of prescription opioids increases
likelihood of transition to injection/heroin use
– Sequelae: increased ER visits, dependence, overdose,
infectious disease; endocarditis; abscesses
• Several recent HCV outbreaks reported
– MA, NY, KY, WI, VA, PA, FL and IN (w/HIV)
• Supply-side strategies alone are insufficient
CDC; DHHS; Cicero 2014; Jones 2013; Hagan 2008; Keyes 2014; Page 2013; Peavy 2012; Arman 2008

33. Differences between HIV and HCV
• HCV is currently more prevalent than HIV
– More people test HCV AB positive
– HCV causing more deaths than HIV
• HCV replicates faster and thus more infectious than HIV
– HCV remains viable for long periods of time outside of the
host, increasing number of transmission fomites
– Results in high viral loads (i.e. there is a lot of virus in per
measure of blood)
• HCV is less likely to be sexually transmitted
• SEPs not as effective reducing HCV incidence compared
to HIV
CDC; Ly 2012; Wicker 2008

34. Lessons from HIV
• HIV rates have fallen dramatically
– PWID account for 8% of new HIV infections v. 55%
in 1990
• Syringe access programs were incredibly
valuable in this effort
• Early HIV messages failed to include
information about risk from ancillary injection
equipment
• Education was widespread, specific,
targeted
CDC; Des Jarlais 2005

35. Urban vs. Non-Urban (Rural, Suburban)
• Higher rates of prescription opioid injection
• Transition to injection may happen earlier
• Less access to harm reduction resources
• Less access to primary and specialized medical care
• Less access to drug treatment, including methadone
and buprenorphine
• Confidentiality and disclosure issues (small, insular
communities)
• High poverty/unemployment rates, lower education
• Less research on effective prevention and treatment
strategies in rural areas
Christian et al 2010; Keyes 2014; Havens et al, 2011; Young et al 2012

36. Influences on Injection-related Risk
• Who
– Number of injection partners; Control over injection; Control
over drug preparation; Power dynamics
• What
– Drug of choice; Formulation; Injection equipment
• Where
– Injection spaces; Privacy; Proximity to services/equipment; Vein
health and location
• When
– Adequate time; Frequency of injection
• Why
– Recreation v. dependence; Trauma; Boredom; Fatalistic
Worldview; Lack of hope for future

37. Why Engage Youth?
• Large numbers of youth are using Rx opioids & heroin
– Enforcement and supply-side strategies alone will not work
for everyone
– Harm reduction and engagement are necessary to reduce
negative consequences of the epidemic
• Youth can and will engage in healthier behaviors when
offered information/tools and treated with respect
• There is a finite window of opportunity to prevent HCV
transmission
– 32% PWID become HCV-infected within 1 year of injecting
– 53% become infected within 5 years
– New injectors develop routines/rituals/patterns
Hagan et al. 2008; Paterson 2008; Raymond 2015

38. Youth
• Isolation from services and medical care; fear
and mistrust
• Invincibility; Haven’t “hit bottom”
• Lack of specific education and knowledge
• Lack of historical memory (e.g. AIDS epidemic)
• Social network issues – Injection patterns,
serosorting, partner roles
• Engagement: Living at home vs. street
involved

39. The Players
• Young people (>12 years of age)
• People who use drugs
– Anyone who experiences an accidental, non-fatal drug
overdose
• Family, friends and partners
• Educators
• Pharmacists
• Healthcare providers
• Community-based organizations
• Houses of worship
• Law enforcement
• Drug sellers

40. Strategies for Engaging Youth
• Meet people where they are – literally and
figuratively
• Keep access low-threshold
• Offer things that people need
• Provide information and tools – not directives,
ultimatums, demands
• Recruit ambassadors/peers
• Be consistent
• Be respectful
• Honor autonomy

41. Meeting People Where They Are
• Schools
• Hangouts (bars, parks, local spots, etc.)
• Medical centers (testing sites, free clinics, VA)
• Pharmacies
• Community-based organizations
• Jails and other state institutions
• Drug treatment facilities
• Mental health centers
• Trauma centers
• Social media

42. Engagement
• Every interaction has the potential to build
trust or diminish it
• Every interaction has the potential reinforce
stigma or challenge it
• Every interaction has the potential to increase
dialogue or shut it down
• Every interaction has the potential to increase
health – baby steps are important

43. Role of Stigma in Perpetuating Risk
• Often decreases willingness to access care and
services
• Erodes relationships and trust
• Can increase patient risk and make healthy
choices less likely
– Fear of disclosure, increased isolation
• Can decrease patient sense of self-worth
– Guilt, shame, self-blame, weakness

44. Syringe Access
• Syringe access programs are critical to engagement
of PWID
– Cost effective, link people to treatment and prevention
services, promote public safety, and reduce health
disparities
– Insufficient access, especially in non-urban areas
– Federal ban on funding of syringe access programs
• Secondary and peer distribution
• Over-the-counter pharmacy access
• Physician prescribing (e.g. buprenorphine docs)
amfAR, 2013

45. Drug Treatment
• Abstinence-based and medicated-assisted therapy
• Young people may not know their options
– More options are needed
– Learn what options are available in your area
• Youth-centered drug treatment is important
• Managed or moderated use are important options
– Alternate routes of use; taking breaks; order of use
• Opioid agonist therapy is highly effective, but not
widely available in non-urban areas
– Methadone, buprenorphine (Suboxone®)
• Confidentiality is needed; parental and family
involvement adds complications
Nolan, 2014

46. Linkage to HCV Testing and Care
• Increased testing is needed; reflex testing
– Testing is a link to engagement, education and
behavioral change
• Offer at Community Health Centers, STI clinics,
syringe access programs, methadone clinics,
buprenorphine docs, correctional facilities
• Increase testing in areas where prescription
opioid misuse is endemic
• Offer incentives for testing in resource-deprived
areas
• Co-localize HCV treatment with drug treatment
settings (SAMHSA and DVH)

47. Role of HCV Treatment
• Traditionally, PWID have had limited access to
HCV treatment
• Treatment restrictions/abstinence requirements
for illicit drug use in most states
• Recent advances in HCV antiviral therapy
– Easy to tolerate
– 95-100% effective, simpler monitoring
– Short duration (8-12 weeks)
• Treatment as prevention
– Minimize transmission within networks
• Treatment as an opportunity for engagement
and ongoing prevention education

48. Thank you!
Emily Winkelstein, MSW
winkelstein@ndri.org
(212) 845-4414

49. Trending Topics Track
Emerging Epidemic: Hepatitis C
Infection among Young Persons
Who Inject Drugs
Presenter
Jon E. Zibbell, PhD, Health Scientist, Division of Viral Hepatitis,
Centers for Disease Control and Prevention
Moderator
Jinhee Lee, PharmD, CDR, Senior Public Health Advisor, Division of
Pharmacologic Therapies, Center for Substance Abuse Treatment,
SAMSHA, and Member, Rx Summit National Advisory Board
With Appreciation To
Emily Winkelstein, MSW, Project Director, Collaborative Hepatitis
Outreach and Integrated Care Evaluation Study, National
Development and Research Institutes