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HIV/HCV Co-infection: Burden of Disease and Care Strategies in Appalachia

  • The Global Epidemic (SH Vermund, Section Editor)
  • Published:
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Abstract

Purpose of Review

The purpose of this review is to address infection with HIV and hepatitis C in the Appalachian region of the USA and the driving forces underlying this epidemic. We seek to discuss epidemiology of disease and the possible interventions to reduce incidence and burden of disease in this resource-limited area.

Recent Findings

The rise of the opioid crisis has fueled a rise in new hepatitis C infection, and a rise in new HIV infection is expected to follow. Injection drug use has directly contributed to the epidemic and continues to remain a risk factor. Men who have sex with men remains a significant risk factor for HIV acquisition as well.

Summary

Progress has been made in the battle against HIV and, to a lesser extent, hepatitis C, but much more can be done. Limited data on co-infection with HIV/HCV are currently available for this at-risk region, but it is clear that Appalachia is highly vulnerable to co-infection outbreaks. A multipronged approach that includes advances in assessment of co-infection and education for both patients and clinicians can help to recognize, manage, and ideally prevent these illnesses.

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References

  1. Appalachian Regional Commission. Available from: https://www.arc.gov/appalachian_region/theappalachianregion.asp.

  2. Yao N, Alcala HE, Anderson R, Balkrishnan R. Cancer disparities in rural Appalachia: incidence, early detection, and survivorship. J Rural Health. 2017;33(4):375–81.

    Article  PubMed  Google Scholar 

  3. National Academies of Sciences E, and Medicine. In: Richard JB, Morgan AF, Jonathan KP, editors. Pain management and the opioid epidemic: Balancing societal and individual benefits and risks of prescription drug use. Washington, D.C.: National Academies Press; 2017.

    Google Scholar 

  4. Manchikanti L, Helm S 2nd, Fellows B, Janata JW, Pampati V, Grider JS, et al. Opioid epidemic in the United States. Pain Physician. 2012;15(3 Suppl):ES9–38.

    PubMed  Google Scholar 

  5. The opioid epidemic: from evidence to impact. Executive summary: America’s opioid epidemic: from evidence to impact. Alexander G, Frattaroli S, Gielen A, editor. Baltimore: Johns Hopkins Bloomberg School of Public Health; 2017.

  6. Kolodny A, Courtwright DT, Hwang CS, Kreiner P, Eadie JL, Clark TW, et al. The prescription opioid and heroin crisis: a public health approach to an epidemic of addiction. Annu Rev Public Health. 2015;36:559–74.

    Article  PubMed  Google Scholar 

  7. Rudd RA, Seth P, David F, Scholl L. Increases in drug and opioid-involved overdose deaths—United States, 2010-2015. MMWR Morb Mortal Wkly Rep. 2016;65(5051):1445–52.

    Article  PubMed  Google Scholar 

  8. Ahrnsbrak R, Bose J, Hedden S, Lipari R, Park-Lee R. Key substance use and mental health indicators in the United States: results from the 2016 National Survey on Drug Use and Health (HHS Publication No. SMA 17-5044, NSDUH Series H-52). In: Center for Behavioral Health Statistics and Quality Substance Abuse and Mental Health Services Administration (SAaMHSA), editor. Rockville, MD, 2017.

  9. Jones CM. The paradox of decreasing nonmedical opioid analgesic use and increasing abuse or dependence—an assessment of demographic and substance use trends, United States, 2003-2014. Addict Behav. 2017;65:229–35.

    Article  PubMed  Google Scholar 

  10. McCabe SE, West BT, Veliz P, McCabe VV, Stoddard SA, Boyd CJ. Trends in medical and nonmedical use of prescription opioids among US adolescents: 1976–2015. Pediatrics. 2017;139(4):e20162387.

    Article  PubMed  PubMed Central  Google Scholar 

  11. Dart RC, Severtson SG, Bucher-Bartelson B. Trends in opioid analgesic abuse and mortality in the United States. N Engl J Med. 2015;372(16):1573–4.

    PubMed  Google Scholar 

  12. Han B, Compton WM, Jones CM, Cai R. Nonmedical prescription opioid use and use disorders among adults aged 18 through 64 years in the United States, 2003-2013. JAMA. 2015;314(14):1468–78.

