Some careful research on Hepatitis C has yielded largely frightening results. The good news is that the virus can be killed by common disinfectants. The bad news is that infectious quantities of the virus can survive on surfaces for seven days, that the virus is commonly found not just on needles but on other injection equipment (e.g., swabs) and that drug users typically do not heat their drugs (e.g., when they melt heroin in a spoon) long enough to kill Hepatitis C.
Many efforts to make injection drug use safer have been underway for years (e.g. needle exchange), modeled on the experience of HIV prevention. I worked on lifting the federal ban on needle exchange funding, but I had no illusions that whatever good that would do for HIV would extend to Hepatitis C. The challenge is even greater than the above findings suggest: Studies of health care workers who experience accidental needle sticks show that Hepatitis C is many times more transmissible than HIV.
Needle exchange and other programs that attempt to promote safer injection rely on behavioral change. Anyone who has been on a diet knows that behavioral change is hard to do lastingly and perfectly, even for people who are not addicted to a drug. It is therefore unsurprising that research using DNA samples from needles returned to exchange programs shows that most have in fact been shared.
What needle exchange does is make sharing less common in a population rather than eliminate such sharing altogether. With a harder to transmit virus such as HIV, that can be enough, but with an easily transmitted virus such as Hepatitis C, it isn’t. And these things snowball rapidly as easier transmission leads to higher prevalence in the drug using population, which creates more risks of exposure. Modelling research by Harold Pollack shows that programs that attempt to make injection safer can reduce population rates of HIV, but not Hepatitis C.
The reality is that in many cities a person who engages in extensive injection drug use is probably going to contract Hepatitis C. Stopping injection drug use entirely is thus a critical public health goal. Eliminating drug use through abstinence-oriented treatment and mutual help organizations is one important route to achieve that goal, but in no country do such interventions reach even 25% of injection drug users. Oral opiate substitution therapies (e.g., buprenorphine maintenance) — in addition to having many other benefits — achieve higher population coverage and are very effective at dramatically reducing or eliminating injection among opiate dependent people. But we do not have comparable interventions for people who inject methamphetamine and cocaine.
That’s why there is probably a Nobel Prize out there for whoever comes up with a vaccine for this incredibly destructive virus.
Postscript: One of the talented and dedicated people with whom I had the privilege to collaborate on lifting the needle exchange funding ban was Jeff Crowley, Director of the White House Office on National AIDS Policy. I saw the other day that Jeff is leaving the White House, making this is as good an opportunity as any for me to wish him well and thank him for his amazing and inspirational public service.