The Opioid Epidemic and Infectious Diseases: A Public Health Crisis
Presented by Sally Lynn Hodder, West Virginia University, Morgantown, USA
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Sally discussed the relationship between substance use and infectious diseases.
More people die from opioid overdose each year in the US compared to those that died from HIV/AIDS in the height of its epidemic.
Drug overdose deaths are increasing in United States from 1999 to 2016:
The regions where drug overdose mortality rates are high match the regions where people live in poverty, particularly in the western parts of United States.
Sally spoke about high rates of opioid prescribing in West Virginia and the associated markers of low socioeconomic and poor health markers.
Rates of acute hepatitis C have been increasing since 2009 in the United States. Most of the growth is in the 20-29 yrs age cohort.
Sally spoke about vertical transmission of hepatitis C and the lack of safety data of direct acting antivirals in pregnant women, and the consequent risks of HCV transmission to the child.
Sally described the matching regions in West Virginia with high rates of opioid overdose and acute hepatitis C infections.
There is a Medicaid (Federal US) program for hepatitis C treatment in the region but it is limited to fibrosis score >F2, substance use/drug-free >3months, and specialist consultation required. Hence, it is difficult for the target population to qualify to receive treatment.
HIV infections associated with injecting drug use has been rising in the US since 2011.
MMWR recently reported an HIV outbreak in West Virginia, with at least 14% associated with injecting drug use:
There has also been increasing rates of acute hepatitis B since 2010 in US. Sally reminded us of the need of widespread hepatitis B vaccination programs.
There have been increases in infections associated with injecting drug use - infective endocarditis, septic arthritis, osteomyelitis, and epidural abscess
- Opioid Substitution therapy:
- Greater research for newer and better treatments for opioid use disorder.
- Enhance harm reduction programs:
- Social enterprise and social reintegration - jobs for people, hope for people, economic development - partnerships required
- Collaboration of Drug and Alcohol programs, Infectious Disease treatment, Justice/drug-diversion programs.
Global Elimination of Hepatitis C
Presented by Jordan J Feld, Toronto General Hospital, Toronto, Canada
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Jordan discussed the differences between eradication, elimination and control, in reference to hepatitis C infection.
WHO has targets for hepatitis C testing from 20% to 90% and hepatitis C treatment from 7% to 80% from 2015 - 2030. An ambitious control target.
Various approaches to Elimination: Global elimination vs National/Regional elimination vs Micro-elimination (ie HIV/HCV, haemophilia, prisoners). 'Think Global, Act Local’
Global burden of HCV:
Jordan discussed that many countries around the world don’t have data on hepatitis C prevalence. This makes it hard to design models of Hepatitis C elimination without good data.
Challenges to overcome: The cascade of care in hepatitis C. In the interferon-era most people didn’t engage in care. Since treatment has improved, there are still major gaps in the cascade of care. Since the introduction of better treatment, there have been increases in sustained virologic response, but not necessarily in testing and engagement in care. There needs to be greater focus on screening and engagement in care.
Australia is leading the way to treating hepatitis C, but it is getting harder to treat those who are hard-to-find and hence more difficult to cure:
Jordan discussed the multiple steps (up to 6) to get a diagnosis and start DAA therapy. For hard-to-reach populations HCV is not necessarily their greatest priority.
In the US there has been some laboratory reflex testing for HCV RNA testing for those that come back HCV antibody positive. Jordan also discussed saliva or blood rapid antibody testing, point of care RNA testing and Dried Blood Spot (in low income countries).
"Ideally - finger prick, treatment, finger prick to confirm treatment cure” i.e. simplifying testing and treatment for hepatitis C.
Jordan discussed that task shifting is critical from a specialist setting to Primary care, Addiction Medicine, and Nurse-led care.
Jordan showed the SVR rates are no different depending on the type of prescriber:
Jordan discussed linkage programs via telehealth from primary care providers to specialist services to assist in the treatment of hepatitis C.
Jordan discussed the barriers to elimination - including stringent eligibility criteria (excluding those who continue to use substances) and the lack of science behind them.
Prevention is also important. For high income countries, there needs to be good Needle and Syringe and Opioid Substitution Therapy Programs.
It is cost-effective to treat people who inject drugs even with reinfection unless prevalence is very high.
The 'Holy Grail' is a vaccine for hepatitis C for the purposes of creating sterile immunity and increasing clearance rate, which is likely needed for a true eradication for hepatitis C. There is some preliminary research underway.
Here are the countries on track to reach elimination:
Despite massive scale up of hepatitis C treatment uptake, unfortunately it has had a very limited overall global effect on hepatitis C prevalence.
Jordan called for harnessing political will and civil society for successful elimination. He discussed some problems in the models of care in some countries:
HCV elimination/control is possible, but HCV eradication not likely possible yet.
Elimination will require:
- improved screening and simplified diagnostics
- improved linkage and novel, simplified models of care
- expanded treatment access…for all
- prevention - safe needles, harm reduction
All of this will require political will and active advocacy from civil society. The WHO is leading the way…model countries as an example to the rest of the world (Australia, Georgia, Egypt).
There is still a lot of work to go.
CROI ASHM Scholar, Bijay Pandey, asked a question about reflex testing of HCV RNA when HCV Antibody is positive, in his rural patient population that has a high incidence of injecting substance use. The presenter, Jordan, agreed that in high prevalence populations, it is effective and sensible to directly screen using HCV RNA without completing initial HCV antibody testing, to simplify the steps to treatment.