Pubdate: Sun, 17 May 2015
Source: Philadelphia Inquirer, The (PA)
Copyright: 2015 Philadelphia Newspapers Inc
Contact:  http://www.philly.com/inquirer/
Details: http://www.mapinc.org/media/340
Author: Don Sapatkin
Bookmark: http://www.mapinc.org/find?143 (Hepatitis)

GETTING THE WORD OUT ON HEPATITIS C, TREATMENT

Every year, hepatitis C kills significantly more Americans than HIV. 
Yet the liver-attacking virus doesn't get nearly the popular respect, 
or trigger the same fears.

That understated reputation will be both a help and a hindrance as 
the public health community tries to control the spread of the virus. 
New cases of hepatitis C rose 150 percent between 2010 and 2013 
nationwide, and even more in New Jersey and Pennsylvania.

By far the highest rates of new cases, according to studies around 
the country, were among adolescents and young adults who inject drugs 
- - particularly in rural areas. This latest wave of hepatitis C is 
linked to the epidemic of addiction to prescription pain pills. As 
tolerance built or money ran out, users began crushing and injecting 
the pills, or buying cheaper heroin, to avoid withdrawal sickness.

Still, baby boomers make up 75 percent of the more than 5 million 
Americans estimated to have hepatitis C. Some of them also injected 
drugs. But many got infected years ago through t ransfusions and 
other contaminated blood products, some while serving in the 
military. Effective screening of donated blood began in 1992, and the 
new- infection rate associated with that source plummeted.

The virus typically causes no symptoms for years; between half and 
three-quarters of people infected don't know it. And though chronic 
infections can eventually cause fatigue and depression, the most 
serious effects, liver cancer and cirrhosis, may not show up for two 
or three decades.

Drugs that can effectively cure the disease with few side effects 
began coming on the market only within the last couple of years, with 
more in the pipeline. They cost tens of thousands of dollars for a 
typical course of treatment, and drugmakers are marketing them 
heavily. The ads are essentially part of a crucial public health 
campaign, because a key element of preventing transmission of 
hepatitis C is simply knowing what it is.

"The important thing is to draw attention to it," said Shruti Mehta, 
an epidemiologist who studies injection-drug users at the Johns 
Hopkins Bloomberg School of Public Health.

HIV was forced into the public's consciousness in the 1980s and ' 90s 
as death spread swiftly through gay communities and AIDS activists 
shamed the government and drugmakers into speeding development of 
effective treatments. Hepatitis C, by contrast, is known as the 
"silent killer."

"There is not as much of a movement for hepatitis C," Mehta said.

People under 30 have no memory of the huge campaign - aimed at HIV 
but benefiting hepatitis C control, as well - for safe sex and clean 
needles. Even today, funding for HIV testing, treatment, and care is 
exponentially greater than for hepatitis C.

Those efforts were concentrated in cities, which historically have 
had the highest rates of HIV and hepatitis C, as well as heroin 
addiction. Advocacy organizations target the highest-risk 
neighborhoods, offering tests and information.

"In rural areas, lots of people may not have come into contact with 
that sort of prevention messaging," said David S. Festinger, a senior 
scientist at the Treatment Research Institute in Philadelphia. 
"People may not understand the consequences of sharing needles."

Philadelphia and Pittsburgh have had needle exchanges for decades - 
users hand in used syringes and get back an equal number of clean 
ones - but they operate in legal gray areas. New Jersey allowed its 
first pilot exchanges to open a few years ago.

Most syringe exchanges offer referrals to treatment and other 
services, and research shows they reduce disease without increasing 
addiction. But they remain controversial and receive no federal 
funding. It took an unprecedented epidemic in a rural Indiana county 
recently for Gov. Mike Pence to approve an emergency exchange 
program. Over the last several months, Scott County has identified at 
least 153 cases of HIV, most of them in people co-infected with 
hepatitis C. It never before had more than five in one year.

"Until the outbreak, the closest place to get an HIV test was about 
30 miles from Scott County," said Alexis Roth, who studies drug-use 
risk behaviors at the Drexel University School of Public Health.

Most rural counties don't have any of the services, from testing to 
outreach and treatment, that are taken for granted in big cities. 
Building the infrastructure would take years and enormous amounts of money.

The initial response to epidemics that are linked to prescription 
drugs has always been to crack down, close pill mills, find the 
physicians who are overprescribing and the patients who are 
doctor-shopping, said Daniel Raymond, policy director of the Harm 
Reduction Coalition in New York.

"We keep seeing t he downstream consequences of failure to ramp up 
treatment," said Raymond. Treatment for HIV is considered a form of 
prevention. The powerful antiretroviral drugs, though not a cure, 
keep the virus at levels so low it will not be transmitted.

The latest hepatitis C treatments are a cure; the virus is gone. For 
injection-drug users, however, banning the disease without attacking 
the addiction will accomplish little; one jab with a dirty needle can 
produce another infection. (Hepatitis C is more easily transmitted 
via needles than by sexual activity; HIV is the opposite.)

Because intravenous drug use has long been considered an urban 
problem, there has been little research into the practices and 
behaviors of addicts in rural areas. The epidemic of prescription 
opioid deaths - mainly from pills taken orally - showed up there 
first, in the late 1990s.

A few recent studies have found rural substance abusers are more 
likely to crush and inject prescription pain pills than shoot heroin, 
which is harder to find far from cities. But pills don't dissolve as 
thoroughly as heroin, requiring bigger needles that can transfer more virus.

More residue also remains on the "works" used to prepare the opioid. 
Even a needle exchange wouldn't get those filters and cookers, adding 
another challenge for controlling the virus.

Preventing the spread of hepatitis C will require multiple approaches.

"There is no single answer," said Festinger, the Philadelphia 
treatment researcher, who likens it to a more familiar health 
challenge. "Diabetes is a combination of, 'you have to take your 
medication, you have to cut down on carbs, you have to exercise,' and 
there also is education."

Nearly all the answers for hepatitis C, however, target the disease 
by first attacking the addiction.

Until proven strategies like medication-assisted treatment and 
syringe exchange programs come to rural areas, "the number of new 
infections will continue to increase" and spread HIV and hepatitis C, 
said Richard S. Garfein, a professor of medicine and an addiction 
specialist at the University of California, San Diego.

"The rate of increase," he added, "will really depend on how 
aggressive our response is."
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MAP posted-by: Jay Bergstrom