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