9261 HEPATITIS C REPORT GALLEY - North West Public Health ...

Hepatitis C in 

injecting drug users 

in the North West 

A Multi-Agency Study 

Penny A.Cook Jim M C Veigh Apurva Patel Qutub Syed Ken Mutton Mark A.Bellis





Penny A. Cook, Jim McVeigh, Apurva Patel, Qutub Syed, Ken Mutton and Mark A. Bellis 

Published by 

Public Health Sector 

School of Health and Human Sciences 

Liverpool John Moores University 

70 Great Crosshall Street 

Liverpool L3 2AB 

Tel: +44 (0151) 231 4316 

Fax: +44 (0151) 231 4320 

e-mail: p.a.cook@livjm.ac.uk 

August 2000 

ISBN 1-902051-19-X 

British Library Cataloguing in Publication Data 

A Catalogue record for this book is available from the British Library 

H EPATITIS C IN INJECTING DRUG USERS IN THE N ORTH W EST

S UMMARY 

Viruses such as HIV, hepatitis C and hepatitis B that are transmitted in the blood pose 

a major health threat for people who inject drugs. Hepatitis C is a particular cause for 

concern for several reasons. Firstly, its prevalence is extremely high among injecting 

drug users (IDUs) (reported levels range between 60 - 80%). Secondly, no vaccine is as 

yet available, and the rapid mutation rate of the virus makes the imminent 

development of one unlikely. Thirdly, treatment is often ineffective, with even the most 

advanced treatment available clearing the infection on only 40% of occasions. Finally, 

a high proportion of cases (around 80%) become chronically infected, and of these, 

around 20% go on to develop serious liver damage, such as cirrhosis or hepatic 

carcinomas. Because individuals can have many years of asymptomatic infection before 

presenting to health services with chronic disease, the scale of the problem is hard to 

assess. Moreover, in IDUs infection with multiple strains of hepatitis C or co-infection 

with hepatitis B or HIV is common, and this exacerbates damage to the liver. 

In the wake of the HIV crisis and the provision of needle exchange schemes, IDUs 

reduced the levels of high risk sharing behaviour. However, hepatitis C is much more 

efficiently transmitted in small amounts of blood, and infections occur via indirect 

sharing of other injecting paraphernalia. At present there is no national strategy for 

the screening and treatment of IDUs. Treatment requires a high level of compliance, 

and has unpleasant side effects such as depression. Since IDUs often display chaotic 

behaviour, they are generally not considered suitable for treatment. However, taking a 

hepatitis C test and the counselling that accompanies it may represent an opportunity 

for addressing risk behaviours and possibly stabilising drug use. 

Aims 

Reviewing current knowledge about hepatitis C epidemiology reveals a number of 

factors that are at present unmeasured but necessary to implement effective and 

economic policies for hepatitis C prevention and treatment. Key amongst these is the 

level of infection in wider drug injecting communities in the North West (not just those 

requesting a test or in treatment at specialist drug agencies). Equally however, 

additional data are needed on the risk behaviours associated with infection and 

information is required on whether and how individuals change such behaviour once 

aware of their hepatitis C serostatus. Consequently, a group of IDUs in the North West 

were recruited in order to: 

1. compare the prevalence of hepatitis C among drug users accessing different types 

of service, and among drug users not accessing services 

2 


2. establish the extent of co-infection of hepatitis C and hepatitis B 

3. elucidate risk factors for hepatitis C infection 

4. explore the effect of knowledge of previous hepatitis test results on behaviour 

5. identify factors that predict sharing of equipment 

6. establish a cohort for follow up and establish feasibility of monitoring hepatitis C 

infection among drug using populations using saliva samples (results not covered 

in this report). 

Key Findings and Recommendations 

This study has identified the following key findings and recommendations: 

• Among the 341 injecting drug users in this study, the prevalence of hepatitis C 

was 53.1% (181 people), hepatitis B 26.6% (89 people) and 19.0% (65 people) 

were co-infected with hepatitis C and B (Section 4.1). Although the study was 

relatively small, different areas of study recruitment provided different levels of 

hepatitis C infection, with those presenting to drugs services requesting a test or 

those in treatment with community drugs teams having the highest prevalence. 

Those who had been for a hepatitis C test before this study were 1.68 times more 

likely to be hepatitis C positive in this study, again suggesting that people 

presenting for tests are more likely to be hepatitis C positive (Section 4.4). 

Models of health impact of hepatitis C should consider potential variations in 

prevalence rates between settings and recognise that most studies to date have 

assessed those most at risk of infection. 

• We crudely estimate that there are around 30,200 drug users currently in contact 

with services in the North West. Using estimates of the proportion of these injecting 

drugs, and applying the hepatitis C prevalence of 53% found in this study, we 

estimate that there are 12,800 people currently chronically infected with hepatitis C. 

Of these, 2,600 will go on to develop serious liver damage (cirrhosis or hepatic 

carcinoma) (Section 5.1). This figure does not include the hidden population of drug 

users, previous or new users entering the drug-using population. 

Health Authorities should anticipate the increase in treatment costs associated with 

treating this high number of patients with liver damage over the next twenty years. 

H EPATITIS C IN INJECTING DRUG USERS IN THE N ORTH W EST 

3

• Those who are infected with hepatitis C are four times more likely to also be 

infected with hepatitis B (Section 4.1). Co-infection increases the risk of 

progression to serious disease. 

Current hepatitis B vaccination programmes should attempt to protect people 

early in their drug injecting career before exposure to hepatitis C. 

