The prioritization of COVID-19 treatment and pandemic restrictions, particularly during virus peaks here in the United States, interrupted all aspects of traditional medical care, from routine check-ups to elective surgeries. Many of us experienced the impact firsthand. This loss of services has included access to drugs and screenings. Among them are antiretrovirals for HIV and testing for hepatitis C (HCV)—a viral infection of the liver that affects about 2.4 million people living in the U.S. (according to some estimates, the actual number may be as high as 4.7 million).
According to research findings published by Boston Medical Center in December 2020, in-person medical visits were dramatically reduced during the pandemic. This resulted in a decrease of HCV testing by 50% in that hospital, as well as a reduction of novel HCV diagnoses there by 60%.
But those lower diagnosis rates have not correlated to fewer HCV transmissions—they have simply meant that new cases weren’t being tracked. That’s alarming news, particularly when one considers that drug use—a leading risk factor for HCV transmission—increased during the pandemic.
More Substance Use, Fewer Substance-Use Services
The Centers for Disease Control and Prevention (CDC) has stated that 13% of Americans reported that they started or increased substance use, including injection drug use, to cope with the pandemic. Thus far, this has resulted in 81,000 drug-overdose deaths for the year ending in May 2020, compared to 70,630 such deaths in 2019.
Conversely, even as intravenous drug use in particular has risen, 43% of syringe services programs across the U.S. have had to cut back on the services they offer. And 25% of programs were forced to close one or more of their sites due to constraints brought on or exacerbated by the pandemic.
Studies have shown a link between such cutbacks and closures and desperate measures taken by people who inject drugs. For instance, a brief article published by the International Journal of Drug Policy in July 2020 determined that reducing access to sterile-needle injections would lead to repeated and shared use of injecting equipment, resulting in an increased risk for invasive bacterial and viral infections.
A notable consequence of reduced needle-exchange programs is occurring in Kanawha County, West Virginia, where an HIV outbreak that is believed to have started in 2018 with just two cases has been linked directly to the local government’s decision to eliminate those services. That policy decision contributed to the locale’s 35 novel HIV diagnoses related to injection drug use in 2020, compared to fewer than five per year before 2019. For context, 64.2% of HIV diagnoses were linked to intravenous drug use in 2019, compared to 12.5% in 2014. Meanwhile, New York City—which has a population of more than 8 million people—reported 36 HIV cases linked to intravenous drug use in 2019.
Ten Times More Infectious Than HIV
The Kanawha County example illustrates what happens when access to safe needle injections is impeded for people who use drugs. It stands to reason that reduced testing and treatment for HCV will prove equally disastrous for public health. This is especially striking when one considers that HCV is 10 times more infectious than HIV through blood-to-blood contact, kills more people in the U.S. than HIV—and any other infectious disease besides COVID-19—and is the leading cause of chronic liver disease in the U.S.
Additionally, from the perspective of safe needle exchanges, the CDC states that these days, most HCV infections occur “by sharing needles, syringes, or any other equipment used to prepare and inject drugs.”
Since 2012, the CDC has recommended that all baby boomers be screened for the virus because testing for it has only been available since 1990. Even with this suggestion in place, about 45% of all adults living with HCV are aware of their status, while most people with acute infections develop chronic infections that can potentially result in life-threatening complications like cirrhosis and chronic liver disease.
One of the more puzzling aspects of HCV is that 80% of acute infections are asymptomatic, and most people who go on to develop liver disease notice symptoms only after it has caused extensive damage. For this reason, HCV is known among medical professionals as “the silent killer.”
The Case for Scaled-Up Screening and Cure Access
For people who have tested positive for HCV and have chronic illness, curative treatments—direct-acting antivirals (DAAs)—now exist. Still, with costs as high as $1,000 a pill and $84,000 for a full 12-week regimen, access remains limited. Many insurance plans only cover part of that treatment, with some rejecting it outright.
Despite cost barriers, recent studies have found that when screening and treatment are streamlined, HCV can be readily and rapidly cured. One such study conducted between March 2018 and January 2019 at 13 local health centers in rural Cambodia found that by reducing unnecessary steps and bureaucracy during the care process, the rate of success for diagnosis, treatment, retention, and cures increased.
The study, published in The Lancet in March, identified 540 people who were living with HCV out of 10,425 screened residents. Over the course of the study, 533 of these individuals living with HCV participated in simple medical consultations about their status, while 530 began treatment, and 515 completed treatment. Of those individuals who completed treatment, 466 participated in medical follow-ups, and of those, 459 attained a confirmed undetectable status for HCV 12 weeks after finishing the treatment (which, unlike with HIV, means they were cured).
Additionally, a study published last fall in the Journal of the American Medical Association (JAMA) suggested that HCV screening for people who inject drugs could be a cost-effective method for combating related infections. The study indicated that increased intervention and testing could potentially decrease the risk of liver disease–related deaths.
Considering the great cost that HCV wreaks upon public and financial health throughout the U.S., increasing testing and access to treatment for HCV is in the interest of everyone across the country. Particularly as the nation comes to terms with its opioid pandemic, eliminating the staggering debt that preventable-though-deadly infections inflict upon the health care system is essential.
Beyond the financial argument, saving the lives of millions of people from a silent death is the right thing to do—regardless of whether they are military veterans or people who inject drugs.