Hepatitis C Virus–HIV Coinfection in the United States Among People Who Inject Drugs: Data Needed for Ending Dual Epidemics

Abstract

The overlapping epidemics of hepatitis C virus (HCV) and HIV infection stem from underlying behaviors and health disparities among disproportionately affected populations, especially people who inject drugs (PWID). Characterizing the prevalence of HCV–HIV coinfection offers improved data to address these underlying determinants of health. We performed a literature search for articles that describe US populations, were published during 2005-2021, and summarized evidence of the prevalence of HCV infection in recent HIV clusters and outbreaks among PWID. In population- and community-based studies, HCV antibody prevalence among PWID with HIV ranged from 10.7% to 71.4%, depending on the setting and study design. HCV–HIV coinfection ranged from 70% to 94% among 5 larger HIV clusters or outbreaks among PWID during 2014-2021; where characterized, HCV diagnosis preceded HIV detection by a median of 4 to 5 years. Robust modernized surveillance is needed to support and measure the progress of city, state, and national activities for ending the HIV epidemic and eliminating hepatitis C. Developing and leveraging surveillance systems can identify missed opportunities for prevention, evaluate care, and build capacity for outbreak investigation. In addition, improved data on injection drug use are crucial to inform efforts for improved HCV and HIV testing, prevention, and treatment in settings that serve PWID. By providing data in a wholistic, integrated manner, public health surveillance programs can support efforts to overcome inefficiencies of disease-specific silos, accelerate delivery of preventive and clinical services, and address the excess disease burden and health disparities associated with HCV–HIV coinfection.

Keywords

HCV HIV coinfection people who inject drugs (PWID)syringe service program (SSP)medication for opioid use disorder (MOUD)syndemic

Syndemics can occur when diseases, social determinants of health, and disparities overlap, concentrate in populations, and interact synergistically to produce excess morbidity.¹ The epidemics of viral hepatitis, HIV, and sexually transmitted disease in the United States intersect with long-standing disparities and poor health outcomes among disproportionately affected populations: people who inject drugs (PWID), people experiencing homelessness, sexual and gender minority groups, and people with a history of incarceration. Understanding and addressing these interactions concurrently, rather than through disease-specific approaches, is crucial for successful disease elimination efforts.

In 2018, the prevalence of current injection drug use (IDU) was estimated at 1.5% of the US population, representing nearly 3.7 million people,² a 4-fold increase from 2011 estimates.³ The number of overdose deaths steadily increased during the past 2 decades⁴ and rose 46% from 2019 through 2021, when the estimated number surpassed 100 000 for the first time.⁵ Rates of acute hepatitis C virus (HCV) infection, for which IDU is the primary reported risk, increased >400% from 2010 to 2020, with 66 700 estimated infections in 2020.⁶ The number of new HCV infections has been highest in US regions most affected by the opioid crisis, particularly the central Appalachian region (Kentucky, Tennessee, Virginia, and West Virginia), although similar increases in IDU and HCV infection have been documented in states such as Massachusetts, Wisconsin, and New York.^7
-12 Approximately 2.2 million civilian, noninstitutionalized adults had HCV infection in the United States during January 2017–March 2020.^13
-16 From 2015 through 2019, at least 7 HIV outbreaks among PWID were identified in the United States.^17,18 At the end of 2019, an estimated 1.1 million people in the United States had diagnosed HIV infection, with recent increases in the number of new HIV diagnoses among PWID. IDU (including IDU and male-to-male sexual contact) was reported among 11% of new HIV diagnoses in 2019.¹⁹

Hepatitis C is one of the primary causes of chronic liver disease in the United States,²⁰ and the American Association for the Study of Liver Diseases/Infectious Diseases Society of America joint guidelines recommend that all people with hepatitis C receive curative treatment.²¹ HCV-related liver injury progresses more rapidly among people who are coinfected with HIV than among other populations, with accelerated rates of progression to cirrhosis, end-stage liver disease, hepatocellular carcinoma,^22
-27 and death.²⁸

In addition to being at increased risk for HIV and hepatitis C, PWID are at increased risk for serious invasive bacterial and fungal infections,²⁹ hepatitis A,^30
-32 hepatitis B,^33,34 and other sexually transmitted infections, such as syphilis,^35
-37 because of unsafe injection behaviors, condomless sexual practices, and limited access to sanitation, which is sometimes associated with homelessness and unstable housing.^31,32,38 A substantial unmet need exists for integrated treatment of IDU-associated infectious diseases and substance use disorders.^39,40 The prevalence of HCV–HIV coinfection among PWID highlights the urgent need for improved data to inform interventions, including comprehensive syringe service programs (SSPs) and substance use disorder treatment, that address the underlying behaviors and health disparities.

The US Viral Hepatitis National Strategic Plan: A Roadmap to Elimination set forth goals for the elimination of viral hepatitis as a public health threat, including prevention of new infections and improvement of viral hepatitis–related health outcomes and health equity.⁴¹ In addition to promoting testing and linkage to hepatitis C care and treatment, current strategies for hepatitis C elimination include substance use disorder treatment, improving hepatitis A and B vaccination coverage, and providing access to evidence-based care—including medication for opioid use disorder—in correctional facilities and SSPs.^40,42,43 Underpinning the success of this roadmap is the need to improve viral hepatitis surveillance and data use to bolster data collection and reporting, enhance sharing and use of clinical viral hepatitis data, and conduct routine analysis of data for public health action. Many of these strategies are critical to the Ending the HIV Epidemic initiative, which also consists of goals for improving surveillance, reducing disparities, and improving preventive services for disproportionately affected populations, including PWID.^44,45

Here, we describe the overlapping epidemics of HCV and HIV infection in the United States with a focus on PWID, who are particularly vulnerable to infection. We reviewed data to summarize estimates of HCV–HIV coinfection prevalence among PWID and discuss gaps in data needed to support efforts to end the HCV and HIV epidemics in this population.⁴¹

Methods

We identified articles on HCV–HIV coinfection by conducting the following PubMed searches on January 22, 2022, restricted to articles written after January 1, 2005, in English that involved humans: “HIV HCV coinfection,” “hepatitis C prevalence among people living with HIV,” “hepatitis C, HIV, match, coinfection,” and “HIV, hepatitis C, registry.” After reviewing 3213 abstracts, we excluded articles that described non–US populations or did not report on coinfection prevalence, resulting in 103 abstracts for further consideration. Review of these articles resulted in additional exclusion of articles that did not include primary data on coinfection prevalence or were health care setting–based studies for which the denominator could not be clearly ascertained. We abstracted data from the 36 references that met criteria for inclusion (eTable in Supplemental Material).^46
-83

We selected additional studies that reported coinfection prevalence among PWID that were known to the authors but were not identified in the literature search.^84
-88 These studies included articles that summarized the prevalence of HCV infection in HIV clusters and outbreaks among PWID reported to CDC through 2021 or articles that were summarized in a recently published CDC literature review for 2000-2020,^17,89
-99 where the denominator for HCV infection prevalence was clearly described.

Results

Health Department Jurisdiction Surveillance Registry Cross-Match Studies

We identified 9 population-based health jurisdiction surveillance registry cross-match studies that met the criteria for inclusion (Table 1),^46
-52,84,85 but we omitted 1 study that was limited to HIV registry cases that excluded PWID.⁴⁹ The 8 studies described regional rates of HCV antibody prevalence among PWID with HIV (10.7%-36.1%) that were generally higher than the prevalence rates among all people with HIV (4.4%-23.6%). Rates of HCV–HIV coinfection among people with HCV antibodies ranged from 0% to 11.3%. Among all HIV registry cases, the prevalence of coinfection (defined as the presence of HCV antibody and HIV infection) was higher among those reporting IDU (10.7%-36.1%) than among those not reporting IDU (3.3%-5.1%).^{46,47,51,52,85} Similarly, the prevalence of reported IDU among people with HCV–HIV coinfection (19.1%-70.8%) was higher than among those with HIV monoinfection (3.0%-18.8%).

Table 1.

Prevalence of HCV infection, HIV infection, and HCV–HIV coinfection^a among PWID in health department jurisdiction surveillance registry cross-match studies,^b 2005-2021

Author	Health department jurisdiction (registry no.)	Year	HIV prevalence among people with HCV antibody, %	HCV antibody prevalence among people with diagnosed HIV, %	HCV antibody prevalence among PWID with diagnosed HIV, %	No. of people in HIV registry with or without HCV antibody	Reported HIV transmission category, no. (%)
Author	Health department jurisdiction (registry no.)	Year	HIV prevalence among people with HCV antibody, %	HCV antibody prevalence among people with diagnosed HIV, %	HCV antibody prevalence among PWID with diagnosed HIV, %	No. of people in HIV registry with or without HCV antibody	IDU, including IDU and MMSC	MMSC	Heterosexual contact	Other or unknown
Bosh et al^46,c	15 states and 2 cities^c (HCV registry: 1 093 050; HIV registry: 504 397)	Registry initiation^c in 2014	4.3 (range, 0-11.3)	6.7 (range, 0.2-13.3)	22.3	Coinfection (n = 33 993)	17 207 (50.6) (includes 4330 [12.7] IDU and MMSC)	8543 (25.1)	4147 (12.2)	4096 (12.0)
Bosh et al^46,c		Registry initiation^c in 2014	4.3 (range, 0-11.3)	6.7 (range, 0.2-13.3)	22.3	Monoinfection (n = 470 404)	59 991 (12.8) (includes 17 475 [3.7] IDU and MMSC)	216 139 (45.9)	100 419 (21.3)	93 855 (18.7)
Stockman^84,d	California (HIV registry: 132 405)	Registry initiation in 2016	Not reported	11^d	34.2	Coinfection (n = 14 565)	6117 (42.0)	Not reported	Not reported	Not reported
Stockman^84,d	California (HIV registry: 132 405)	Registry initiation in 2016	Not reported	11^d	34.2	Monoinfection (n = 117 840)	11 784 (10.0)	Not reported	Not reported	Not reported
Das et al^48,e	Washington, DC (HIV registry: 12 965)	Registry initiation^e in 2016	Not reported	13.3	—^e	Coinfection (n = 1726)	—^e	—^e	—^e	—^e
Das et al^48,e	Washington, DC (HIV registry: 12 965)	Registry initiation^e in 2016	Not reported	13.3	—^e	Monoinfection (overall: 11 239; available transmission category data: 10 649)	1020 (9.6) (includes 277 [2.6] IDU and MMSC)	4980 (46.8)	3044 (28.6)	1471 (13.8)
Siza et al^47,f	Alabama (HIV registry: 5679)	2007-2016	Not reported	4.4	23.8	Coinfection (n = 259)	51 (19.7) (includes 14 [5.4] IDU and MMSC)	86 (33.2)	52 (20.1)	70 (27.0)
Siza et al^47,f	Alabama (HIV registry: 5679)	2007-2016	Not reported	4.4	23.8	Monoinfection (n = 5420)	163 (3.0) (includes 73 [1.3] IDU and MMSC)	2659 (49.1)	801 (14.8)	1797 (33.2)
Thomasson et al^85,g	West Virginia (HIV registry: 2237)	2001-2013	Not reported	9.4	25.6	Coinfection (n = 211)	112 (53.1) (includes 21 [10.0] IDU and MMSC)	45 (21.3)	28 (13.3)	26 (12.3)
Thomasson et al^85,g	West Virginia (HIV registry: 2237)	2001-2013	Not reported	9.4	25.6	Monoinfection (n = 2026)	326 (16.1) (includes 67 [3.3] IDU and MMSC)	1068 (52.7)	341 (16.8)	291 (14.4)
Prussing et al^50,h	New York City (HIV registry: 140 606)	2000-2010	Not reported	16.4	Not reported	Coinfection (n = 23 035)^h	—^h	—^h	—^h	—^h
Prussing et al^50,h	New York City (HIV registry: 140 606)	2000-2010	Not reported	16.4	Not reported	Monoinfection (n = 117 571)^h	—^h	—^h	—^h	—^h
Butt et al^51,i	Michigan (HIV registry: 13 936)	2006-2009	Not reported	4.1	10.7	Coinfection (n = 578)	203 (35.1) (includes 59 [10.2] IDU and MMSC)	218 (37.7)	58 (10.0)	99 (17.1)
Butt et al^51,i	Michigan (HIV registry: 13 936)	2006-2009	Not reported	4.1	10.7	Monoinfection (n = 13 358)	1699 (12.7) (includes 480 [3.6] IDU and MMSC)	6592 (49.3)	2531 (18.9)	2536 (19.0)
Speers et al^52,j	Colorado, Connecticut, and Oregon (HCV registry: 137 084; HIV registry: 30 732)	Registry initiationⁱ in 2008	Range: 1.8-4.9	Range: 4.4-23.6	36.1	Coinfection (n = 3999)	2835 (70.9) (includes 486 [12.1] IDU and MMSC)	576 (14.4)	272 (6.8)	316 (7.9)
Speers et al^52,j		Registry initiationⁱ in 2008	Range: 1.8-4.9	Range: 4.4-23.6	36.1	Monoinfection (n = 26 733)	5026 (18.8) (includes 1641 [6.1] IDU and MMSC)	14 512 (54.3)	3834 (14.3)	3361 (12.6)

Abbreviations: HCV, hepatitis C virus; IDU, injection drug use; MMSC, male-to-male sexual contact; PWID, people who inject drugs.

HCV–HIV coinfection is defined as the presence of HIV infection with coexisting positive hepatitis C antibody indicating current or past hepatitis C infection.

The table includes 2 cross-match studies not identified in the literature review but known to the authors through presentation at a scientific conference^84,85 and omits 1 cross-match study identified in the literature review that was limited to HIV registry cases with risk reported as MMSC without IDU, thus excluding PWID.⁴⁹

All jurisdictions had reported HIV infection stage 3 (AIDS) since the early 1980s; reporting start dates ranged from 1981 to 2002 for HIV and from 1981 to 2004 for HCV. Percentage HCV prevalence in the HIV registry and percentage HIV prevalence in the HCV registry, respectively, for individual jurisdictions: Arizona (8% and 2%), Connecticut (9% and 5%), Florida (5% and 4%), Iowa (0% and <1%), Louisiana (2% and 3%), Maryland (10% and 9%), Massachusetts (7% and 3%), Michigan (6% and 2%), Minnesota (6% and 3%), North Dakota (7% and 1%), South Carolina (7% and 5%), Texas (8% and 4%), Virginia (5% and 3%), Washington State (8% and 2%), and Wisconsin (9% and 2%). Cities comprised New York City (7% and 11%) and San Francisco, California (11% and 13%). Overall, coinfection prevalence was 22.2% among injection drug users and 3.9% among non–injection drug users.

Stockman et al⁸⁴ reported results in whole numbers.

AIDS reporting start dates ranged from 1981 to 1985, HIV from 1985 to 2002, and HCV from 1993 to 2005 in the 3 states. Transmission categories reported for people with HIV and either hepatitis B or hepatitis C coinfection were as follows: IDU, 27.2%; IDU and MMSC, 6.0%; MMSC, 32.9%; heterosexual contact, 23.4%; risk not identified, 10.0%. Transmission categories for 10 649 people with HIV monoinfection were reported, which excluded 590 people with HIV and hepatitis B infection. Among 1789 people with IDU as a transmission category (including IDU and MMSC), 43.0% had hepatitis B and/or HCV coinfection.

Coinfection prevalence was 23.8% among injection drug users and 3.8% among non–injection drug users.

Coinfection prevalence was 25.6% among injection drug users and 3.3% among non–injection drug users.

Coinfection category also includes 1942 people reported to have hepatitis B infection, hepatitis C antibody, and HIV infection. The monoinfection category also includes 6231 (4%) people reported to have HIV and hepatitis B coinfection but not HCV infection. Transmission category percentages estimated for HCV–HIV coinfection: IDU, approximately 60%; MMSC, approximately 10%-15%; heterosexual contact, approximately 10%-20%; risk not identified, approximately 20%. Transmission category percentages estimated for HIV monoinfection: IDU, approximately 15%; MMSC, approximately 30%-40%; heterosexual contact, approximately 15%-20%; risk not identified, approximately 30%.

Coinfection prevalence was 10.7% among injection drug users and 3.6% among non–injection drug users.

AIDS reporting began in 1980. Denominators of people in the HCV registry: 137 084. Percentage HCV coinfection among people with HIV: 5% in Colorado, 24% in Connecticut, and 4% in Oregon. Percentage HIV coinfection among people with HCV: 2% in Colorado, 5% in Connecticut, and 2% in Oregon. Coinfection prevalence was 36.1% among injection drug users and 5.1% among non–injection drug users.

HCV and HIV Coinfection in US Studies Among PWID

We identified 5 studies of PWID recruited for HIV and HCV testing (Table 2),^56,57,86
-88 4 of which used respondent-driven sampling, in which a small number of initial participants (“seeds”) were selected to complete the survey and recruit their peers to participate, which may have reached PWID not routinely engaged in health care. Across all 5 studies, the HCV antibody prevalence among PWID living with HIV ranged from 28.6% to 71.4%, and the HIV prevalence among HCV antibody–positive PWID ranged from 2.3% to 5.7% (9% in 1 study reporting HIV prevalence among HCV RNA–positive people). Among PWID overall, the prevalence of HIV infection ranged from 2.3% to 9%, HCV antibody prevalence from 27.8% to 67.7%, and HCV (antibody)–HIV coinfection from 1.2% to 2.2% (4% in 1 study that reported HIV and HCV [RNA] coinfection).