• Having ever visited prison, and the number of prison stays, were both strong 

predictors of hepatitis C infection (Figure 1). Prison represents a potential injecting 

and non-injecting risk for hepatitis C. For example sharing of personal items such 

as razors may lead to infection, and those few study participants infected but not 

identified as injectors were more likely to have been in prison. 

More awareness of these other, albeit low risk, activities is needed generally but in 

particular in prisons. 

• Chaotic behaviours such as polydrug use (Figure 3), use of less commonly misused 

drugs (Section 4.3) and a longer history of injecting (Figure 2) all predicted hepatitis 

C infection. 

Harm reduction measures can be targeted at such high risk groups and predictors 

identified in this study can be used as indicators as to which populations or 

individuals are at most risk of infection or most likely to be infected. 

• Significant levels of sharing were revealed. Almost 40% had shared some form of 

injecting equipment over the previous four weeks, and 7% had shared needles 

(Table 4). Consistent with more chaotic behaviour, sharing injecting equipment is 

more likely to occur in those with polydrug use (Section 4.5). Also, sharing injecting 

equipment is most common in new injectors (those who have been injecting for up 

to five years) (Figure 5). 

Work is urgently needed to reach young vulnerable groups of drug users who 

have recently begun injecting or may progress to injecting drugs. Such work 

requires education on the risks of injecting to reduce high risk behaviours or 

ideally prevent them even before they begin. 

4 


• A previous positive result for hepatitis C did not appear to result in a change in 

sharing behaviour (Section 4.4). However, those who had presented for previous 

tests were more likely to be reformed sharers (i.e. not currently sharing). This may 

be because counselling received at the time of the test was successful in reducing 

subsequent risk behaviour regardless of the actual results of the test. However, it 

may relate to those asking for a test already having decided to protect their health. 

Further work should examine in more detail the links between hepatitis C testing 

and the identified reduction in sharing behaviour. 

• Sharing injecting equipment is more likely to occur in smaller groups of fellow 

users (Figure 4), possibly because the user feels safe among friends or with a 

partner. The high prevalence of hepatitis C in drug users in the North West means 

sharing with anyone carries a high risk of hepatitis C infection. 

Information about the risks of sharing should stress this includes close friends and 

sexual partners. Health information should also help users address the problems 

around refusing to share with a partner. 

A CKNOWLEDGMENTS 

We would like to thank staff at each drug unit for recruiting subjects and 

administering questionnaires and the drug unit clients for taking part in the survey. We 

thank Rod Thomson and the North West health authorities for supporting this study, 

Gerry Hale for his help in co-ordinating the project, and Nick Beeching (Infectious 

Disease Unit, University Hospital Aintree) and Diana Leighton (Public Health Sector, 

Liverpool John Moores University) for comments on the manuscript. Andrew Weild 

(PHLS Communicable Disease Surveillance Centre) and David Hillier (Prison Health 

Policy Unit) provided helpful information on current policy on hepatitis C education for 

prisoners. Finally, we thank Colin Heron for assistance with the production of this report. 


5

C ONTENTS 

Summary 2 

Aims 2 

Key Findings and Recommendations 3 

Acknowledgments 5 

1 Introduction 8 

1.1 Background 8 

1.2 Transmission 8 

1.3 Prisons 10 

1.4 Drug use in the North West 11 

1.5 Harm reduction policies 13 

1.6 Screening 13 

1.7 Tests for hepatitis C 14 

1.8 Disease course and treatment 14 

2 Aims and Objectives 16 

3 Methods 17 

3.1 Subjects 17 

3.2 Questionnaire 17 

3.3 Testing 18 

3.4 Statistics 18 

4 Results 19 

4.1 Comparison of injectors and non injectors 19 

4.2 Contact groups 21 

4.3 Predictors of hepatitis C and hepatitis B infection 23 

4.4 Previous hepatitis C test history 29 

4.5 Predicting sharing behaviour 30 

4.6 Blood donation 32 

5 Discussion 33 

5.1 Contact Groups 33 

5.2 Co-infection between hepatitis B and hepatitis C 34 

5.3 Risk factors 34 

5.4 Effects of testing on risk behaviour 35 

5.5 Sharing behaviour 36 

5.6 Blood Donation 37 

5.7 Further research 37 

5.8 Conclusions and Recommendations 38 

References 40 

6 


List of tables 

Table 1 Basic results 19 

Table 2 Hepatitis C and B status as determined during this study 22 

and recall of testing history in relation to contact type 

Table 3 Effects of risk factors on the prevalence of hepatitis C and 24 

hepatitis B infection 

Table 4 Percentage of individuals sharing injecting equipment 27 

(ever and in the previous four weeks) by current 

serostatus and test history 

Table 5 Percentage (number) of subjects using and injecting 28 

each type of drug 

List of figures 

Figure 1 Percentage of injecting drug users with hepatitis C and B 23 

infection against number of times individuals have been 

in prison 

Figure 2 Percentage of drug users infected with hepatitis C and B 25 

against length of history of injecting drug use 

Figure 3 Percentage of injecting drug users with hepatitis C and B 26 

infection against number of different drugs injected 

during lifetime 

Figure 4 Percentage of injecting drug users sharing injecting 30 

equipment stratified by size of the group of fellow drug 

takers present when last injecting 

Figure 5 The percentage of injecting drug users sharing any 31 

form of injecting equipment in the previous four weeks 

(needles, syringes or other paraphernalia), categorised 

by time since first injected 


7

1. INTRODUCTION 

1.1 Background 

Viruses such as the human immunodeficiency virus (HIV), hepatitis C and hepatitis B 

that are transmitted through blood pose a major health threat particularly for people 

who inject drugs. