Hepatitis C – Epidemiology, Substance Abuse and Treatment

Regional Disparities

Ten countries—China, India, Indonesia, Nigeria, Pakistan, Ethiopia, Bangladesh, Viet Nam, Philippines, and the Russian Federation—collectively shoulder nearly two-thirds of the global burden of both hepatitis B and C.

•Highest Prevalence: Egypt historically reported some of the highest prevalence rates (estimated 15–20% in the past), though it became the first country to achieve WHO “gold tier” status on the path to elimination in 2023.

•Africa: Central Africa has some of the highest regional prevalence rates, with individual countries like Cameroon estimated at 13.8%.

•Europe and Americas: These regions generally show lower prevalence, with most Northern European and North American countries reporting rates below 1%.

Progress Toward 2030 Elimination Goals

The WHO has set a target to diagnose 90% and treat 80% of people with chronic hepatitis by 2030, but current coverage remains low.

•Diagnosis Rate: Only 36% of people living with chronic hepatitis C have been diagnosed as of 2022.

•Treatment Coverage: Approximately 20% (12.5 million people) had received curative treatment by the end of 2022.

•Cure Rates: Modern direct-acting antiviral (DAA) treatments can cure more than 95% of people with hepatitis C, and costs in some low-income countries have dropped to as low as $60 per course.

Substance Abuse and Hepatitis C Link

The link between Hepatitis C (HCV) and substance abuse is primarily driven by blood-to-blood contact during the use of drugs, with injection drug use being the most common risk factor for new infections. However, substance abuse also impacts on how the virus progresses and how easily it can be treated.

1. Transmission Routes

While needles and syringes are the most well-known vehicles for transmission, other methods of substance use also carry risks:

•Injection Equipment: HCV is highly infectious and can survive on surfaces and equipment (like cookers, cottons, water, and alcohol swabs) for up to 6 weeks.

•Non-Injection Drug Use: Sharing pipes for smoking (e.g., crack or methamphetamine) can transmit the virus if the pipe burns or cracks the user’s lips, leading to blood-to-blood contact. Sharing straws or implements for snorting drugs is also a potential route due to nasal membrane erosion and bleeding.

•Secondary Exposure: People with chronic HCV often have a decreased ability for their blood to clot, making it more likely for blood to be present on clothing or nearby surfaces after an injection episode, which can expose others.

2. Impact of Specific Substances

Different substances affect the body’s ability to fight or manage the virus:

•Alcohol: Alcohol use is particularly dangerous for those with HCV because it promotes viral replication and accelerates the progression of liver damage to cirrhosis and liver cancer. It also weakens the immune system’s ability to clear the virus naturally.

•Methamphetamine: Research indicates that methamphetamine can inhibit the body’s innate immunity, specifically suppressing interferon-alpha, which facilitates HCV replication in liver cells.
•General Disinhibition: The use of alcohol or drugs can impair judgment, making individuals more likely to engage in high-risk behaviors like sharing equipment or having unprotected sex.

Hepatitis C Treatment

Primary Addiction Medicine Care of Connecticut offers management and treatment of Hepatitis C infection after a thorough physical exam and appropriate blood work including a Hepatitis C Viral Load and Genotype.

We may recommend additional imaging, such as abdominal ultrasound or FibroScan, and GI specialty consultation if needed.

Modern treatment for Hepatitis C is highly effective, with cure rates reaching 95% to 98%. The standard of care uses Direct-Acting Antivirals (DAAs), which are all-oral medications that have largely replaced older, more difficult treatments like interferon.

1. Common Treatments

•Epclusa (sofosbuvir/velpatasvir): A pangenotypic pill (treats all 6 genotypes) typically taken for 12 weeks.

•Mavyret (glecaprevir/pibrentasvir): A pangenotypic treatment that can often be completed in just 8 weeks for patients without cirrhosis.

•Harvoni (ledipasvir/sofosbuvir): Commonly used for genotypes 1, 4, 5, and 6, with treatment lasting 8 to 24 weeks.

Vosevi (sofosbuvir/velpatasvir/voxilaprevir): This medication is typically used for patients who have not achieved a cure with earlier DAA therapies.

2. How the Treatment Works

DAAs directly target the virus at multiple life cycle stages.

•Targeting Enzymes: The medication blocks specific proteins (enzymes) that the Hepatitis C virus needs to grow and copy itself.

•Stopping Replication: By inhibiting these proteins, the drugs prevent the virus from making new copies. Without the ability to reproduce and spread to new liver cells, the virus eventually dies out and is cleared from the body.

•A Modern Approach: Unlike older treatments that boosted the entire immune system (and caused flu-like symptoms), DAAs target only the virus, leading to fewer and milder side effects.

3. How to Take Medication

Successful treatment depends on strict adherence to your daily schedule.

Frequency: Most regimens require taking one to three pills once daily at about the same time.

4. Food Requirements:

Mavyret and Vosevi should be taken with food to help your body absorb them properly.

Epclusa and Harvoni may be taken either with food or on an empty stomach.

•Duration: A full course usually lasts 8 or 12 weeks. It’s important to finish your entire prescription, even if you begin to feel well, to ensure the virus is completely removed from your body.

•Monitoring: Your doctor will have blood tests 12 weeks after you finish the course. When the virus is no longer detectable, it means you are medically cured (this is called a Sustained Virologic Response, or SVR).