Table 2.

Prevalence of HCV infection, HIV infection, and HCV–HIV coinfection^a among PWID in US studies

Author	Location	Year	Population, no.	HIV prevalence, %	Hepatitis C antibody prevalence, %	Coinfection^a prevalence among all PWID, %	HIV coinfection among HCV antibody–positive PWID, %	HCV antibody prevalence among HIV-positive PWID, %
Chapin-Bardales et al^88,b	NHBS^c sites in 10 US cities^d	2018	PWID recruited during the 2018 NHBS^c cycle who completed HIV testing and HCV antibody and RNA testing (n = 3795)	9	60	4 (HCV RNA and HIV positive)	9 among HCV RNA–positive people	44 HCV RNA positive
Abara et al^86,b	NHBS^c sites in 8 US cities^e	2015	PWID recruited during the 2015 NHBS^c cycle who completed HIV testing and HCV antibody testing (n = 4094)	4.3	55.2	2.1	3.9	50.3
Salek et al⁵⁷	Hawaii islands: O’ahu, Maui, Kaua’i, Hawai’i	2012	Annual HIV and HCV testing among a random sample of PWID clients of a community mobile van syringe exchange program, with 90% response rate (n = 130)	2.3	67.7	1.5	2.3	66.7
Akselrod et al⁵⁶	Suburban Fairfield and New Haven counties, Connecticut	2008-2011	HIV and HCV testing (annual) among PWID recruited through RDS starting with clients of substance use treatment programs and social service agencies (n = 446 [98.2% of participants] with laboratory data)	3.1	40.1	2.2	5.6	71.4
Garfein et al^87,b	San Diego County, California	2009-2010	HIV and HCV testing among PWID aged 18-40 y recruited through RDS, venue-based sampling, and convenience sampling (n = 510 [90.1% of eligible people screened])	4.2	27.8 (positive for HCV antibody or HCV RNA)	1.2	5.7	28.6

Abbreviations: HCV, hepatitis C virus; NHBS, National HIV Behavioral Surveillance; PWID, people who inject drugs; RDS, respondent-driven sampling.

HCV–HIV coinfection is defined as the presence of HIV infection with coexisting positive hepatitis C antibody indicating current or past hepatitis C infection.

Included 3 relevant studies known to the authors not identified in the literature review.

NHBS is a cross-sectional periodic survey that monitors the prevalence of HIV sexual risk and drug use behaviors, HIV testing, and use of HIV prevention services in populations at high risk of HIV infection, including PWID.¹ When funds are available, NHBS provides hepatitis C antibody and RNA testing to PWID in selected project areas.²

Chapin-Bardales et al⁸⁸ reported NHBS data in whole numbers only and included NHBS data from 10 US cities: Chicago, Illinois; Dallas, Texas; Houston, Texas; Los Angeles, California; Miami, Florida; New York, New York; Philadelphia, Pennsylvania; San Francisco, California; San Juan, Puerto Rico; and Washington, DC.

Abara et al⁸⁶ reported data from 8 US cities: Chicago, Illinois; Dallas, Texas; Denver, Colorado; Los Angeles, California; Nassau-Suffolk, New York; New Orleans, Louisiana; New York, New York; and Seattle, Washington.

HCV Infection in Recent HIV Clusters and Outbreaks Among PWID

From 2014 to 2021, HCV coinfection was observed in 69.8%-93.8% of newly diagnosed HIV cases among the 5 largest HIV outbreaks among PWID that incorporated HCV antibody or RNA testing (Table 3).^{89
-92,95,98,99} In contrast, smaller HIV cluster and outbreak investigations^93,94,96,97 reported more varied HCV–HIV coinfection rates (28.6%-64.3%). In 2 large outbreaks for which the temporal sequence of infection was reported, diagnosis of HCV preceded diagnosis of HIV by a median of 4 to 5 years.^89,95 In a large HIV outbreak among PWID in Scott County, Indiana, HCV–HIV coinfection was identified in 92% of new HIV cases. The largest HCV molecular cluster (n = 130) in this outbreak consisted of 4 cases of hepatitis C previously diagnosed in 2010, 5 years prior to recognition of the HIV outbreak.⁹⁹

Table 3.

US clusters and outbreaks of HIV among PWID with prevalence of HCV coinfection^a reported, 2014-2021

Reference	Location	Year	HCV antibody prevalence among newly identified HIV cases, no. (%)	Time from HCV detection to HIV diagnosis
Hudson et al,⁸⁹ Hershow et al⁹⁰	Kanawha County, West Virginia	2019-2021	61/65 (93.8)	HCV detected a median 4 y prior to HIV
McClung et al⁹¹	Cabell County, West Virginia	2018-2019	72/82 (87.8)	Not reported
Kim et al⁹²	Philadelphia, Pennsylvania	2018	81/116 (69.8)	Not reported
Tookes et al⁹³	Miami/Dade County, Florida	2018	4/7 (57.1)	Not reported but 3 of 4 HCV infections detected at least 1 y prior to HIV infection
Boyette and Alaska Department of Health and Social Services⁹⁴	Alaska	2018	2/7 (28.6)	Not reported
Alpren et al⁹⁵	Northeastern Massachusetts	2015-2018	116/129 (89.9)	HCV detected a median 4 y prior to HIV infection
Samoff et al⁹⁶	Western North Carolina	2017-2018	9/14 (64.3)	Not reported
Sizemore et al⁹⁷	Knox County or East Tennessee Public Health Region	2017	3/8 (37.5) PWID^b	Not reported
Peters et al,⁹⁸ Ramachandran et al⁹⁹	Scott County, Indiana	2014-2015	167/181 (92.3)	Not reported, although in some cases HCV infections detected at least 5 y prior to HIV infection

Abbreviations: HCV, hepatitis C virus; MMSC, male-to-male sexual contact; PWID, people who inject drugs.

HCV–HIV coinfection is defined as the presence of HIV infection with coexisting positive hepatitis C antibody indicating current or past hepatitis C infection.

Of 31 people newly diagnosed with HIV infection, 14 (45.2%) were tested for HCV; 8 (25.8%) reported injection drug use; 4 (12.9%) reported injection drug use and MMSC; 10 (32.3%) reported MMSC; 9 (29.0%) reported heterosexual contact; and 4 (12.9%) had other or unknown risk factors.

A comprehensive literature review of HCV–HIV coinfection studies not focused on PWID is summarized (eTable in Supplemental Material).

Discussion

Hepatitis C and HIV interact in predictable patterns: the prevalence of HCV infection is higher than the prevalence of HIV infection,^56,57,86
-88 and the prevalence of IDU is higher among people coinfected with HIV and HCV than among people infected with HIV only.^{46,47,51,52,85} In our review, HCV antibody prevalence among PWID with HIV ranged from 10.7% to 71.4% in population- and community-based studies (Tables 1 and 2) and from 69.8% to 93.8% among the 5 larger HIV outbreaks or clusters (Table 3). Where the question has been evaluated, HCV infection preceded HIV infection in outbreaks among PWID by a median of 4 to 5 years. This relationship is supported by an ecologic association between the population prevalence of HCV infection and HIV in a review of US and international population-level studies.¹⁰⁰ The positive association between prevalence of hepatitis C and HIV suggests that HCV infection may be an important marker of IDU and other behavioral or social determinants of health that could increase the risk for future HIV infection among PWID.

While these studies demonstrate a substantial prevalence of infection among PWID, testing is likely performed for a low percentage of people in this high-risk group. For example, in an analysis of nationwide health insurance claims data during 2010-2017, among people identified as PWID through a clinical diagnosis algorithm, approximately 90% missed opportunities for HIV or HCV testing.¹⁰¹ Many previously missed opportunities for HIV testing among PWID in the year prior to diagnosis were identified in one of the larger recent HIV outbreaks.¹⁰² Because PWID may be difficult to reach in routine surveys¹⁰ as well as for clinic-based prevention services,¹⁸ the prevalence of HCV–HIV coinfection may be underestimated.

