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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
                     Confirmed   Probable
7000

6000

5000

4000

3000

2000

1000

  0
       2000   2002      2004     2006       2008   2010
                                                   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
HCV and HIV Co-Infection among Adolescents and Young Adults in Massachusetts: Implications for Prevention
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   % Male   % Female
             HIV/HCV
 15–24           27         56%       44%
 years


 25-29           38         63%       37%
 years
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

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HCV and HIV Co-Infection among Adolescents and Young Adults in Massachusetts: Implications for Prevention

  • 1. 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
  • 2. 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
  • 3. 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
  • 4. HCV Surveillance in Massachusetts - 2  Viral hepatitis surveillance in Massachusetts is conducted using web-based system (MAVEN)
  • 5. Reported Cases of HCV Infection in Massachusetts: 2000-2010 Confirmed Probable 7000 6000 5000 4000 3000 2000 1000 0 2000 2002 2004 2006 2008 2010 Data as of 5/2011
  • 6. 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)
  • 7. 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
  • 8. 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
  • 10. 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
  • 11. 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?
  • 12. 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
  • 13. 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
  • 14. 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.
  • 15. Results of HIV/HCV data match, Massachusetts, 2005-2010 Age Group # Co-infected % Male % Female HIV/HCV 15–24 27 56% 44% years 25-29 38 63% 37% years
  • 16. 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
  • 17. 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
  • 18. 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
  • 19. 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
  • 20. 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