    Article  PubMed  CAS  Google Scholar 

  13. Lipari RN, Van Horn SL, Hughes A, Williams M. State and substate estimates of nonmedical use of prescription pain relievers. In: Center for Behavioral Health Statistics and Quality Substance Abuse and Mental Health Services Administration (SAaMHSA), editor. Rockville, MD, 2017

  14. Martins SS, Sarvet A, Santaella-Tenorio J, Saha T, Grant BF, Hasin DS. Changes in US lifetime heroin use and heroin use disorder: prevalence from the 2001-2002 to 2012-2013 National Epidemiologic Survey on Alcohol and Related Conditions. JAMA Psychiatry. 2017;74(5):445–55.

    Article  PubMed  PubMed Central  Google Scholar 

  15. Keyes KM, Cerda M, Brady JE, Havens JR, Galea S. Understanding the rural-urban differences in nonmedical prescription opioid use and abuse in the United States. Am J Public Health. 2014;104(2):e52–9.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Zhang Z IA, Meit M, English N, Dunn M, Bowers K. An analysis of mental health and substance abuse disparities & access to treatment services in the Appalachian Region. In: Reports from the Appalachian Regional Commission. National Opinion Research Center (NORC) at the University of Chicago, and East Tennessee State University, editors. 2008.

  17. Centers for Disease C, Prevention. CDC grand rounds: prescription drug overdoses—a U.S. epidemic. MMWR Morb Mortal Wkly Rep. 2012;61(1):10–3.

    Google Scholar 

  18. Moody L, Satterwhite E, Bickel WK. Substance use in rural central Appalachia: current status and treatment considerations. Rural Ment Health. 2017;41(2):123–35.

    Article  PubMed  PubMed Central  Google Scholar 

  19. Suryaprasad AG, White JZ, Xu F, Eichler BA, Hamilton J, Patel A, et al. Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006-2012. Clin Infect Dis. 2014;59(10):1411–9.

    Article  PubMed  CAS  Google Scholar 

  20. Love MM, Cohn TJ, Pierce TW, Hastings SL. Trends in injection use among prescription opioid-misusing individuals in the rural United States. Rural Ment Health. 2016;40(3–4):180–92.

    Article  Google Scholar 

  21. Young AM, Havens JR, Leukefeld CG. A comparison of rural and urban nonmedical prescription opioid users’ lifetime and recent drug use. Am J Drug Alcohol Abuse. 2012;38(3):220–7.

    Article  PubMed  Google Scholar 

  22. Young AM, Havens JR, Leukefeld CG. Route of administration for illicit prescription opioids: a comparison of rural and urban drug users. Harm Reduct J. 2010;7:24.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Havens JR, Oser CB, Leukefeld CG, Webster JM, Martin SS, O’Connell DJ, et al. Differences in prevalence of prescription opiate misuse among rural and urban probationers. Am J Drug Alcohol Abuse. 2007;33(2):309–17.

    Article  PubMed  Google Scholar 

  24. O’Brien D. Overcoming Opioid Overdose in Rural America. The White House: President Barack Obama. Washington, D.C. 2015. Available from: https://obamawhitehouse.archives.gov/blog/2015/09/21/overcoming-opioid-overdose-rural-america.

  25. Faul M, Dailey MW, Sugerman DE, Sasser SM, Levy B, Paulozzi LJ. Disparity in naloxone administration by emergency medical service providers and the burden of drug overdose in US rural communities. Am J Public Health. 2015;105(Suppl 3):e26–32.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Meit M HM, Tanenbaum E, Hoffmann T. Appalachian diseases of despair. In: Report for the Appalachian Regional Commission. The Walsh Center for Rural Health Analysis National Opinion Research Center (NORC) at the University of Chicago, editor. 2017.

  27. Cicero TJ, Surratt H, Inciardi JA, Munoz A. Relationship between therapeutic use and abuse of opioid analgesics in rural, suburban, and urban locations in the United States. Pharmacoepidemiol Drug Saf. 2007;16(8):827–40.

    Article  PubMed  CAS  Google Scholar 

  28. Havens JR, Young AM, Havens CE. Nonmedical prescription drug use in a nationally representative sample of adolescents: evidence of greater use among rural adolescents. Arch Pediatr Adolesc Med. 2011;165(3):250–5.

    Article  PubMed  Google Scholar 

  29. A comparison of rural and urban substance abuse treatment admissions. In: Center for Behavioral Health Statistics and Quality SAaMHSA, editor. Rockville, MD, 2012.

