Despite their increased risk, only one-third of adolescents and young adults with known opioid use disorder (OUD) were screened for hepatitis C, according to a study released at the IDWeek conference in San Francisco. Furthermore, of those screened for hepatitis C, only 11% were also screened for HIV.
"We're missing an opportunity to identify and treat young people who are at risk for this deadly infection," said Rachel L. Epstein, M.D., M.A., the study's lead author and a post-graduate research fellow with Boston Medical Center. "Screening for OUD and other drug use, and then testing for hepatitis C in those at high risk, can help us do a better job of eliminating this serious infection, especially now that very effective hepatitis C medications are approved for teenagers."
The study was conducted by analyzing 269,124 electronic medical records of teens and young adults ages 13-21 from 57 federally qualified health centers across the U.S. from 2012 to 2017. Of the 875 young people who were diagnosed with OUD, only 36% were tested for hepatitis C. Of those who received screening, 11% had been exposed to hepatitis C.
The researchers also found that of those screened for hepatitis C, only 11% were also screened for HIV. Despite the explosion of HIV and hepatitis C cases linked to opioid use among people in places such as Scott County, Indiana, and in Massachusetts, these data suggest that providers may not be screening enough young people for either disease. Furthermore, Epstein reported in a press conference that black and Latinx youth were more likely to be screened for hepatitis C, although they were less likely to be using opioids, suggesting that providers potentially wrongly considered white youth to be less at risk.
"The issue is complicated by the fact that not enough at-risk youth are screened for opioid or other drug use for a variety of reasons, including lack of time, comfort level between clinician and patient, and privacy and stigma concerns," said Epstein. "And even when drug use is identified, there's a belief that youth are less likely to test positive for hepatitis C, which isn't necessarily the case as we show in our study. Clearly, this is an overlooked group that is at high risk."
While the reasons for the lack of screening are unclear, one was raised by Donna Futterman, M.D., director of the Adolescent AIDS Program, Children's Hospital at Montefiore (a mentor to Epstein who sat in on the presentation). She noted that the lack of hepatitis C screening guidelines for young people can be a double edged sword. In New York state, young people can be screened for hepatitis C without written or verbal consent, which has increased the detection of hepatitis among them at Montefiore. However, in other states or with other providers, without federal guidance from the Centers for Disease Control and Prevention or state public health department guidance, providers may be unaware of the risk of hepatitis C in young people, as well as having nothing to refer to for protocols.
Also, the media focus on prescription pill forms of opioids may lead clinicians to assume that young people are not injecting heroin or other opioids using syringes they're sharing with other users -- which most people consider the highest risk factor for drug-related hepatitis transmission. Nevertheless, hepatitis C is also transmitted through sex, so even for young people who are not injecting drugs, prescription opioid use may still come with both hepatitis C and HIV risk.
"What we learned in HIV is that any drug that substantially changes your behavior can increase your risk for HIV," said Futterman. "So crack was not injected, but crack became a stronger risk factor for HIV than any other drug that was used," she added.
Opioid use has been much in the news lately, as harm reduction advocates, physicians, and politicians struggle to find solutions. But much like syringe-access programs, some solutions are fraught with the politics of elected officials not wanting to appear to condone illegal drug use, and they can block solutions that reduce associated health risks. Advocates in cities and states are still fighting to have government funding for syringe access programs, and more recently, a fight for publicly supported safe injection sites has been waged across the country. California Governor Jerry Brown rejected a proposal to implement safe injection sites across that state, while former Pennsylvania Governor Ed Rendell announced that he was supporting a safe injection site plan for Philadelphia. And, despite a largely dysfunctional Congress, the Senate has passed a bill by a near-unanimous vote to create more funding streams for addiction and overdose treatment through a new grant program and the lifting of restrictions on Medicaid. President Trump is expected to sign the bill into law.
"As the opioid overdose epidemic rages on with no abatement in sight, we must take every advantage we're afforded to engage with people who use drugs," said Monique Tula, executive director of Harm Reduction Coalition. "Routine HIV and [hepatitis C] screening for people who disclose they use opioids is a simple and effective way to open up a discussion about potential risk, including transmission of chronic diseases and vulnerability for fatal overdoses. At its best, assuming people have all the information they need to make healthy choices is tantamount to neglect, and at its worst contributes to their harm."