The Centers for Disease Control and Prevention (CDC) reported this week that the hepatitis C virus (HCV) now kills more Americans annually than HIV, the virus that causes AIDS. Most of the deaths occur in middle-aged adults — 3% of baby boomers are infected — and about half of people infected don’t know they have the virus.
Like HIV, HCV is spread through contact with contaminated blood and less commonly through sex. Hepatitis C is now the leading cause of liver transplant, but newly approved drugs can cure the disease before it gets that far — current clinical trials also suggest improvements in treatment are on the horizon — if people are screened and treated in time. Since hepatitis C typically doesn’t cause symptoms until serious damage has been done, early screening is crucial.
Healthland spoke with Dr. John Ward, who heads the CDC’s effort to fight hepatitis C, about who is at risk of infection, how the disease is really spread and why it’s important to know your hepatitis C status now.
How likely is HCV transmission during sex?
It’s a very unusual mode of transmission. That’s not to say it doesn’t happen, but it’s so infrequent that we don’t recommend condom use. [Dr. Ward is referring here to vaginal intercourse in monogamous heterosexual couples in which one partner is infected.] It hasn’t shown to be spread that way through sexual contact as a mode of transmission in the U.S.
HCV is not expressed in the secretions and body fluids people [usually] get exposed to during sex, in contrast to HIV and hepatitis B, which are found in vaginal secretions and semen.
One exception that has become a problem is among HIV-positive gay men — there, a multitude of studies has shown that HCV transmission is not only found, but is becoming more common as an STD among men who have sex with men who are HIV positive. The reason for that could be that because of their lower level of immunity, they may get higher levels of HCV in their blood or they may engage in sexual practices where there is more blood contact such as rectal intercourse. Some of them are also having a large number of sex partners.
What proportion of hepatitis C infections is due to IV drug use?
At least 50% of current cases are related to injection drug use, perhaps more as many cases are reported to the CDC without a risk [factor] identified.
HCV is much more transmissible than HIV [through blood]. The numbers of injection drug users infected are several-fold higher than the number infected with HIV because it’s so much more easily transmissible.
Needle exchange does help in preventing transmission of HCV but it’s not as effective as it is against HIV.
Is Generation X at even greater risk than baby boomers? Household survey data suggest that drug use peaked overall in the early 1980s, among Gen Xers rather than boomers.
The data I’m aware of suggest that injection drug use was more common when the boomers were in their 20s and 30s. And they were not as mindful of safe ways to inject as [people] were beginning in the ’90s because of HIV-prevention campaigns. … We’re worried now that we’re seeing increased case reports linked to drug use in people [injecting] things like Oxycontin.
What is the risk of hepatitis C associated with dialysis or blood transfusions?
The blood supply is very well protected by screening, and blood transfusions are very safe from HCV. Where [transmission] does tend to occur is in outpatient settings like dialysis clinics, but also where people are getting injections, particularly repeated injections: cancer chemotherapy and pain management are the ones that come to mind.
We see too many outbreaks of hepatitis C in health-care settings because of poor infection control. There was a large outbreak several years ago in a colonoscopy clinic. Proper infection control was not followed in that setting. It’s not so much needles being reused, it’s syringes being reused or [injectable] pain medication getting contaminated because it’s used for multiple patients.
What can you do to protect yourself in these situations?
The patient can always ask the provider, ‘Are you following good infection control practices? Has that syringe been used by another person?’ The great majority of the time [there is good infection control]. But it never hurts for patients to reinforce the message that they are concerned about safety. It’s another way of reinforcing best practices.
We have 3 million people living with HCV and they cycle through the health care system and because it’s so transmissible, when you have a lapse in infection control, that HCV is going to get transmitted.
Can hepatitis C be spread through cocaine straws or bills?
It is possible to transmit through cocaine straws — you can get blood contact that way. Some studies have related it to snorting cocaine. Also to tattooing, not in the usual tattoo parlors, but in recreational or amateur tattooing among young people or people who are incarcerated.
I understand there are new medications that make HCV much more treatable.
The benefits of screening and care have gone up in the last year with the licensing of two new drugs, which when added to the drugs previously used, result in [viral] clearance — or essentially a cure — for about 70% people treated with three-drug therapy. It has also shortened the duration of therapy from 48 to 24 weeks.
Does treatment still include interferon, which can cause the side effect of depression?
Pegylated interferon is still part of the regimen, but the other exciting aspect of HCV treatment is that the pipeline is very rich with new drugs in clinical trials. Just two weeks ago, [researchers found] an all-oral non-interferon regimen that achieved high rages of cure.
The whole concept of HCV treatment has changed in the last three to four months. It’s going from a condition that’s difficult to treat to one that’s going to be easy to treat in just the next three to four years.
Should people wait to get treated?
Some people need to be treated now because of the status of their liver disease, but it’s important for all people with HCV [to know their status] so they can understand where are they in the course of the disease and can make informed decisions, like, Can I wait? or Do I need to be treated now? And what can I do to protect my liver, such as lowering alcohol use or getting vaccinated against hepatitis B and A. The benefits of knowing your status and being in care are increasing.