  30. Disproportionately high rates of substance abuse in Appalachia [press release]. Appalachian Regional Commission (ARC) Study, 2008.

  31. Centers for Disease C, Prevention. Vital signs: overdoses of prescription opioid pain relievers—United States, 1999–2008. MMWR Morb Mortal Wkly Rep. 2011;60(43):1487–92.

    Google Scholar 

  32. McDonald DC, Carlson K, Izrael D. Geographic variation in opioid prescribing in the U.S. J Pain. 2012;13(10):988–96.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Paulozzi LJ, Mack KA, Hockenberry JM. Variation among states in prescribing of opioid pain relievers and benzodiazepines—United States, 2012. J Saf Res. 2014;51:125–9.

    Article  Google Scholar 

  34. Health disparities in Appalachia. In: Report for the Appalachian Regional Commission (ARC)., PDA, Inc., The Cecil G. Sheps Center for Health Services Research, Appalachian Regional Commission, editors. 2017.

  35. Van Handel MM, Rose CE, Hallisey EJ, Kolling JL, Zibbell JE, Lewis B, et al. County-level vulnerability assessment for rapid dissemination of HIV or HCV infections among persons who inject drugs, United States. J Acquir Immune Defic Syndr. 2016;73(3):323–31.

    Article  PubMed  PubMed Central  Google Scholar 

  36. Bluthenthal RN, Wenger L, Chu D, Bourgois P, Kral AH. Drug use generations and patterns of injection drug use: birth cohort differences among people who inject drugs in Los Angeles and San Francisco, California. Drug Alcohol Depend. 2017;175:210–8.

    Article  PubMed  PubMed Central  Google Scholar 

  37. Jones CM, Christensen A, Gladden RM. Increases in prescription opioid injection abuse among treatment admissions in the United States, 2004-2013. Drug Alcohol Depend. 2017;176:89–95.

    Article  PubMed  Google Scholar 

  38. Valdiserri R, Khalsa J, Dan C, Holmberg S, Zibbell J, Holtzman D, et al. Confronting the emerging epidemic of HCV infection among young injection drug users. Am J Public Health. 2014;104(5):816–21.

    Article  PubMed  PubMed Central  Google Scholar 

  39. Jordan AE, Jarlais DD, Hagan H. Prescription opioid misuse and its relation to injection drug use and hepatitis C virus infection: protocol for a systematic review and meta-analysis. Syst Rev. 2014;3:95.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Compton WM, Jones CM, Baldwin GT. Relationship between nonmedical prescription-opioid use and heroin use. N Engl J Med. 2016;374(2):154–63.

    Article  PubMed  CAS  Google Scholar 

  41. Prescription opioids and heroin. In: Report from the National Institute on Drug Abuse (NIDA), editor. Updated 2018.

  42. Muhuri P GJ, Davies M. Associations of nonmedical pain reliever use and initiation of heroin use in the United States. In: Center for Behavioral Health Statistics and Quality Substance Abuse and Mental Health Services Administration (SAaMHSA), editor. Rockville, MD, 2013.

  43. Jones CM, Logan J, Gladden RM, Bohm MK. Vital signs: demographic and substance use trends among heroin users—United States, 2002-2013. MMWR Morb Mortal Wkly Rep. 2015;64(26):719–25.

    PubMed  PubMed Central  Google Scholar 

  44. Jones CM. Heroin use and heroin use risk behaviors among nonmedical users of prescription opioid pain relievers—United States, 2002-2004 and 2008-2010. Drug Alcohol Depend. 2013;132(1–2):95–100.

    Article  PubMed  Google Scholar 

  45. Boodram B, Mackesy-Amiti ME, Latkin C. The role of social networks and geography on risky injection behaviors of young persons who inject drugs. Drug Alcohol Depend. 2015;154:229–35.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Havens JR, Walker R, Leukefeld CG. Prevalence of opioid analgesic injection among rural nonmedical opioid analgesic users. Drug Alcohol Depend. 2007;87(1):98–102.

    Article  PubMed  Google Scholar 

  47. Klevens RM, Hu DJ, Jiles R, Holmberg SD. Evolving epidemiology of hepatitis C virus in the United States. Clin Infect Dis. 2012;55(Suppl 1):S3–9.

