HCV and HIV Co-Infection among Adolescents and Young

Adults in Massachusetts: Implications for Prevention

Daniel Church, Shauna Onofrey, Betsey John, Kerri Barton, Alfred DeMaria

Massachusetts Department of Public Health August, 2011

Goals of Presentation

Review information on recent increase of hepatitis C virus (HCV) infection among young injection drug users (IDU) in Massachusetts

Discuss a registry match with HCV and HIV surveillance data for adolescents and young adults

Discuss the prevention implications these data have on HIV and viral hepatitis prevention programs

HCV Surveillance in Massachusetts - 1

Hepatitis C has been a reportable disease in Massachusetts since 1992

Reportable both as acute disease and HCV infection (mostly chronic)

Case classification according to CDC Guidelines (2005) Provider-based reporting system, working with local

health departments on acute case investigations No direct funding to support viral hepatitis surveillance

HCV Surveillance in Massachusetts - 2

Viral hepatitis surveillance in Massachusetts is conducted using web-based system (MAVEN)

Reported Cases of HCV Infection in Massachusetts: 2000-2010

0

1000

2000

3000

4000

5000

6000

7000

2000 2002 2004 2006 2008 2010

Confirmed Probable

Data as of 5/2011

HCV Infection Among Youth in Massachusetts

Starting in 2002, an increase of newly diagnosed HCV infection has been noted among youth ages 15-25

Between 2002 and 2007, an increase of 73 to 127 cases per 100,000 population was reported in this age group

MDPH has received over one thousand newly diagnosed cases in this age group annually since 2007

Data suggest the increase is due to youth injecting drugs (mostly heroin)

MMWR: Rates of newly reported cases of hepatitis C virus infection (confirmed and probable) among persons aged 15--24 years and among all other age groups ---

Massachusetts, 2002--2009

MMWR: Age distribution of newly reported confirmed cases of hepatitis C virus infection ---

Massachusetts, 2002 and 2009

* N = 6,281; excludes 35 cases with missing age or sex information. † N = 3,904; excludes 346 cases with missing age or sex information.

Source: Onofrey et al MMWR: May 6, 2011 / 60(17);537-541

What is the response?

All MDPH-funded HIV prevention and screening programs providing education and referral on viral hepatitis 23 programs funded to provide comprehensive

screening, including HIV, HCV and STDs

Provider education CDC Epi-Aid Enhanced surveillance

Major questions remain

How are cases being introduced to injection practices?

How can HCV transmission be prevented in this population?

What does this epidemic look like among those NOT in care (not diagnosed)?

What is the impact on HIV transmission?

Impact of HIV/HCV co-infection

HIV/HCV co-infection has serious negative consequences More rapid HCV disease progression Increased risk of death/liver failure/HCC More limited HIV treatment options

HIV Surveillance in Massachusetts

HIV and AIDS both reportable to MDPH by name (HIV by name since 1/1/2007)

Funded primarily by CDC cooperative agreement Data are maintained in a separate non-networked

system As of 12/1/2008, 18,136 alive HIV/AIDS cases in

Massachusetts 4,870 with history of IDU or MSM/IDU As seen nationally, newly reported HIV cases attributed to

IDU in Massachusetts have decreased in recent years

Data match with HIV/HCV

Data match conducted in January, 2011 Data on reported HCV cases between ages of 15 and

29 years for the period 2005 to 2010 extracted and provided to HIV/AIDS surveillance staff for match

Following data match, data de-identified for analyses 4,381 HCV cases matched to 29,399 cases of

individuals ever reported with HIV/AIDS.

Results of HIV/HCV data match, Massachusetts, 2005-2010

Age Group # Co-infected HIV/HCV

% Male % Female

15–24 years

27 56% 44%

25-29 years

38 63% 37%

Case rates of HIV/HCV co-infection by county

County N Case rate (per 100,000 population)

Worcester 15 9.6

Suffolk 8 3.7

Essex 9 6.5

Hampden 8 8.0

Middlesex 6 1.9

Discussion

Numbers of HIV/HCV co-infection among people ages 15-29 years in Massachusetts is small, despite the evidence for substantial HCV transmission

However, data suggest that HIV is present in some social networks May be more concentrated in urban areas, especially in

central Massachusetts

Risk of HIV acquisition may increase with age/duration of injection

Conclusions

HCV transmission among young IDU in Massachusetts is increasing

HIV/HCV co-infection is evident in this population Numbers are currently small, suggesting opportunity to

prevent HIV infection in this population Implementing effective HCV and HIV prevention

programs and systems for this population is critical HCV prevention in this population is complex and requires

innovative and fully integrated programs HCV prevention is HIV prevention Programs should include screening for both HIV and HCV

Conclusions - 2

Surveillance for HIV and HCV infection is essential for tracking this syndemic Funding needed to support HCV surveillance in all

jurisdictions Increased surveillance on all co-infected cases

indicated

Finally…

Decreased HIV transmission among IDU nationally does not mean that risk of acquisition is absent – expansion and integration of prevention programs for young drug users should be a high priority