Synergies of prevention with HAART and HCV therapy

While secondary prevention of HIV and hepatitis C infection can be accomplished through behavioral risk modification at the level of the individual, treatment of HIV and HCV can prevent further spread at the level of the population. Studies have shown that HIV transmission is much less likely among individuals who have lower levels of circulating virus (Gray et al, 2001). Currently, the best-known way to ensure undetectable levels of virus is through highly active antiretroviral therapy (HAART). However, despite the availability of HAART since 1996 and evidence that injection drug users do adhere to these therapies, achieving both virologic and immunologic response, users consistently lag behind other groups in HAART access (Mocroft et al., 1999; Roca et al., 1999; Celentano et al., 2001). Access to HCV treatment among injection drug users is far worse than even HAART access. Until 2002, US national guidelines for HCV treatment called for exclusion of injection drug users from treatment for HCV, primarily due to concerns related to low adherence and a high risk of re-infection (National Institutes ofHealth Consensus Development Conference Panel Statement, 1997). However, a number of studies have demonstrated that injection drug users could successfully take HCV treatment and re-infection could be avoided if risk-reduction counseling was provided simultaneously (Backmund et al, 2001; Sylvestre, 2002). In response to these findings and advocacy, the guidelines were reversed in 2002 and injection drug use was no longer considered to be an exclusion criterion (National Institutes of Health Consensus Development Conference Panel Statement, 2002). Even with this change, few injection drug users have received HCV treatment, and though approximately 30 percent of IDUs are co-infected with HCV and HIV, even fewer co-infected patients have received treatment (Restrepo et al, 2005; Stoove et al, 2005). HCV treatment is complicated to take and is associated with a high rate of side effects, including depression and suicidal ideation, which can be particularly problematic for this population who have high rates of psychiatric co-morbidity. Efforts are under way to develop new comprehensive care strategies that incorporate HIV treatment, HCV treatment, psychiatric treatment, and other social programs.

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