    Article  PubMed  PubMed Central  Google Scholar 

  48. Werb D, Buxton J, Shoveller J, Richardson C, Rowell G, Wood E. Interventions to prevent the initiation of injection drug use: a systematic review. Drug Alcohol Depend. 2013;133(2):669–76.

    Article  PubMed  Google Scholar 

  49. Grebely J, Oser M, Taylor LE, Dore GJ. Breaking down the barriers to hepatitis C virus (HCV) treatment among individuals with HCV/HIV coinfection: action required at the system, provider, and patient levels. J Infect Dis. 2013;207(Suppl 1):S19–25.

    Article  PubMed  PubMed Central  Google Scholar 

  50. Havens JR, Lofwall MR, Frost SD, Oser CB, Leukefeld CG, Crosby RA. Individual and network factors associated with prevalent hepatitis C infection among rural Appalachian injection drug users. Am J Public Health. 2013;103(1):e44–52.

    Article  PubMed  PubMed Central  Google Scholar 

  51. Havens JR, Oser CB, Leukefeld CG. Injection risk behaviors among rural drug users: implications for HIV prevention. AIDS Care. 2011;23(5):638–45.

    Article  PubMed  PubMed Central  Google Scholar 

  52. Young AM, Havens JR. Transition from first illicit drug use to first injection drug use among rural Appalachian drug users: a cross-sectional comparison and retrospective survival analysis. Addiction. 2012;107(3):587–96.

    Article  PubMed  Google Scholar 

  53. Staton-Tindall M, Webster JM, Oser CB, Havens JR, Leukefeld CG. Drug use, hepatitis C, and service availability: perspectives of incarcerated rural women. Soc Work Public Health. 2015;30(4):385–96.

    Article  PubMed  PubMed Central  Google Scholar 

  54. Zibbell JE, Iqbal K, Patel RC, Suryaprasad A, Sanders KJ, Moore-Moravian L, et al. Increases in hepatitis C virus infection related to injection drug use among persons aged </=30 years—Kentucky, Tennessee, Virginia, and West Virginia, 2006-2012. MMWR Morb Mortal Wkly Rep. 2015;64(17):453–8.

    PubMed  PubMed Central  Google Scholar 

  55. Denniston MM, Jiles RB, Drobeniuc J, Klevens RM, Ward JW, McQuillan GM, et al. Chronic hepatitis C virus infection in the United States, National Health and Nutrition Examination Survey 2003 to 2010. Ann Intern Med. 2014;160(5):293–300.

    Article  PubMed  PubMed Central  Google Scholar 

  56. Patrick SW, Bauer AM, Warren MD, Jones TF, Wester C. Hepatitis C virus infection among women giving birth—Tennessee and United States, 2009-2014. MMWR Morb Mortal Wkly Rep. 2017;66(18):470–3.

    Article  PubMed  PubMed Central  Google Scholar 

  57. Fleischauer AT, Ruhl L, Rhea S, Barnes E. Hospitalizations for endocarditis and associated health care costs among persons with diagnosed drug dependence—North Carolina, 2010-2015. MMWR Morb Mortal Wkly Rep. 2017;66(22):569–73.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Rates of Persons Living with Diagnosed HIV, 2014. Emory University Rollins School of Public Health, Gilead Sciences. Available from: https://aidsvu.org/map/#{“datatype”:“prevalence”,“maptype”:“county”,“overall”:“selected”,“ratescases”:“rates”}.

  59. Hall HI, Li J, McKenna MT. HIV in predominantly rural areas of the United States. J Rural Health. 2005;21(3):245–53.

    Article  PubMed  Google Scholar 

  60. Conrad C, Bradley HM, Broz D, Buddha S, Chapman EL, Galang RR, et al. Community outbreak of HIV infection linked to injection drug use of oxymorphone—Indiana, 2015. MMWR Morb Mortal Wkly Rep. 2015;64(16):443–4.

    PubMed  PubMed Central  Google Scholar 

  61. Peters PJ, Pontones P, Hoover KW, Patel MR, Galang RR, Shields J, et al. HIV infection linked to injection use of oxymorphone in Indiana, 2014-2015. N Engl J Med. 2016;375(3):229–39.

    Article  PubMed  CAS  Google Scholar 

  62. Morano JP, Zelenev A, Lombard A, Marcus R, Gibson BA, Altice FL. Strategies for hepatitis C testing and linkage to care for vulnerable populations: point-of-care and standard HCV testing in a mobile medical clinic. J Community Health. 2014;39(5):922–34.