The relationship among HCV infection, HIV infection, and IDU has several implications for disease prevention and control. First, prevention pathways for HCV and HIV are similar. The combination of sufficient sterile injection paraphernalia for all injections and medication for opioid use disorder reduces hepatitis C transmission by 74%,¹⁰³ and these measures are critical for preventing HIV transmission.¹⁰⁴ Comprehensive SSPs can address not only the need for sterile injection equipment and safe disposal, but also provision of or referral to social, mental health, and medical services including substance use disorder treatment, testing and treatment for infectious diseases, and nalaxone distribution.¹⁰⁵ While SSPs are a critical link for testing, prevention, and treatment for HIV and HCV infection, they can also help PWID address the broader range of syndemic social, mental health, and medical challenges. National plans for ending the HIV epidemic and eliminating viral hepatitis as a public health problem share key strategies and populations, specifically targeting improvement of the distribution and quality of SSPs.^41,44,45

Second, active surveillance is important for HCV and HIV infection, as well as infectious diseases such as hepatitis A and B.^106,107 Improvements in HCV surveillance systems could allow for earlier identification of populations with a high incidence or prevalence of hepatitis C; that information could be used to mitigate or prevent subsequent infections associated with IDU, including HIV.¹⁷ Identifying and investigating outbreaks among PWID leads to a better understanding of patterns of coinfection and appropriate prevention and control measures. Robust data are needed to estimate disease prevalence and measure progress toward goals of ending the HIV epidemic and eliminating viral hepatitis as a public health threat.^41,44 In addition, understanding vulnerabilities at the population level is critical to assessing the potential impact of HCV–HIV coinfection on communities. Many factors, such as poverty, employment, race, and physician capacity to offer buprenorphine treatment, have been used to predict county-level vulnerability to the rapid spread of HCV and HIV.¹⁰⁸ Better integration of surveillance data with data on social determinants of health, including composite indexes such as the Social Vulnerability Index,^109,110 can provide important context and guide disease elimination planning. Readily accessible data-driven estimates are powerful advocacy tools that can motivate the allocation of resources for hepatitis C and HIV programs; however, further evaluation is needed to understand the impact of these tools on reducing the prevalence of disease.¹¹¹

Lastly, lessons learned from HCV–HIV outbreaks among PWID can inform prevention, detection, and responses to future outbreaks. Lack of access to evidence-based care for PWID, including SSPs, medication for opioid use disorder, and HIV preexposure prophylaxis, has been documented during investigations of outbreaks of HIV among PWID; contributing social factors have included homelessness, exchanging sex for drugs, incarceration, and discrimination and stigma.^{17,18,89-92,95,98,99,112} In response to HIV outbreaks among PWID, state and local health departments have expanded testing for HIV^{90
-93,95,96,98,112} and hepatitis C^90,93,96,98; expanded access to HIV preexposure prophylaxis^90
-92; offered training of service providers on HIV and stigma reduction⁹⁰; enhanced linkage to HIV^{90
-93,95,96,98} and substance use disorder^90,91,95,98 treatment services; expanded SSP access^{91
-93,95,98,112}; and hired additional partner services staff members (eg, disease intervention specialists) to reach people who may be medically underserved, experiencing homelessness, or using drugs.^90,91,95,98 Given that HCV infection might frequently precede HIV infection,^89,95,99 implementation or intensification of these evidence-based prevention activities should ideally take place at the first sign of increasing HCV infections.

This literature review was subject to several limitations that highlight data gaps to be addressed in future programs and studies. First, relatively few studies included data on the prevalence of current HCV–HIV coinfection among PWID. When such data were provided, they were primarily based on measures of the prevalence of HCV antibody (an indicator of past or current HCV infection), although some studies also described the prevalence of HCV RNA (an indicator of current HCV infection). However, among untreated HCV antibody–positive PWID, the prevalence of current infection is typically ≥70%.^113
-115 Second, our search approach was not intended to be a systematic review of the literature; thus, some articles on the prevalence of HCV–HIV coinfection prevalence may not have been identified, as evidenced by the inclusion of some studies known to the authors that did not appear in the search results.

Data Needs and Opportunities for the Future

The accelerated progression of HCV-related liver disease among people with HIV and the substantial coinfection prevalence across populations have prompted American Association for the Study of Liver Diseases/Infectious Diseases Society of America guidance²¹ and the World Health Organization¹¹⁶ to urge diagnosis and treatment of HCV infection among all people living with HIV. Successful HCV elimination efforts among people with HIV have been initiated in other industrialized nations, such as Australia, Scotland, and the Netherlands.^117
-124 To support this goal in the United States, integrated data sharing between HIV and HCV surveillance and clinical systems is necessary to better understand the prevalence of HCV–HIV coinfection and develop HCV and HIV care cascades¹²⁵—a sequence of steps that follow progression from testing and treatment to viral clearance for hepatitis C or viral suppression for HIV.¹²⁶ A need exists to develop methods of simple and secure data sharing among HIV and HCV surveillance programs in health departments. Cascades are important data tools because they can identify missed opportunities for HCV and HIV prevention and linkage to care and inform population-wide interventions for those in need.

To this end, the Health Resources and Services Administration is supporting a demonstration project to link people with HCV–HIV coinfection in the Ryan White HIV/AIDS Program to HCV care by leveraging existing public health surveillance with clinical data systems. Ryan White HIV/AIDS programs and federally qualified health centers are well positioned to facilitate HCV testing and treatment given the strong health advocacy and patient–provider relationships fostered in these HIV care environments.^117,127,128 Existing HIV care strategies, such as using retention specialists and adherence support, monitoring viral suppression, counseling on harm reduction, and addressing stigma and other barriers to care, can also be leveraged to provide comprehensive HCV care in a co-localized setting for both infections.^127,128

To address the health disparities related to IDU, better data are needed on the prevalence of IDU, risk behaviors, and access to evidence-based services for PWID. CDC is supporting multiple programs to describe the infectious consequences of IDU and improve access to SSPs.^129
-131 The National HIV Behavioral Surveillance system is a comprehensive system for biobehavioral surveillance in metropolitan areas among populations with a high prevalence of HIV, including PWID.¹³² Data on risk factors, testing, and receipt of prevention services are collected. All participants are offered HIV testing and, in some cases, HCV testing.¹³³ To expand surveillance of PWID, CDC is piloting the Injection Drug Use Surveillance Project, which recruits PWID from SSPs in urban, suburban, and rural settings and assesses injection behavior, use of harm reduction services, and overdose prevention. HIV and HCV testing are offered, as well as linkage to care, as needed.^134,135 Lastly, CDC has implemented a national SSP survey that measures service delivery capacity, service gaps, and operational challenges faced.^136,137 Together, these data will provide a comprehensive picture of the public health burden of IDU, infectious complications, and access to evidence-based preventive services.

The Viral Hepatitis National Strategic Plan prioritizes integrating the efforts of hepatitis, HIV, and sexually transmitted infections surveillance systems to better address data quality and interrelated risk factors.⁴¹ Efforts to further integrate activities include developing interoperable surveillance systems by standardizing electronic case reporting and data collection strategies and removing barriers to sharing data between surveillance programs. The efficient exchange of surveillance data will reduce data entry errors and expedite the transfer of data to public health policy makers and other partners. These efforts are aligned with the goals of CDC’s Data Modernization Initiative, a multiyear national effort to modernize core data and surveillance infrastructure across the federal and state public health landscape.¹³⁸ A long-term outcome of the initiative is to develop a state-of-the-art workforce in the areas of data science, health information technology, and cybersecurity to deploy approaches that move the public health community from “siloed and brittle public health data systems to connected, resilient, adaptable, and sustainable ‘response-ready’ systems capable of meeting today’s and tomorrow’s health challenges.”¹³⁸

Public Health Implications

National plans for ending the HCV and HIV epidemics among PWID share important strategies for prevention, including test-and-treat, comprehensive SSPs, and treatment of substance use disorder.^41,44,45 Robust integrated surveillance of HCV–HIV disease incidence and prevalence, IDU, and social determinants of health is needed to inform public health programs at city, state, and national levels. By providing data on these overlapping epidemics in a wholistic, integrated manner, public health surveillance programs can overcome the inefficiencies of disease-specific silos, accelerate the delivery of preventive and clinical services, and address the health disparities and social drivers associated with HCV–HIV coinfection.

Supplemental Material

sj-xlsx-1-phr-10.1177_00333549231181348 – Supplemental material for Hepatitis C Virus–HIV Coinfection in the United States Among People Who Inject Drugs: Data Needed for Ending Dual Epidemics

Supplemental material, sj-xlsx-1-phr-10.1177_00333549231181348 for Hepatitis C Virus–HIV Coinfection in the United States Among People Who Inject Drugs: Data Needed for Ending Dual Epidemics by Anne C. Moorman, Danae Bixler, Eyasu H. Teshale, Megan Hofmeister, Henry Roberts, Johanna Chapin-Bardales and Neil Gupta in Public Health Reports

Footnotes

Acknowledgements

The authors acknowledge contributions from Nathan Furukawa, MD, Division of Viral Hepatitis, National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention.

Disclaimer

The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Anne C. Moorman, BSN, MPH

Danae Bixler, MD, MPH

Megan Hofmeister, MD, MS, MPH

Supplemental Material

Supplemental material for this article is available online at . The authors have provided these supplemental materials to give readers additional information about their work. These materials have not been edited or formatted by Public Health Reports’s scientific editors and, thus, may not conform to the guidelines of the AMA Manual of Style, 11th edition.

References

Singer

Bulled

Ostrach

Whither syndemics? Trends in syndemics research, a review 2015-2019. Glob Public Health. 2020;15(7):943-955. doi:10.1080/17441692.2020.1724317

Bradley

Hall

Asher

, et al Estimated number of people who inject drugs in the United States. Clin Infect Dis. 2023;76(1):96-102. doi:10.1093/cid/ciac543

Lansky

Finlayson

Johnson

, et al Estimating the number of persons who inject drugs in the United States by meta-analysis to calculate national rates of HIV and hepatitis C virus infections. PLoS One. 2014;9(5):e97596. doi:10.1371/journal.pone.0097596

Hedegaard

Miniño

Spencer

Warner

Drug overdose deaths in the United States, 1999-2020. NCHS Data Brief. 2021;426:1-8.

National Center for Health Statistics. US overdose deaths in 2021 Increased half as much as in 2020—but are still up 15%. May 11, 2022. Accessed April 18, 2023. https://www.cdc.gov/nchs/pressroom/nchs_press_releases/2022/202205.htm

Centers for Disease Control and Prevention. Viral hepatitis surveillance report 2020. Accessed August 15, 2022. https://www.cdc.gov/hepatitis/statistics/2020surveillance/index.htm

Zibbell

Asher

Patel

, et al Increases in acute hepatitis C virus infection related to a growing opioid epidemic and associated injection drug use, United States, 2004 to 2014. Am J Public Health. 2018;108(2):175-181. doi:10.2105/AJPH.2017.304132

Centers for Disease Control and Prevention. Viral hepatitis surveillance—United States. Accessed March 21, 2022. https://www.cdc.gov/hepatitis/statistics/SurveillanceRpts.htm

Zibbell

Iqbal

Patel

, et al Increases in hepatitis C virus infection related to injection drug use among persons aged ≥30 years—Kentucky, Tennessee, Virginia, and West Virginia, 2006-2012. MMWR Morb Mortal Wkly Rep. 2015;64(17):453-458.

10.

Bradley

Hall

Rosenthal

Sullivan

Ryerson

Rosenberg

ES.

Hepatitis C virus prevalence in 50 US states and DC by sex, birth cohort, and race: 2013-2016. Hepatol Commun. 2020;4(3):355-370. doi:10.1002/hep4.1457

11.

Schillie

Wester

Osborne

Wesolowski

Ryerson

AB.

CDC recommendations for hepatitis C screening among adults—United States, 2020. MMWR Recomm Rep. 2020;69(2):1-17. doi:10.15585/mmwr.rr6902a1

12.

Holtzman

Asher

Schillie

The changing epidemiology of hepatitis C virus infection in the United States during the years 2010 to 2018. Am J Public Health. 2021;111(5):949-955. doi:10.2105/AJPH.2020.306149

13.

Kim

Cholankeril

Dennis

, et al Trends in the prevalence of hepatitis C virus infection based on the insurance status in the United States from 2013 to 2018. Liver Int. 2022;42(2):340-349. doi:10.1111/liv.15113

14.

Hofmeister

Rosenthal

Barker

, et al Estimating prevalence of hepatitis C virus infection in the United States, 2013-2016. Hepatology. 2019;69(3):1020-1031. doi:10.1002/hep.30297

15.

Thompson

Symum

Sandul

, et al Vital signs: hepatitis C treatment among insured adults—United States, 2019-2020. MMWR Morb Mortal Wkly Rep. 2022;71(32):1011-1017. doi:10.15585/mmwr.mm7132e1

16.

Kruszon-Moran

QuickStats: percentage of adults aged ≥18 years with current hepatitis C virus infection, by health insurance coverage—National Health and Nutrition Examination Survey, United States, January 2017–March 2020. MMWR Morb Mortal Wkly Rep. 2022;71(32):1035. doi:10.15585/mmwr.mm7132a4

17.

Oster

Lyss

McClung

, et al HIV cluster and outbreak detection and response: the science and experience. Am J Prev Med. 2021;61(5, suppl 1):S130-S142. doi:10.1016/j.amepre.2021.05.029

18.

Lyss

Buchacz

McClung

Asher

Oster

AM.

Responding to outbreaks of human immunodeficiency virus among persons who inject drugs—United States, 2016-2019: perspectives on recent experience and lessons learned. J Infect Dis. 2020;222(suppl 5):S239-S249. doi:10.1093/infdis/jiaa112

19.

Centers for Disease Control and Prevention. HIV surveillance report: diagnoses of HIV infection in the United States and dependent areas, 2019. 2019. Accessed April 17, 2023. https://www.cdc.gov/hiv/pdf/library/reports/surveillance/cdc-hiv-surveillance-report-2018-updated-vol-32.pdf

20.

Moon

Singal

Tapper

EB.

Contemporary epidemiology of chronic liver disease and cirrhosis. Clin Gastroenterol Hepatol. 2020;18(12):2650-2666. doi:10.1016/j.cgh.2019.07.060

21.

American Association for the Study of Liver Diseases, Infectious Diseases Society of America. HCV guidance: recommendations for testing, managing, and treating hepatitis C. 2022. Accessed April 18, 2023. https://www.hcvguidelines.org/evaluate/testing-and-linkage

22.

Telfer

Sabin

Devereux

Scott

Dusheiko

Lee

The progression of HCV-associated liver disease in a cohort of haemophilic patients. Br J Haematol. 1994;87:555-561. doi:10.1111/j.1364-2141.1994.tb08312.x

23.

Soto

Sánchez-Quijano

Rodrigo

, et al Human immunodeficiency virus infection modifies the natural history of chronic parenterally-acquired hepatitis C with an unusually rapid progression to cirrhosis. J Hepatol. 1997;26(1):1-5. doi:10.1016/s0168-8278(97)80001-3

24.

Benhamou

Bochet

Di Martino

, et al Liver fibrosis progression in human immunodeficiency virus and hepatitis C virus coinfected patients. Hepatology. 1999;30(4):1054-1058. doi:10.1002/hep.510300409

25.

Graham

Baden

, et al Influence of human immunodeficiency virus infection on the course of hepatitis C virus infection: a meta-analysis. Clin Infect Dis. 2001;33(4):562-569. doi:10.1086/321909

26.

Kirk

Mehta

Astemborski

, et al HIV, age, and the severity of hepatitis C virus–related liver disease: a cohort study. Ann Intern Med. 2013;158(9):658-666. doi:10.7326/0003-4819-158-9-201305070-00604

27.

Foster

Hofmeister

Kupronis

, et al Increase in hepatitis A virus infections—United States, 2013-2018. MMWR Morb Mortal Wkly Rep. 2019;68(18):413-415. doi:10.15585/mmwr.mm6818a2

28.

Chen

Ding

Seage

III Kim

AY.

Meta-analysis: increased mortality associated with hepatitis C in HIV-infected persons is unrelated to HIV disease progression. Clin Infect Dis. 2009;49(10):1605-1615. doi:10.1086/644771

29.

See

Gokhale

Geller

, et al National public health burden estimates of endocarditis and skin and soft-tissue infections related to injection drug use: a review. J Infect Dis. 2020;222(suppl 5):S429-S436. doi:10.1093/infdis/jiaa149

30.

Hofmeister

Xing

Foster

, et al Factors associated with hepatitis A mortality during person-to-person outbreaks: a matched case-control study—United States, 2016-2019. Hepatology. 2021;74(1):28-40. doi:10.1002/hep.31645

31.

Doshani

Weng

Moore

Romero

Nelson

NP.

Recommendations of the Advisory Committee on Immunization Practices for use of hepatitis A vaccine for persons experiencing homelessness. MMWR Morb Mortal Wkly Rep. 2019;68(6):153-156. doi:10.15585/mmwr.mm6806a6

32.

Montgomery

Eckert

Hofmeister

, et al Strategies for successful vaccination among two medically underserved populations: lessons learned from hepatitis A outbreaks. Am J Public Health. 2021;111(8):1409-1412. doi:10.2105/AJPH.2021.306308

33.

Shing

Xing

Teshale

Jiles

RB.

Prevalence of hepatitis B virus infection among US adults aged 20-59 years with a history of injection drug use: National Health and Nutrition Examination Survey, 2001-2016. Clin Infect Dis. 2020;70(12):2619-2627. doi:10.1093/cid/ciz669

34.

Tressler

Kushner

Bhandari

Factors associated with hepatitis B exposure among people who report using methamphetamine: National Health and Nutrition Examination Survey 2009-2016. J Infect Dis. 2020;221(2):243-250. doi:10.1093/infdis/jiz445

35.

Oster

Sternberg

Nebenzahl

, et al Prevalence of HIV, sexually transmitted infections, and viral hepatitis by urbanicity, among men who have sex with men, injection drug users, and heterosexuals in the United States. Sex Transm Dis. 2014;41(4):272-279. doi:10.1097/olq.0000000000000110

36.

Reno

Fox

Highfill

, et al The emerging intersection between injection drug use and early syphilis in nonurban areas of Missouri, 2012-2018. J Infect Dis. 2020;222(suppl 5):S465-S470. doi:10.1093/infdis/jiaa056

37.

Chow

EPF

Grulich

Fairley

. Epidemiology and prevention of sexually transmitted infections in men who have sex with men at risk of HIV. Lancet HIV. 2019;6(6):e396-e405. doi:10.1016/s2352-3018(19)30043-8

38.

Hotton

Mackesy-Amiti

Boodram

Trends in homelessness and injection practices among young urban and suburban people who inject drugs: 1997-2017. Drug Alcohol Depend. 2021;225:108797. doi:10.1016/j.drugalcdep.2021.108797

39.

Levitt

Mermin

Jones

See

Butler

JC.

Infectious diseases and injection drug use: public health burden and response. J Infect Dis. 2020;222(suppl 5):S213-S217. doi:10.1093/infdis/jiaa432

40.

Centers for Disease Control and Prevention. Syringe services programs (SSPs). 2019. Accessed March 21, 2023. https://www.cdc.gov/ssp/index.html

41.

US Department of Health and Human Services. Viral Hepatitis National Strategic Plan: a roadmap to elimination for the United States, 2021-2025. 2020. Accessed April 6, 2023. https://www.hhs.gov/sites/default/files/Viral-Hepatitis-National-Strategic-Plan-2021-2025.pdf

42.

Javed

Pegram

Burk

Ali

Facente

Asher

. Syringe services programs: a technical package of effective strategies and approaches for planning, design, and implementation. 2020. Accessed March 21, 2023. https://www.cdc.gov/ssp/docs/SSP-Technical-Package.pdf

43.

Carnes

Asher

Bohm

Bessler

PA.

Access to HIV, viral hepatitis, and substance use disorder treatment/overdose prevention services: a qualitative analysis of syringe service programs (SSPs) serving rural PWID. Subst Use Misuse. 2021;56(13):1933-1940. doi:10.1080/10826084.2021.1958863

44.

US Department of Health and Human Services. What is “ending the HIV epidemic in the US”? July 1, 2022. Accessed March 21, 2022. https://www.hiv.gov/federal-response/ending-the-hiv-epidemic/overview

45.

Broz

Carnes

Chapin-Bardales

, et al Syringe services programs’ role in ending the HIV epidemic in the US: why we cannot do it without them. Am J Prev Med. 2021;61(5, suppl 1):S118-S129. doi:10.1016/j.amepre.2021.05.044

46.

Bosh

Coyle

Hansen

, et al HIV and viral hepatitis coinfection analysis using surveillance data from 15 US states and two cities. Epidemiol Infect. 2018;146(7):920-930. doi:10.1017/S0950268818000766

47.

Siza

Bixler

Davidson

Proportion and characterization of co-infections of HIV and hepatitis C or hepatitis B among people with HIV in Alabama, 2007-2016. South Med J. 2020;113(6):298-304. doi:10.14423/smj.0000000000001104

48.

Das

Opoku

Allston

Kharfen

Detecting spatial clusters of HIV and hepatitis coinfections. PLoS One. 2018;13(9):e0203674. doi:10.1371/journal.pone.0203674

49.

Gabai

Moore

Penrose

, et al Hepatitis C infection among men who have sex with men living with HIV in New York City, 2000-2015. Sex Transm Infect. 2020;96(6):445-450. doi:10.1136/sextrans-2019-054208

50.

Prussing

Chan

Pinchoff

, et al HIV and viral hepatitis co-infection in New York City, 2000-2010: prevalence and case characteristics. Epidemiol Infect. 2015;143(7):1408-1416. doi:10.1017/S0950268814002209

51.

Butt

Wilkins

Hamilton

Todem

Gardiner

Saeed

Hepatitis B and C co-infection in HIV/AIDS population in the state of Michigan. Epidemiol Infect. 2013;141(12):2604-2611. doi:10.1017/s0950268813000538

52.

Speers

Klevens

Vonderwahl

, et al Electronic matching of HIV/AIDS and hepatitis C surveillance registries in three states. Public Health Rep. 2011;126(3):344-348. doi:10.1177/003335491112600307

53.

Reau

Sulkowski

Thomas

, et al Epidemiology and clinical characteristics of individuals with hepatitis C virus infection in the United States, 2017-2019. Adv Ther. 2021;38(12):5777-5790. doi:10.1007/s12325-021-01928-y

54.

van Boemmel-Wegmann

Lo Re

3rd Park

Early treatment uptake and cost burden of hepatitis C therapies among newly diagnosed hepatitis C patients with a particular focus on HIV coinfection. Dig Dis Sci. 2020;65(11):3159-3174. doi:10.1007/s10620-019-06037-z

55.

Millman

Luo

Nelson

Vellozzi

Weiser

Missed opportunities for prevention and treatment of hepatitis C among persons with HIV/HCV coinfection. AIDS Care. 2020;32(7):921-929. doi:10.1080/09540121.2019.1668533

56.

Akselrod

Grau

Barbour

Heimer

Seroprevalence of HIV, hepatitis B virus, and HCV among injection drug users in Connecticut: understanding infection and coinfection risks in a nonurban population. Am J Public Health. 2014;104(9):1713-1721. doi:10.2105/AJPH.2013.301357

57.

Salek

Katz

Lenze

Lusk

Des Jarlais

DC.

Seroprevalence of HCV and HIV infection among clients of the nation’s longest-standing statewide syringe exchange program: a cross-sectional study of Community Health Outreach Work to Prevent AIDS (CHOW). Int J Drug Policy. 2017;48:34-43. doi:10.1016/j.drugpo.2017.06.009

58.

Blackwell

Rodgers

Franco

, et al Predictors of linkage to care for a nontargeted emergency department hepatitis C screening program. Am J Emerg Med. 2020;38(7):1396-1401. doi:10.1016/j.ajem.2019.11.034

59.

Torian

Felsen

Xia

, et al Undiagnosed HIV and HCV infection in a New York City emergency department, 2015. Am J Public Health. 2018;108(5):652-658. doi:10.2105/AJPH.2018.304321

60.

Mohammed

Martin

Sadashige

Jaker

Paul

An anonymous unlinked sero-prevalence survey of HIV HCV in an urban emergency department. J Clin Virol. 2013;58(suppl 1):e19-e23. doi:10.1016/j.jcv.2013.08.025

61.

Kim

Locke

Park

Magee

Bacchetti

Khalili

Race and hepatitis C care continuum in an underserved birth cohort. J Gen Intern Med. 2018;34(10):2005-2013. doi:10.1007/s11606-018-4649-6

62.

Simoncini

Hou

Carlson

, et al Disparities in treatment with direct-acting hepatitis C virus antivirals persist among adults coinfected with HIV and hepatitis C virus in US clinics, 2010-2018. AIDS Patient Care STDS. 2021;35(10):392-400. doi:10.1089/apc.2021.0087

63.

Willis

Kim

Achenbach

, et al Hepatitis C coinfection and extrahepatic cancer incidence among people living with HIV. HIV Med. 2022;23(6):620-628. doi:10.1111/hiv.13218

64.

Willis

Cole

Westreich

, et al Chronic hepatitis C virus infection and subsequent HIV viral load among women with HIV initiating antiretroviral therapy. AIDS. 2018;32(5):653-661. doi:10.1097/QAD.0000000000001745

65.

Sun

Althoff

Jing

, et al Trends in hepatocellular carcinoma incidence and risk among persons with HIV in the US and Canada, 1996-2015. JAMA Netw Open. 2021;4(2):e2037512. doi:10.1001/jamanetworkopen.2020.37512

66.

Breskin

Westreich

Hurt

, et al The effects of hepatitis C treatment eligibility criteria on all-cause mortality among people with human immunodeficiency virus. Clin Infect Dis. 2019;69(9):1613-1620. doi:10.1093/cid/ciz008

67.

Troy

Rossheim

Siik

Cunningham

Kerry

JA.

Association of CMV, HBV, or HCV co-infection with vaccine response in adults with well-controlled HIV infection. Hum Vaccin Immunother. 2016;12(5):1295-1299. doi:10.1080/21645515.2015.1121336

68.

Chen

Thio

Kamangar

Cox

Wiberg

KJ.

Evolving trends in the prevalence of hepatitis C virus antibody positivity among HIV-infected men in a community-based primary care setting. J Viral Hepat. 2020;27(11):1202-1213. doi:10.1111/jvh.13354

69.

Hall

Jenkins

Hulgan

, et al Hepatitis C coinfection and mortality in people living with HIV in middle Tennessee. AIDS Res Hum Retroviruses. 2020;36(3):193-199. doi:10.1089/AID.2019.0113

70.

Cachay

Hill

Wyles

, et al The hepatitis C cascade of care among HIV infected patients: a call to address ongoing barriers to care. PLoS One. 2014;9(7):e102883. doi:10.1371/journal.pone.0102883

71.

Freiman

Huang

White

, et al Current practices of screening for incident hepatitis C virus (HCV) infection among HIV-infected, HCV-uninfected individuals in primary care. Clin Infect Dis. 2014;59(12):1686-1693. doi:10.1093/cid/ciu698

72.

Clanon

Muleller

Harank

Integrating treatment for hepatitis C virus infection into an HIV clinic. Clin Infect Dis. 2005;40(suppl 5):S362-S366. doi:10.1086/427454

73.

Spradling

Richardson

Buchacz

, et al Trends in hepatitis C virus infection among patients in the HIV Outpatient Study, 1996-2007. J Acquir Immune Defic Syndr. 2010;53(3):388-396. doi:10.1097/QAI.0b013e3181b67527

74.

Tsui

Vittinghoff

Anastos

, et al Hepatitis C seropositivity and kidney function decline among women with HIV: data from the Women’s Interagency HIV Study. Am J Kidney Dis. 2009;54(1):43-50. doi:10.1053/j.ajkd.2009.092.009

75.

Noska

Liu

Kuo

, et al Validity of self-reported hepatitis C virus status among criminal justice–involved persons living with HIV. J Correct Health Care. 2021;27(3):167-171. doi:10.1089/jchc.19.05.0045

76.

Rosen

Schoenbach

Wohl

White

Stewart

Golin

CE.

Characteristics and behaviors associated with HIV infection among inmates in the North Carolina prison system. Am J Public Health. 2009;99(6):1123-1130. doi:10.2105/ajph.2007.133389

77.

Chew

Blum

Javanbakht

, et al Low prevalence of hepatitis C co-infection in recently HIV-infected minority men who have sex with men in Los Angeles: a cross-sectional study. BMC Infect Dis. 2015;15:538. doi:10.1186/s12879-015-1279-z

78.

Tieu

H-V

Laeyendecker

Nandi

, et al Prevalence and mapping of hepatitis C infections among men who have sex with men in New York City. PLoS One. 2018;13(7):e0200269. doi:10.1371/journal.pone.0200269

79.

Hernandez

Trujillo

Sicro

, et al High hepatitis C virus seropositivity, viremia, and associated risk factors among trans women living in San Francisco, California. PLoS One. 2021;16(3):e0249219. doi:10.1371/journal.pone.0249219

80.

Backus

Phillips

Boothroyd

, et al Effects of hepatitis C virus coinfection on survival in veterans with HIV treated with highly active antiretroviral therapy. J Acquir Immune Defic Syndr. 2005;39(5):613-619.

81.

Kramer

El-Serag

Taylor

, et al Hepatitis C virus–related complications are increasing in women veterans: a national cohort study. J Viral Hepat. 2017;24(11):955-965. doi:10.1111/jvh.12728

82.

Sanchez

Scheer

Shallow

Pipkin

Huang

Epidemiology of the viral hepatitis–HIV syndemic in San Francisco: a collaborative surveillance approach. Public Health Rep. 2014;129(suppl 1):S95-S101. doi:10.1177/00333549141291S114

83.

Williams-Nguyen

Hawes

Nance

, et al Association between chronic hepatitis C virus infection and myocardial infarction among people living with HIV in the United States. Am J Epidemiol. 2020;189(6):554-563. doi:10.1093/aje/kwz236

84.

Stockman

LJ.

Surveillance to identify care and monitor trends in hepatitis C and HIV coinfection in California. Presented at: National Alliance of State and Territorial AIDS Directors Technical Assistance Meeting; October 12, 2018; Baltimore, Maryland.

85.

Thomasson

Blankenship

Hoffman

Hudson

Human immunodeficiency virus and hepatitis C coinfection in West Virginia, 2001-2013. Presented at: 64th Annual Epidemic Intelligence Service Conference; April 20-23, 2015; Atlanta, Georgia. Accessed April 18, 2023. https://www.cdc.gov/eis/downloads/2015-EIS-Conference-v2.pdf

86.

Abara

Trujillo

Broz

, et al Age-related differences in past or present hepatitis C virus infection among people who inject drugs: national human immunodeficiency virus behavioral surveillance, 8 US cities, 2015. J Infect Dis. 2019;220(3):377-385. doi:10.1093/infdis/jiz142

87.

Garfein

Rondinelli

Barnes

RFW

, et al HCV infection prevalence lower than expected among 18-40-year-old injection drug users in San Diego, CA. J Urban Health. 2013;90(3):516-528. doi:10.1007/s11524-012-9728-0

88.

Chapin-Bardales

Asher

Broz

, et al Hepatitis C virus infection and co-infection with HIV among PWID in 10 US cities. Abstract presented at: Conference on Retroviruses and Opportunistic Infections; March 8-11, 2020; Boston, Massachusetts.

89.

Hudson

Bonacci

Moorman

, et al Hepatitis C virus infection preceding an outbreak of HIV among persons who inject drugs—Kanawha County, West Virginia, 2019-2021. Clin Infect Dis. 2023;76(3):e752-e754. doi:10.1093/cid/ciac619

90.

Hershow

Wilson

Bonacci

, et al Notes from the field: HIV outbreak during the COVID-19 pandemic among persons who inject drugs—Kanawha County, West Virginia, 2019-2021. MMWR Morb Mortal Wkly Rep. 2022;71(2):66-68. doi:10.15585/mmwr.mm7102a4

91.

McClung

Atkins

Kilkenny

, et al Response to a large HIV outbreak, Cabell County, West Virginia, 2018 and 2019. Am J Prev Med. 2021;61(5):S143-S150. doi:10.1016/j.amepre.2021.05.039

92.

Kim

Conyngham

Smith

, et al Understanding the intersection of behavioral risk and social determinants of health and the impact on an outbreak of human immunodeficiency virus among persons who inject drugs in Philadelphia. J Infect Dis. 2020;222(suppl 5):S250-S258. doi:10.1093/infdis/jiaa128

93.

Tookes

Bartholomew

Geary

, et al Rapid identification and investigation of an HIV risk network among people who inject drugs—Miami, FL, 2018. AIDS Behav. 2020;24(1):246-256. doi:10.1007/s10461-019-02680-9

94.

Boyette

, Alaska Department of Health and Social Services. HIV update—Alaska, 2018. State of Alaska Epidemiol Bull. 2019;6:1. Accessed April 18, 2023. http://www.epi.alaska.gov/bulletins/docs/b2019_06.pdf

95.

Alpren

Dawson

John

, et al Opioid use fueling HIV transmission in an urban setting: an outbreak of HIV infection among people who inject drugs‚ Massachusetts, 2015-2018. Am J Public Health. 2020;110(1):37-44. doi:10.2105/ajph.2019.305366

96.

Samoff

Mobley

Hudgins

, et al HIV outbreak control with effective access to care and harm reduction in North Carolina, 2017-2018. Am J Public Health. 2020;110(3):394-400. doi:10.2105/AJPH.2019.305490

97.

Sizemore

Fill

M-M

Mathieson

, et al Using an established outbreak response plan and molecular epidemiology methods in an HIV transmission cluster investigation, Tennessee, January–June 2017. Public Health Rep. 2020;135(3):329-333. doi:10.1177/0033354920915445

98.

Peters

Pontones

Hoover

, et al HIV infection linked to injection use of oxymorphone in Indiana, 2014-2015. N Engl J Med. 2016;375(3):229-239. doi:10.1056/NEJMoa1515195

99.

Ramachandran

Thai

Forbi

, et al A large HCV transmission network enabled a fast-growing HIV outbreak in rural Indiana, 2015. EBioMedicine. 2018;37:374-381. doi:10.1016/j.ebiom.2018.10.007

100.

Vickerman

Hickman

May

Kretzschmar

Wiessing

. Can hepatitis C virus prevalence be used as a measure of injection-related human immunodeficiency virus risk in populations of injecting drug users? An ecological analysis. Addiction. 2010;105(2):311-318. doi:10.1111/j.1360-0443.2009.02759.x

101.

Bull-Otterson

Huang

Zhu

King

Edlin

Hoover

KW.

Human immunodeficiency virus and hepatitis C virus infection testing among commercially insured persons who inject drugs, United States, 2010-2017. J Infect Dis. 2020;222(6):940-947. doi:10.1093/infdis/jiaa017

102.

Bonacci

Moorman

Bixler

, et al Prevention and care opportunities for people who inject drugs in an HIV outbreak—Kanawha County, West Virginia, 2019-2021. J Gen Intern Med. 2023;38(3):828-831. doi:10.1007/s11606-022-07875-w

103.

