The Third National Hepatitis C Strategy 2010 - 2013

5.2 People who inject drugs

Page last updated: July 2010

People who inject drugs are the highest priority population at risk of hepatitis C infection and for hepatitis C prevention efforts. They also comprise a significant proportion of people living with the disease and are a significant priority population for care, treatment and support. Approximately 90 per cent of new and 80 per cent of existing hepatitis C infections are attributed to injecting drug use. These people have education and support needs that can be addressed through access to sterile injecting equipment and harm reduction services, appropriately targeted injecting drug user peer education and information, and support in testing, diagnosis and management, including treatment.

Evidence from surveys of people who access injecting equipment exclusively from pharmacies show higher rates of re-use of equipment than those who access equipment exclusively from NSPs, supporting both the importance of the program and how access to peer education can help.13

The diversity of the population of people who inject drugs is recognised. Recent evidence suggests that people from CALD communities who inject drugs are at greater risk of exposure to hepatitis C because of their higher levels of social isolation and low knowledge of BBVs.14

Aboriginal and Torres Strait Islander peoples who inject drugs have significantly higher rates of hepatitis C. Lack of access to clean equipment, community attitudes and the fear of stigma or discrimination can severely hinder hepatitis C prevention and treatment efforts, particularly in rural and remote communities.

Women, including young women, who inject drugs are believed to be at increased risk of hepatitis C infection due to the power dynamics that often exist between men and women in social networks and injecting practices.15 This extends to a lack of power in decision making about injecting practices and women’s status in the hierarchy of injecting networks.16, 17 Indeed, women in each of this strategy’s priority populations have special needs, including those from CALD backgrounds, those in custodial settings and those living in rural and remote areas.

People who have been exposed to hepatitis C through injecting drug use may not recognise their exposure risk. Stigma associated with injecting drug use and fear of discrimination can make it difficult for people with a history of injecting drug use to access hepatitis C diagnosis and management. Undiagnosed, chronic hepatitis C will cause progressive liver disease18 and associated morbidity and treatment complications. Australia has very high rates of hepatitis C diagnosis, but primary care providers need to remain vigilant to the potential for hepatitis C, particularly in patients with signs of liver disease and irrespective of assumptions about a patient’s risk of exposure.

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5.2.1 Aboriginal and Torres Strait Islander peoples who inject drugs

The Third National Aboriginal and Torres Strait Islander Blood Borne Viruses and Sexually Transmissible Infections Strategy 2010–2013 has also made reducing BBV transmission associated with injecting drug use a priority, in response to recent rises in hepatitis C infections. Successive strategies have cautioned about the potential for HIV to become endemic in Aboriginal and Torres Strait Islander communities. While this has not eventuated, increases in hepatitis C infection among these communities suggest that this could happen.19

Aboriginal and Torres Strait Islander peoples who inject drugs have a higher incidence of hepatitis C than do other Australians. They are significantly over-represented in adult and juvenile custodial settings, which compounds their risk of exposure. Since reporting of their status remains inadequate, estimates of population prevalence are difficult, but would appear to be three-fold higher than the non-indigenous population.20

Aboriginal and Torres Strait Islander peoples may progress to hepatitis C-associated liver disease faster than other population groups because of chronic disease and other risk factors. Ensuring access to culturally appropriate harm reduction strategies, injecting drug user peer education and healthcare and social welfare services is imperative to reduce the impact of hepatitis C on the community.

5.2.2 People at risk of hepatitis C infection as new, or potential injectors

People who are new to injecting are also a high priority population for hepatitis C prevention initiatives. While research results vary somewhat, the median age of initiation to injecting drug use is age 17 to 18 years.21, 22 Young people have a greater dependence on others for administering their first injection and obtaining injecting equipment.23, 24[, 25 There is a high risk of contracting hepatitis C shortly after the onset of injecting.26 It is therefore essential that people new to injecting:
  • have access to education about hepatitis C
  • understand the routes of transmission and the high risk of hepatitis C associated with injecting compared to other modes of drug administration
  • are supported to develop skills to prevent exposure to hepatitis C
  • have access to sterile injecting equipment to reduce their risk of acquiring hepatitis C.
Young people are also at risk of hepatitis C and other BBVs and STIs because of risk taking behaviour and lack of understanding about the routes of transmission and the possible consequences of their actions. People can also be placed at risk of contracting hepatitis C and other BBVs through unsafe piercing and tattooing. As piercing and tattooing is common in young people, it is important that they understand how hepatitis C and other BBVs can be transmitted.

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13 Bryant J, Topp L, Hopwood M, Iversen J, Treloar C & Maher L, ‘Is point of access to needles and syringes related to needle sharing? Comparing data collected from pharmacies and needle and syringe programs in south east Sydney’, Drug and Alcohol Review. In press. Accepted September 2009.
14 Maher L, Jalaludin B, Chant K, Jayasuriya R, Sladden T, Kaldor JM & Sargent PL 2006, ‘Incidence and risk factors for hepatitis C seroconversion in injecting drug users in Australia’, Addiction, vol. 101, pp. 1499–1508.
15 Crockett B & Gifford S 2004, ‘Eyes wide shut’: narratives of women living with hepatitis C in Australia. Women and Health, 39(4): pp. 117–137.
16 Bryant J, Brener L, Hull P & Treloar C ‘Needle sharing in sexual relationships: Serodiscordance and the gendered character of injecting’, Drug and alcohol dependence. In press. Accepted October 2009.
17 Maher L, Jalaludin B, Chant K, Jayasuriya R, Sladden T, Kaldor JM & Sargent PL 2006, ‘Incidence and risk factors for hepatitis C seroconversion in injecting drug users in Australia’, Addiction, 101, pp. 1499–1508.
18 Thein HH & Dore G 2009, ‘Natural history of hepatitis C virus infection’, In Dore G., Temple-Smith, M. & Lloyd A. Hepatitis C: An expanding perspective. IP Communications, Sydney.
19 NCHECR, 2009, National Surveillance Report.
20 Ibid.
21 O’Brien S, Day C, Black E, Thetford C & Dolan K 2006, Injecting Drug Users’ Understanding of Hepatitis C, National Drug and Alcohol Research Centre, technical report no. 262, New South Wales, National Drug and Alcohol Research Centre, University of New South Wales, Sydney.
22 Treloar C, Abelson J, Cao W, Brener L, Kippax S, Schultz M & Bath N, Barriers and incentives to treatment for illicit drug users. Canberra: Commonwealth of Australia, 2004, National Drug Strategy Monograph Series no. 5.
23 Ross J, Cohen J, Darke S, Hando J & Hall , 1994, ‘Transition between routes of administration and correlates of injecting amongst regular amphetamine users’, NDARC Monograph.
24 Queensland Alcohol & Drug Research and Education Centre, 2005, Beyond Transmission: Guidelines for hepatitis C education targetting young people who inject drugs.
25 Abelson A, Treloar C, Crawford J, Kippax S, van Beek I & Howard J, ‘Some characteristics of early onset injecting drug users prior to and at the time of their first injection’, Addiction. 2006; 101: pp. 548–55.
26 Van Beek I, Dwyer R, Dore G, Luo K & Kaldor J, 1998, ‘Infection with HIV and hepatitis C virus among injecting drug users in a prevention setting: retrospective cohort study’, British Medical Journal 1998; 317: pp. 433–43