HIV, Hepatitis C outbreak continues in Indiana

BATESVILLE, IN (FOX19) - It's been months since the story about southeastern Indiana’s HIV epidemic went national and now, the state is still trying to bounce back from what Governor Pence called 'the worst outbreak in state history.' The outbreak is stemming from the widespread heroin problem in the region.

On Thursday, FOX19 NOW spoke with a doctor in Batesville, Indiana who told us if users don't get tested for HIV soon, the problem is only going to get worse.

The heroin crisis in Indiana has caused an explosion of not only HIV cases but Hepatitis C cases in the area as well.

Read more....

Hepatitis C patients who use drugs need multidisciplinary treatment: B.C. study

Treating patients with hepatitis C who inject illegal drugs using only medication is ineffective without also addressing the complex social issues they face, finds a new study from the University of Victoria.

Although new hepatitis C drugs can cure the liver-wasting disease in most patients, new research suggests the treatment does little to help patients who inject drugs, some of society’s most vulnerable citizens who are also the most challenging to help.

“There’s quite a bit of attention to medical advances (in hepatitis C treatment), but it doesn’t really impact the people most affected (by hepatitis C),” said Bruce Wallace, co-author of the study and an assistant professor at UVic’s School of Social Work. “People are being excluded from access to treatment and it is the people who need it the most.

Read more....

Medication Adherence Trial In Hepatitis C Patients Launched

A new medication adherence application from emocha helps keep HCV patients on track.

According to the CDC, approximately three to four million individuals are chronically infected with Hepatitis C Virus (HCV) in the United States and at least three quarters of those who become infected will develop chronic infection which, if left untreated, can produce long-term complications and even death.

HCV therapy has been revolutionized by recent developments in treatments, including oral options that achieve high levels of HCV cure when taken as directed. That means medication adherence is a high priority for both healthcare providers and payers, both in terms of the potential benefits and because of the high costs of these medications, which can be up to $1,000 per pill or more than $80,000 for an entire course of treatment.

Read more....

Understanding HCV disease progression rates among PWID

The Hepatitis C virus (HCV) infection is a chronic blood-borne viral infection that affects an estimated 160 million people, or 2-3% of the population world-wide. Alarmingly, chronic HCV infection accounts for one-quarter of the cases of cirrhosis and hepatocellular carcinoma (HCC). If HCV is left untreated, chronic liver disease will occur in 60-70% of the cases, cirrhosis in 5-20% of the cases, and 1-5% will die from decompensated cirrhosis or HCC.

In most high-income countries, such as the United States, where drug injection is the primary route of HCV transmission, the disease is concentrated among people who inject drugs (PWID). While it is estimated that 50-80% of PWID are chronically infected, fewer than 5% of PWID have received treatment.

In a new study, "Hepatitis C virus (HCV) disease progression in people who inject drugs (PWID): A systematic review and meta-analysis," published in the International Journal of Drug Policy, a team of researchers from New York University's Center for Drug Use and HIV Research (CDUHR) assessed existing data on the natural history of HCV among PWID. A total of twenty-one studies examined over 8500 PWID, who contributed nearly 120,000 person-years at risk, for the study of four major HCV-related outcomes included in the synthesis.

Read more....

Surge in Youth HCV Presents Hepatologists With Tough Choices

Recently Mark S. Sulkowski, MD, of the John Hopkins University School of Medicine, in Baltimore, saw a teenage patient who had contracted hepatitis C after starting to shoot up as a 12-year-old.

The case is but one in a spike of new infections with the hepatitis C virus (HCV) being driven largely by an epidemic of injection drug use, particularly among adolescents and young adults, according to the Centers for Disease Control and Prevention.

“Sadly, with the heroin epidemic, I’m increasingly seeing teenagers in my practice,” Dr. Sulkowski said earlier this year at the inaugural midyear meeting of the American Association for the Study of Liver Diseases.

See more at: 

Hepatitis C cases on rise in northeast Indiana, Allen County proposes needle-exchange program

FORT WAYNE, Ind. (October 6, 2015) — Officials in northeastern Indiana’s Allen County have taken a first step toward creating a needle exchange to combat the county’s growing hepatitis C cases.