Platt

Minozzi

Reed

, et al Needle syringe programmes and opioid substitution therapy for preventing hepatitis C transmission in people who inject drugs. Cochrane Database Syst Rev. 2017;9(9):CD012021. doi:10.1002/14651858.CD012021.pub2

104.

Johnson

Rivadeneira

Adegbite

, et al Human immunodeficiency virus prevention for people who use drugs: overview of reviews and the ICOS of PICOS. J Infect Dis. 2020;222(suppl 5):S278-S300. doi:10.1093/infdis/jiaa008

105.

Adams

JM.

Making the case for syringe services programs. Public Health Rep. 2020;135(1):10S-12S. doi:10.1177/0033354920936233

106.

Hofmeister

Yin

Nelson

Weng

Gupta

Trends and opportunities: hepatitis A virus infection, seroprevalence, and vaccination coverage—United States, 1976-2020. Public Health Rep. 2023. In press. doi:10.1177/00333549231184007

107.

Bixler

Roberts

Panagiotakopoulous

Nelson

Spradling

Teshale

EH.

Progress and unfinished business: hepatitis B in the United States, 1980-2019. Public Health Rep. Published online June 9, 2023. doi:10.1177/00333549231175548

108.

van Handel

Rose

Hallisey

, et al County-level vulnerability assessment for rapid dissemination of HIV or HCV infections among persons who inject drugs, United States. J Acquir Immune Defic Syndr. 2016;73(3):323-331. doi:10.1097/QAI.0000000000001098

109.

Council of State and Territorial Epidemiologists. Jurisdiction level vulnerability assessment toolkit. July 2021. Accessed July 24, 2022. https://resources.cste.org/JLVAToolkit_v5

110.

Agency for Toxic Substances and Disease Registry. CDC/ATSDR Social Vulnerability Index. November 2022. Accessed July 24, 2022. https://www.atsdr.cdc.gov/placeandhealth/svi/index.html

111.

Sullivan

Johnson

Pembleton

, et al Epidemiology of HIV in the USA: epidemic burden, inequities, contexts, and responses. Lancet. 2021;397(10279):1095-1106. doi:10.1016/s0140-6736(21)00395-0

112.

Buskin

Erly

Glick

, et al Detection and response to an HIV cluster: people living homeless and using drugs in Seattle, Washington. Am J Prev Med. 2021;61(5, suppl 1):S160-S169. doi:10.1016/j.amepre.2021.04.037

113.

Thomas

Seeff

LB.

Natural history of hepatitis C. Clin Liver Dis. 2005;9(3):383-398, vi. doi:10.1016/j.cld.2005.05.003

114.

Wiessing

Ferri

Grady

, et al Hepatitis C virus infection epidemiology among people who inject drugs in Europe: a systematic review of data for scaling up treatment and prevention. PLoS One. 2014;9(7):e103345. doi:10.1371/journal.pone.0103345

115.

Moorman

Drobenuic

Kamili

Prevalence of false-positive hepatitis C antibody results, National Health and Nutrition Examination Study (NHANES) 2007-2012. J Clin Virol. 2017;89:1-4. doi:10.1016/j.jcv.2017.01.007

116.

World Health Organization. Global Hepatitis Report, 2017. World Health Organization; 2017. Accessed April 18, 2023. https://www.who.int/publications/i/item/9789241565455

117.

Feld

Ward

JW.

Key elements on the pathway to HCV elimination: lessons learned from the AASLD HCV Special Interest Group 2020. Hepatol Commun. 2021;5(6):911-922. doi:10.1002/hep4.1731

118.

Martinello

Yee

Bartlett

, et al Moving towards hepatitis C microelimination among people living with human immunodeficiency virus in Australia: the CEASE Study. Clin Infect Dis. 2020;71(6):1502-1510. doi:10.1093/cid/ciz985

119.

Garvey

Cooke

Smith

, et al

Decline in hepatitis C virus (HCV) incidence in men who have sex with men living with human immunodeficiency virus: progress to HCV microelimination in the United Kingdom?

Clin Infect Dis. 2021;72(2):233-238. doi:10.1093/cid/ciaa021

120.

Braun

Hampel

Ledergerber

, et al A treatment-as-prevention trial to eliminate hepatitis C among men who have sex with men living with human immunodeficiency virus (HIV) in the Swiss HIV Cohort Study. Clin Infect Dis. 2021;73(7):e2194-e2202. doi:10.1093/cid/ciaa1124

121.

Rizk

Miceli

Shiferaw

, et al Implementing a comprehensive HCV clinic within an HIV clinic: a model of care for HCV micro-elimination. Open Forum Infect Dis. 2019;6(10):ofz361. doi:10.1093/ofid/ofz361

122.

Doyle

van Santen

Iser

, et al Microelimination of hepatitis C among people with human immunodeficiency virus coinfection: declining incidence and prevalence accompanying a multicenter treatment scale-up trial. Clin Infect Dis. 2021;73(7):e2164-e2172. doi:10.1093/cid/ciaa1500

123.

Liu

Kao

JH.

Last mile to microelimination of hepatitis C virus infection among people living with human immunodeficiency virus. Clin Infect Dis. 2021;73(7):e2172-e2174. doi:10.1093/cid/ciaa1499

124.

Smit

Boyd

Rijnders

BJA

, et al HCV micro-elimination in individuals with HIV in the Netherlands 4 years after universal access to direct-acting antivirals: a retrospective cohort study. Lancet HIV. 2021;8(2):e96-e105. doi:10.1016/s2352-3018(20)30301-5

125.

Centers for Disease Control and Prevention. Updated US Public Health Service guidelines for the management of occupational exposures to HBV, HCV, and HIV and recommendations for postexposure prophylaxis. MMWR Recomm Rep. 2001;50(RR11):1-42.

126.

Montgomery

Sizemore

Wingate

, et al Development of a standardized, laboratory result–based hepatitis C virus clearance cascade for public health jurisdictions. Public Health Rep. Published online May 4, 2023. doi:10.1177/00333549231170044

127.

Health Resources and Services Administration, HIV/AIDS Bureau. Leveraging a data to care approach to cure hepatitis C within the Ryan White HIV/AIDS Program (RWHAP). Funding opportunity HRSA-20-077. 2020. Accessed April 6, 2023. https://www.hrsa.gov/grants/find-funding/HRSA-20-077

128.

Clement

Collins

Wilder

Mugavero

Barker

Naggie

Hepatitis C virus elimination in the human immunodeficiency virus–coinfected population: leveraging the existing human immunodeficiency virus infrastructure. Infect Dis Clin North Am. 2018;32(2):407-423. doi:10.1016/j.idc.2018.02.005

129.

Centers for Disease Control and Prevention. Integrated viral hepatitis surveillance and prevention funding for health departments (IVHSP): special projects for PWID (component 3). 2022. Accessed March 21, 2022. https://www.cdc.gov/hepatitis/policy/2103_CoAg-comp-3-PWID.htm

130.

Centers for Disease Control and Prevention. Strengthening syringe services programs (SSPs). CDC-RFA-PS22-2208. 2022. Accessed August 1, 2022. https://www.cdc.gov/hepatitis/policy/FO-CDC-RFA-PS22-2208.htm

131.

Centers for Disease Control and Prevention. National Harm Reduction Technical Assistance Center. Accessed April 2, 2022. https://harmreductionhelp.cdc.gov/s

132.

Centers for Disease Control and Prevention. National HIV Behavioral Surveillance (NHBS). 2023. Accessed July 30, 2022. https://www.cdc.gov/hiv/statistics/systems/nhbs/index.html

133.

Centers for Disease Control and Prevention. Lab collaborations. 2022. Accessed July 30, 2022. https://www.cdc.gov/hiv/statistics/systems/nhbs/collaborations.html

134.

Centers for Disease Control and Prevention. Behavioral and Clinical Surveillance Branch. 2022. Accessed August 1, 2022. https://www.cdc.gov/hiv/division-of-hiv-prevention/bcsb/index.html

135.

Centers for Disease Control and Prevention. Injection Drug Use Surveillance Project. 2023. Accessed August 1, 2022. https://omb.report/omb/0920-1325

136.

Centers for Disease Control and Prevention. Overview of notice of funding opportunity announcement (NOFO): PS19-1909. 2019. Accessed August 1, 2022. https://www.cdc.gov/nchhstp/funding/announcements/ps19-1909/index.html

137.

Centers for Disease Control and Prevention. National syringe services program (SSP) evaluation. 2023. Accessed August 1, 2022. https://omb.report/omb/0920-1359

138.

Centers for Disease Control and Prevention. Data Modernization Initiative. 2022. Accessed March 21, 2022. https://www.cdc.gov/surveillance/data-modernization/index.html

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