    Article  PubMed  Google Scholar 

  63. Young AM, Jonas AB, Havens JR. Social networks and HCV viraemia in anti-HCV-positive rural drug users. Epidemiol Infect. 2013;141(2):402–11.

    Article  PubMed  CAS  Google Scholar 

  64. Aspinall EJ, Nambiar D, Goldberg DJ, Hickman M, Weir A, Van Velzen E, et al. Are needle and syringe programmes associated with a reduction in HIV transmission among people who inject drugs: a systematic review and meta-analysis. Int J Epidemiol. 2014;43(1):235–48.

    Article  PubMed  Google Scholar 

  65. McCormack S, Dunn DT, Desai M, Dolling DI, Gafos M, Gilson R, et al. Pre-exposure prophylaxis to prevent the acquisition of HIV-1 infection (PROUD): effectiveness results from the pilot phase of a pragmatic open-label randomised trial. Lancet. 2016;387(10013):53–60.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Molina JM, Capitant C, Spire B, Pialoux G, Cotte L, Charreau I, et al. On-demand preexposure prophylaxis in men at high risk for HIV-1 infection. N Engl J Med. 2015;373(23):2237–46.

    Article  PubMed  CAS  Google Scholar 

  67. Marrazzo JM, del Rio C, Holtgrave DR, Cohen MS, Kalichman SC, Mayer KH, et al. HIV prevention in clinical care settings: 2014 recommendations of the International Antiviral Society-USA Panel. JAMA. 2014;312(4):390–409.

    Article  PubMed  CAS  Google Scholar 

  68. Gountas I, Sypsa V, Anagnostou O, Martin N, Vickerman P, Kafetzopoulos E, et al. Treatment and primary prevention in people who inject drugs for chronic hepatitis C infection: is elimination possible in a high-prevalence setting? Addiction. 2017;112(7):1290–9.

    Article  PubMed  PubMed Central  Google Scholar 

  69. Zelenev A, Li J, Mazhnaya A, Basu S, Altice FL. Hepatitis C virus treatment as prevention in an extended network of people who inject drugs in the USA: a modelling study. Lancet Infect Dis. 2017;18(2):215–24.

    Article  PubMed  Google Scholar 

  70. Rodger AJ, Cambiano V, Bruun T, Vernazza P, Collins S, van Lunzen J, et al. Sexual activity without condoms and risk of HIV transmission in serodifferent couples when the HIV-positive partner is using suppressive antiretroviral therapy. JAMA. 2016;316(2):171–81.

    Article  PubMed  Google Scholar 

  71. Friedmann PD, Lemon SC, Stein MD, Etheridge RM, D'Aunno TA. Linkage to medical services in the drug abuse treatment outcome study. Med Care. 2001;39(3):284–95.

    Article  PubMed  CAS  Google Scholar 

  72. Bruneau J, Zang G, Abrahamowicz M, Jutras-Aswad D, Daniel M, Roy E. Sustained drug use changes after hepatitis C screening and counseling among recently infected persons who inject drugs: a longitudinal study. Clin Infect Dis. 2014;58(6):755–61.

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Center of Excellence in Inflammation, Infectious Diseases and Immunity, College of Medicine, East Tennessee State University, Johnson City, TN, USA

    Jonathan P. Moorman

  2. Department of Medicine, Division of Infectious Diseases, College of Medicine, East Tennessee State University, Johnson City, TN, USA

    Jonathan P. Moorman & Matthew R. Krolikowski

  3. Department of Community and Behavioral Health, College of Public Health, East Tennessee State University, Johnson City, TN, USA

    Stephanie M. Mathis & Robert P. Pack

  4. Center for Prescription Drug Abuse Prevention and Treatment, East Tennessee State University, Johnson City, TN, USA

    Stephanie M. Mathis & Robert P. Pack

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  1. Jonathan P. Moorman
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  2. Matthew R. Krolikowski
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  3. Stephanie M. Mathis
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  4. Robert P. Pack
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Correspondence to Jonathan P. Moorman.

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Moorman, J.P., Krolikowski, M.R., Mathis, S.M. et al. HIV/HCV Co-infection: Burden of Disease and Care Strategies in Appalachia. Curr HIV/AIDS Rep 15, 308–314 (2018). https://doi.org/10.1007/s11904-018-0404-1

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