The Fort Wayne-Allen County Board of Health unanimously approved a resolution Monday calling for a needle-exchange program to slow the spread of the disease among intravenous drug users.

Allen County has had about 270 new hepatitis C cases during the first nine months of 2015. That’s more than in any of the past three years.

Read more....

NYU Researchers Find Development of Serious Liver Damage in Mid- to Late-adulthood Among People Who Inject Drugs with Untreated Chronic Hepatitis C Infection

October 5, 2015
N-56 2015-16

Few people who inject drugs are engaged in needed care for chronic HCV infection; Early engagement in treatment needs to be a policy priority for these individuals

The Hepatitis C virus (HCV) infection is a chronic blood-borne viral infection that affects an estimated 160 million people, or 2-3% of the population world-wide. Alarmingly, chronic HCV infection accounts for one-quarter of the cases of cirrhosis and hepatocellular carcinoma (HCC). If HCV is left untreated, chronic liver disease will occur in 60–70% of the cases, cirrhosis in 5–20% of the cases, and 1–5% will die from decompensated cirrhosis or HCC.

In most high-income countries, such as the United States, where drug injection is the primary route of HCV transmission, the disease is concentrated among people who inject drugs (PWID). While it is estimated that 50–80% of PWID are chronically infected, fewer than 5% of PWID have received treatment.

In a new study, “Hepatitis C virus (HCV) disease progression in people who inject drugs (PWID): A systematic review and meta-analysis,” published in the International Journal of Drug Policy, a team of researchers from New York University’s Center for Drug Use and HIV Research (CDUHR) assessed existing data on the natural history of HCV among PWID. A total of twenty-one studies examined over 8500 PWID, who contributed nearly 120,000 person-years at risk, for the study of four major HCV-related outcomes included in the synthesis.

Read more....

HCV Current Initiative: Addressing the National Epidemics of Prescription Opioid misuse and Hepatitis C through Unique Partnerships

By Dominique Saunders, Viral Hepatitis Prevention Coordinator, Kansas Department of Health and Environment and Sarah Knopf-Amelung, Project Manager, Mid-America ATTC, University of Missouri-Kansas City School of Nursing and Health Studies - See more at: https://blog.aids.gov/2015/09/hcv-current-initiative-addressing-the-national-epidemics-of-prescription-opioid-misuse-and-hepatitis-c-through-unique-partnerships.

Recently, there has been a spotlight on America’s prescription opioid misuse and overdose epidemics.  However, too often, people remain unaware of the related hepatitis C virus (HCV) epidemic. The Centers for Disease Control and Prevention (CDC) reported an estimated 150% increase in new HCV infections from 2010 to 2013 and, further, that most of the new infections were associated with injection drug use. An analysis of state and national data indicate that a large proportion of new HCV infections are occurring in young people (<30 years of age) in rural and suburban areas who use oral prescription opioid analgesics before transitioning to injecting. - See more at: https://blog.aids.gov/2015/09/hcv-current-initiative-addressing-the-national-epidemics-of-prescription-opioid-misuse-and-hepatitis-c-through-unique-partnerships.

At the same time, recent years have seen advances that have revolutionized the field of hepatitis C. Groundbreaking treatments with cure rates as high as 90-100% are now available.  Preventive screenings without cost-sharing under the Affordable Care Act make HCV screening more accessible for many people.  And the national Viral Hepatitis Action Plan increases coordination across federal programs and includes among its priorities the urgent need to reduce viral hepatitis associated with drug use behaviors. - See more at: https://blog.aids.gov/2015/09/hcv-current-initiative-addressing-the-national-epidemics-of-prescription-opioid-misuse-and-hepatitis-c-through-unique-partnerships.

Read more....

What’s behind Hepatitis C increase in Franklin County?

GREENFIELD — As Hepatitis C rates have risen sharply in Franklin County, neighboring Hampshire County has seen a slower trend and a lower rate, tempered perhaps by prevention efforts.

Franklin County’s rate of 131 newly discovered Hepatitis C cases per 100,000 residents in 2014 was just under the statewide rate of 134, while Hampshire County trailed with a rate of 73. This is a population-adjusted measure, using numbers collected by the Mass. Department of Public Health. In simple numbers, Franklin County had 94 new cases in 2014 and Hampshire County 116.

Greenfield saw 40 newly discovered cases of the blood-borne liver disease in 2014, while its larger sister to the south saw 29. Northampton’s population of 28,549 at the last census outnumbered Greenfield 3 to 2.

Read more....

New hep C campaign to target boomers, IV drug users

A new state-run campaign will heavily push screening for hepatitis C among baby boomers and intravenous drug users.

Set to launch in mid-October, the Delaware Division of Public Health program aims to reach out to health care providers, especially primary care doctors and substance abuse clinicians, to educate them on whom to screen and how the disease is transmitted.

A story in The News Journal this month detailed how the state’s wave of heroin addiction is driving an explosion of hepatitis C cases among intravenous drug users and the barriers they face to get expensive medication.

Read more.....

More than 200,000 Brits chronically infected with HCV

Around 214,000 individuals are chronically infected with hepatitis C (HCV) in the UK, national estimates from Public Health England (PHE) suggest.

Injecting drug use continues to be the most important risk factor for HCV infection in the UK with half of people who inject drugs (PWID) are thought to have been infected in England and Wales; levels are lower in Northern Ireland (23%) and higher in Scotland (57%).

However, across the UK, more individuals are being tested and diagnosed and  “over the last five years particular improvements have been seen in primary care where surveillance indicates that testing has risen by 21%, 46% and 53% in England, Northern Ireland and Scotland respectively”, PHE’s new report Hepatitis C in the UK states.

Read more....

Reinfection after hepatitis C cure: prevention may require long-term support for people who have injected drugs

Reinfection rates after hepatitis C cure among people who inject drug users, as well as past drug users, are relatively low, according to findings from studies from Norway and Canada presented at the International Liver Congress in Vienna in April.

The findings suggest that current and former injecting drug users who have been cured of hepatitis C require ongoing support to remain free of hepatitis C, but also indicate that fears of a high rate of reinfection should not be used as a reason to withhold hepatitis C treatment from people who inject drugs.

A meta-analysis of studies of hepatitis C treatment outcomes in people who inject drugs, published in 2013, found an incidence of between 2.4 and 6.4 per 100 person-years of follow-up, but a subsequent meta-analysis found that the reinfection rate could be as high as 8%. (Aspinall 2013, Hill 2014)

Read more....

Snapshots, by Alan Franciscus, Editor-in-Chief

Article: Prevalence and risk factors for patient-reported joint pain among patients with HIV/Hepatitis C coinfection, Hepatitis C monoinfection, and HIV monoinfection—A Ogdie et al.
   Source:  BMC Musculoskeletal Disorders 2015, 16:93  doi:10.1186/s12891-015-0552-z

A common symptom that people with hepatitis C report is pain—liver pain, muscle and joint pain, fibromyalgia, headaches and the list goes on and on.  The aim of the current study was to determine the prevalence of patient reported joint pain among 3 groups (a total of 202 patients, mostly males): HCV mono-infection (93 patients); HIV-mono-infection (30 patients); and HIV/HCV co-infection (79 patients).  The ages and genders were similar across all three groups.  More than half were Black. 

The Multi-Dimensional Health Assessment Questionnaire was used to determine joint pain and any related symptoms. The patients were also interviewed and their charts were reviewed. 

The Bottom Line:  Joint pain was more commonly reported in HCV-monoinfected patients than in HIV/HCV-coinfected patients—71% vs. 56.  Joint paint was also more commonly reported in HCV mono-infected patients than in HIV-monoinfected patients—71% vs 50%.

The study found that a previous diagnosis of arthritis and current smoking were risk factors for joint pain among people who are infected with hepatitis C. 

Editorial Comment:  This is another reason why everyone with hepatitis C should be treated.  There are so many symptoms and conditions caused by hepatitis C.   

For more information see this month’s HealthWise.

Article: Liver-related death among HIV/hepatitis C virus-co-infected individuals: implications for the era of directly acting antivirals—D Grint et al. 
   Source: AIDS. 2015 Apr 13. [Epub ahead of print]

The new interferon-free therapies provide similar cure rates in people who are co-infected with HIV and hepatitis C as in people who are mono-infected with hepatitis C.  However, access is being restricted due the higher costs of the newer medications.  

In general, people who are co-infected with HIV and hepatitis C have a faster rate of HCV disease progression than someone with hepatitis C mono-infection.  Even so, treatment is being restricted to those with the greatest risk of liver-related death.  The current study sought to provide a degree of guidance on who should be prioritized for receiving the new direct acting antiviral medications (DAAs) or HCV inhibitor combination medications.  The study looked at the liver-related deaths of the people who were co-infected with HIV and hepatitis C.

In the current study 3,941 HCV antibody positive patients who were part of a European study (EuroSIDA) and who were followed-up after 1 January 2000 were included. 

Liver-related deaths accounted for 145 of 670 (21.6%) deaths in the study population. Liver-related death rates peaked in those aged 35-45 years, and occurred almost exclusively in those with at least F2 fibrosis at baseline.  Note: The Metavir scale is F0, no activity, F1 for inflammation, F2 for light scarring, F3 for moderate-severe scarring and F4 for cirrhosis. 

The Bottom Line: The authors reported that the 5- year probability of liver related death (LRD) was low for those with F0-F1, but substantial for those F2, F3 and F4. 

The authors also noted that “treatment with DAAs should be prioritized for those with at least a F2 fibrosis.  Early initiation of cART with the aim of avoiding low CD4 cell counts should be considered essential to decrease the risk of LRD and the need for HCV treatment.” 

Editorial Comment:  I wonder how many people coinfected with HIV/HCV are F0-F1, how quickly people progress from one stage to another, how often do you need to monitor people in stage F0/F1, how much does it cost to monitor, and would it be cheaper in the long run to treat everyone?  

Article: Hepatitis A and B among young persons who inject drugs—Vaccination, past, and present infection. MG Collier et al.
  Source:  Vaccine. 2015 Apr 15. pii: S0264-410X(15)00472-7. doi: 10.1016/j.vaccine.2015.04.019. [Epub ahead of print]

It is recommended that people who inject drugs (PWID) should be vaccinated against hepatitis A (HAV) and hepatitis B (HBV). There is some evidence that some young individuals who were vaccinated as children may have lost their immunity.  The current study sought to understand the current HAV and HBV immunity status among 519 persons who inject drugs.   The study group included 18 to 40 year olds who lived in San Diego—49% were non-Hispanic white, 7% were non-Hispanic Blank, 27% were White Hispanic, 4% were born outside of the U.S. 

The Bottom Line:  After being tested it was found that 47% were susceptible to HBV infection and 63% were susceptible to hepatitis A infection.  Additionally, 26% tested positive for HCV antibodies.  The authors reported that even though the participants believed that they had been vaccinated, many had not.  The authors commented that "Programs serving this population should vaccinate PWIDs against HAV and HBV and not rely on self-report of vaccination."

 
Editorial Comment:  This recommendation makes perfect sense. People forget about what vaccines they received as children or if they were vaccinated at all.  If you have hepatitis C it is even more important to be protected.  Becoming co-infected with another hepatitis virus such as HAV or HBV can lead to serious health consequences, even death.   The HAV vaccine can be given without serologic testing since it will do no actual harm.   It is important, however, to give the HBV serologic test to make sure that people are not already infected with the hepatitis B virus before giving the HBV vaccine.  The HBV vaccine doesn’t provide any benefit to people who have acute or chronic HBV and might just might give people a false sense of security and prevent much needed follow-up medical care.

http://hcvadvocate.org/news/newsLetter/2015/advocate0615.html#3

Cape Cod Hepatitis C rates highest in state among young people

Users of heroin and other intravenous drugs face dangers beyond addiction, prison, and overdose. Deadly blood-borne diseases, transmitted through shared needles, are rampant among IV drug users.

For the past several years, Barnstable County has led Massachusetts in the rate of new infections of Hepatitis C among people aged 15 to 25. An especially dangerous virus that attacks its host’s liver, often resulting in cirrhosis or cancer, Hepatitis C infected 344.3 of every 100,000 residents of Barnstable County in 2012, the latest year for which figures are available. The incidence rate for Plymouth, the second leading county, was 194.57.

Read more...

CDC Issues Health Advisory Concerning HIV And Hepatitis C Co-Infection Outbreaks

Outbreak of Recent HIV and HCV Infections among Persons Who Inject Drugs

This is an official

CDC HEALTH ADVISORY

Distributed via the CDC Health Alert Network
April 24, 2015, 11:00 ET (11:00 AM ET)
CDCHAN-00377

Summary

The Indiana State Department of Health (ISDH) and the Centers for Disease Control and Prevention (CDC) are investigating a large outbreak of recent human immunodeficiency virus (HIV) infections among persons who inject drugs (PWID). Many of the HIV-infected individuals in this outbreak are co-infected with hepatitis C virus (HCV). The purpose of this HAN Advisory is to alert public health departments and healthcare providers of the possibility of HIV outbreaks among PWID and to provide guidance to assist in the identification and prevention of such outbreaks.

Background

From November 2014 to January 2015, ISDH identified 11 new HIV infections in a rural southeastern county where fewer than 5 infections have been identified annually in the past. As of April 21, 2015, an on-going investigation by ISDH with assistance from CDC has identified 135 persons with newly diagnosed HIV infections in a community of 4,200 people; 84% were also HCV infected. Among 112 persons interviewed thus far, 108 (96%) injected drugs; all reported dissolving and injecting tablets of the prescription-type opioid oxymorphone (OPANA® ER) using shared drug preparation and injection equipment.¹

This HIV outbreak was first recognized by a local disease intervention specialist. In late 2014, interviews conducted with three persons newly diagnosed with HIV infections in three separate venues (i.e., an outpatient clinic, a drug rehabilitation program, during a hospitalization) indicated that two of these persons had recently injected drugs and had numerous syringe-sharing and sexual partners. Contact tracing identified eight additional HIV infections leading to the current outbreak investigation, which has demonstrated that HIV had spread recently and rapidly through the local network of PWID. Without an attentive health department, active case finding, and additional testing provided as part of this investigation, this cluster may not have been identified.

Urgent action is needed to prevent further HIV and HCV transmission in this area and to investigate and control any similar outbreaks in other communities.

Injection drug use accounts for an estimated 8%² of the approximate 50,000 annual new HIV infections in the United States.³ & HCV infection is the most common blood-borne infection in the United States and percutaneous exposure via drug-injecting equipment contaminated with HCV-infected blood is the most frequent mode of transmission. Nationally, acute HCV infections have increased 150% from 2010 to 2013,⁴ and over 70% of long-term PWID may be infected with HCV.⁵ Abuse of prescription-type opioids is increasing nationally⁶ and opioid-analgesic poisoning deaths have nearly quadrupled from 1999 through 2011.⁷ Rates of acute HCV infection are increasing, especially among young nonurban PWID, often in association with abuse of injected prescription-type opioids. These increases have been most substantial in nonurban counties east of the Mississippi River.⁸

Recommendations for Health Departments

• Review the most recent sources of data on HIV diagnoses, HCV diagnoses (acute as well as past or present), overdose deaths, admissions for drug treatment, and drug arrests. Attributes of communities at risk for unrecognized clusters of HIV and HCV infection include the following:
  • Recent increases in the:
    • Number of HIV infections attributed to injection drug use,
    • Number of HCV infections, particularly among persons aged < 35 years;
  • High rates of injection drug use and especially prescription-type opioid abuse, drug-related overdose, drug treatment admission, or drug arrests.
• Ensure complete contact tracing for all new HIV diagnoses and testing of all contacts for HIV and HCV infection.
• Ensure persons actively injecting drugs or at high-risk of drug injection (e.g., participating in drug substitution programs, receiving substance abuse counseling or treatment, recently or currently incarcerated) have access to integrated prevention services,⁹ and specifically:
  • Are tested regularly for HIV and HCV infection (consider more frequent testing based on frequency of injection drug usage or sharing of injection equipment);
  • If diagnosed with HIV or HCV infection:
    • Are rapidly linked to care and treatment services;
  • If actively injecting drugs:
    • Have access to medication-assisted therapy (e.g., opioid substitution therapy) as well as other substance abuse services, if not already engaged,
    • Are counseled not to share needles and syringes or drug preparation equipment (e.g., cookers, water, filters),
    • Have access to sterile injection equipment from a reliable source.
  • If not HIV infected but actively injecting drugs:
    • Are referred for consideration of HIV pre-exposure prophylaxis¹⁰ and if potentially exposed within the past 72 hours (e.g., shared drug preparation or injection equipment with a known or potentially HIV-infected person) HIV post-exposure prophylaxis^11,12
• Remind venues that may encounter unrecognized infections, such as emergency departments and community-based clinical practices (e.g., family medicine, general medicine, prenatal care) of the importance of routine opt-out HIV testing as well as HCV testing per current recommendations^13-15
• Local health departments should notify their state health department and CDC of any suspected clusters of recent HIV or HCV infection.

