摘要：Hepatitis C virus infection is a significant public health problem in the United States and an important cause of morbidity and mortality. Recent reports document HCV infection increases among young injection drug users in several US regions, associated with America’s prescription opioid abuse epidemic. Incident HCV infection increases among young injectors who have recently transitioned from oral opioid abuse present an important public health challenge requiring a comprehensive, community-based response. We summarize recommendations from a 2013 Office of HIV/AIDS and Infectious Disease Policy convening of experts in epidemiology, behavioral science, drug prevention and treatment, and other research; community service providers; and federal, state, and local government representatives. Their observations highlight gaps in our surveillance, program, and research portfolios and advocate a syndemic approach to this emerging public health problem. Hepatitis C virus infection is a significant public health problem in the United States and an important cause of morbidity and mortality, surpassing HIV as a cause of death in 2007. 1 An estimated 2.7 to 3.9 million persons in the United States are currently living with HCV infection, 2 and yet the majority of persons who are infected are unaware of their infection 3,4 —placing them at greater risk for cirrhosis, liver cancer, and premature mortality. 5 In 2010, the Institute of Medicine reported that the lack of knowledge and awareness of the seriousness of chronic viral hepatitis among health care providers, policymakers, and at-risk populations—in combination with inadequate resources—has impeded an effective national public health response. 6 Although the incidence of this bloodborne virus has declined in the past 2 decades because, in part, of the screening of the national blood supply initiated in 1992, 3 as well as HIV-prevention interventions aimed at persons who inject drugs, the US Centers for Disease Control and Prevention (CDC) conservatively estimates that approximately 17 000 new HCV infections occur annually in the United States. 7 Furthermore, recent reports document increases in HCV infection among adolescent and young adult injection drug users (IDUs) in several US regions including New York, 8 Massachusetts, 9 and Wisconsin. 10 The parenteral transmission of HCV has long been recognized, but emerging epidemiological data point to several distinct features of these young IDUs who are becoming infected with HCV. When describing the HCV-infected population of the United States from 1999 through 2002, researchers analyzing data from the National Health and Nutrition Examination Survey noted that HCV antibody prevalence was significantly higher among men than women, among non-Hispanic Black relative to non-Hispanic White persons, and among those aged 40 to 49 years. 11 This is in contrast to the findings emerging from outbreak investigations of adolescent and young adult (i.e., ranging from 15 to 29 years of age) IDUs newly diagnosed with HCV who are equally likely to be male or female, predominantly White, and of a younger age. 8–12 The CDC has reported increases in newly identified HCV infections among those aged 15 to 24 years in Massachusetts 9 and persons aged younger than 30 years in New York 8 and Wisconsin. 10 Another telling feature of this emerging epidemic is the observation that the IDUs who are becoming infected with HCV are often found in suburban and rural communities 9,10,13 —not just in urban settings—and that many of these young men and women report a history of oral prescription opioid abuse before the initiation of injection drug use. 10,12,14 In fact, an important observation related to the discussion of emerging HCV infections among younger drug users is its temporal, geographic, and situational overlap with America’s epidemic of prescription drug abuse. Over the past 2 decades, prescription drug abuse—the intentional use of a medication with intoxicating properties outside a physician’s prescription 15 —has increased among youths and young adults in the United States. 16–18 In its 2011 national survey of youths in public and private schools, grades 9 through 12, the CDC reported that nationwide, 20.7% of students had taken a prescription drug without a doctor’s prescription 1 or more times during their life. 19 The survey also reported that taking prescription drugs without a doctor’s prescription was more frequent for White students (22.9%) than for Hispanic (19.4%) or Black (14.7%) students. 19 Furthermore, ethnographic work suggests that prescription opioid abuse is a key factor in the transition to injection drug use; this observation has been made among both urban 20 and rural drug users. 21 On February 26 and 27, 2013, the US Office of HIV/AIDS and Infectious Disease Policy, Office of the Assistant Secretary for Health, hosted a national consultation to better define and identify strategies to address the emerging epidemic of HCV infection among young adults who initiate drug use with oral opioids and then transition to injection drug use. Forty-eight experts in epidemiology, behavioral science, and drug prevention and treatment joined other researchers; representatives of federal, state, and local government; and community service providers to share information, identify knowledge gaps, and suggest approaches that could be undertaken to enhance the public health response to this emerging health problem. The discussions were structured around a primary focus of preventing HCV infection but were, by design, multidisciplinary in nature. This summary presents selected highlights from the presentations and a high-level synthesis of the meeting discussion, including recommendations that emerged for confronting this serious public health issue. Information is framed around 4 cross-cutting themes: epidemiology and surveillance of HCV infection, HCV prevention among IDUs, drug abuse treatment as an HCV-prevention strategy, and multidisciplinary research priorities to address knowledge gaps. Strictly speaking, this was not a consensus conference; instead, the observations and recommendations contained in this commentary were developed by the consultants in small-group breakout sessions.