Recommendations for Healthcare Providers

• Ensure all persons diagnosed with HCV infection are tested for HIV infection,¹⁶ and that all persons diagnosed with HIV infection are tested for HCV infection.¹⁷
• Ensure persons receiving treatment for HIV and/or HCV infection adhere to prescribed therapy and are engaged in ongoing care.
• Encourage HIV and HCV testing of syringe-sharing and sexual partners of persons diagnosed with either infection.
• Report all newly diagnosed HIV and HCV infections to the health department.
• For all persons with substance abuse problems:
  • Refer them for medication-assisted treatment (e.g., opioid substitution therapy) and counseling services,
  • Use effective treatments (e.g., methadone, buprenorphine), as appropriately indicated.
• For any persons for whom opioids are under consideration for pain management:
  • Discuss the risks and benefits of all pain treatment options, including ones that do not involve prescription analgesics.
  • Note that long-term opioid therapy is not associated with reduced chronic pain.¹⁸
• Contact the state or local health department to report suspected clusters of recent HIV or HCV infection.

For more information:

• AASLD/IDSA/IAS–USA. HCV testing and linkage to care. Recommendations for testing, managing, and treating hepatitis C. http://www.hcvguidelines.org/full-report/hcv-testing-and-linkage-care
• Centers for Disease Control and Prevention. Integrated Prevention Services for HIV Infection, Viral Hepatitis, Sexually Transmitted Diseases, and Tuberculosis for Persons Who Use Drugs Illicitly: Summary Guidance from CDC and the U.S. Department of Health and Human Services. 2012: http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6105a1.htm?s_cid=rr6105a1_w.
• Centers for Disease Control and Prevention. HIV and Injection Drug Use fact sheet. (http://www.cdc.gov/hiv/pdf/g-l/cdc-hiv-idu-fact-sheet.pdf
• Centers for Disease Control and Prevention. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. 2006; http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm.
• Centers for Disease Control and Prevention and Association of Public Health Laboratories. Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations. http://dx.doi.org/10.15620/cdc.23447
• Centers for Disease Control and Prevention. Testing for HCV infection: an update of guidance for clinicians and laboratorians. MMWR Morb Mortal Wkly Rep. May 10 2013;62(18):362-365.
• Centers for Disease Control and Prevention. MMWR Integrated Services Report. (http://www.cdc.gov/mmwr/preview/mmwrhtml/rr6105a1.htm?s_cid=rr6105a1_w)
• Centers for Disease Control and Prevention. HIV and Injection Drug Use fact sheet. (http://www.cdc.gov/hiv/pdf/g-l/cdc-hiv-idu-fact-sheet.pdf)
• US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States - 2014 clinical practice guideline. 2014; http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf.
• Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. 2015; http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf.

References

1. Spiller MW, Broz D, Wejnert C, Nerlander L, Paz-Bailey G. HIV Infection and HIV-Associated Behaviors Among Persons Who Inject Drugs - 20 Cities, United States, 2012. MMWR Morb Mortal Wkly Rep. Mar 20 2015;64(10):270-275.
2. Centers for Disease Control and Prevention. HIV Surveillance Report, 2013; vol. 25. http://www.cdc.gov/hiv/library/reports/surveillance/, last accessed April 22, 2015.
3. Prejean J, Song R, Hernandez A, et al. Estimated HIV incidence in the United States, 2006-2009. PLoS ONE. 2011;6(8):e17502.
4. Hagan H, Des Jarlais DC, Stern R, et al. HCV synthesis project: preliminary analyses of HCV prevalence in relation to age and duration of injection. The International journal on drug policy. Oct 2007;18(5):341-351.
5. Maxwell JC. The prescription drug epidemic in the United States: a perfect storm. Drug and alcohol review. May 2011;30(3):264-270.
6. Chen LH HH, Warner M. Drug-poisoning deaths involving opioid analgesics: United States, 1999–2011. NCHS data brief, no 166. Hyattsville, MD: National Center for Health Statistics. 2014.
7. Suryaprasad AG, White JZ, Xu F, 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. Nov 15 2014;59(10):1411-1419.
8. Centers for Disease Control and Prevention. Integrated prevention services for HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis for persons who use drugs illicitly: summary guidance from CDC and the U.S. Department of Health and Human Services. MMWR Recomm Rep. Nov 9 2012;61(Rr-5):1-40.
9. US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States - 2014 clinical practice guideline. 2014; http://www.cdc.gov/hiv/pdf/prepguidelines2014.pdf.
10. Centers for Disease Control and Prevention. Antiretroviral Postexposure Prophylaxis After Sexual, Injection-Drug Use, or Other Nonoccupational Exposure to HIV in the United States Recommendations from the U.S. Department of Health and Human Services. 2005; http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5402a1.htm.
11. Kuhar DT, Henderson DK, Struble KA, et al. Updated US Public Health Service guidelines for the management of occupational exposures to human immunodeficiency virus and recommendations for postexposure prophylaxis. Infection control and hospital epidemiology. Sep 2013;34(9):875-892.
12. Centers for Disease Control and Prevention. Revised Recommendations for HIV Testing of Adults, Adolescents, and Pregnant Women in Health-Care Settings. 2006; http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5514a1.htm. Accessed April 22, 2015.
13. Centers for Disease Control and Prevention and Association of Public Health Laboratories. Laboratory Testing for the Diagnosis of HIV Infection: Updated Recommendations. http://dx.doi.org/10.15620/cdc.23447. Accessed April 22, 2015.
14. Centers for Disease Control and Prevention. Testing for HCV infection: an update of guidance for clinicians and laboratorians. MMWR Morb Mortal Wkly Rep. May 10 2013;62(18):362-365.
15. AASLD/IDSA/IAS–USA. HCV testing and linkage to care. Recommendations for testing, managing, and treating hepatitis C. http://www.hcvguidelines.org/full-report/hcv-testing-and-linkage-care. Accessed April 22, 2015.
16. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. 2015; http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed April 22, 2015.
17. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. 2015; http://www.aidsinfo.nih.gov/ContentFiles/AdultandAdolescentGL.pdf. Accessed April 22, 2015.
18. Chou R, Turner JA, Devine EB, et al. The effectiveness and risks of long-term opioid therapy for chronic pain: a systematic review for a National Institutes of Health Pathways to Prevention Workshop. Ann Intern Med. Feb 17 2015;162(4):276-286.

The Centers for Disease Control and Prevention (CDC) protects people's health and safety by preventing and controlling diseases and injuries; enhances health decisions by providing credible information on critical health issues; and promotes healthy living through strong partnerships with local, national and international organizations.

Department of Health and Human Services

HAN Message Types

• Health Alert: Conveys the highest level of importance; warrants immediate action or attention. Example: HAN00001
• Health Advisory: Provides important information for a specific incident or situation; may not require immediate action. Example: HAN00346
• Health Update: Provides updated information regarding an incident or situation; unlikely to require immediate action. Example: HAN00342
• Info Service: Provides general information that is not necessarily considered to be of an emergent nature. Example: HAN00345

###
This message was distributed to state and local health officers, state and local epidemiologists, state and local laboratory directors, public information officers, HAN coordinators, and clinician organizations.
###

Source: http://emergency.cdc.gov/han/han00377.asp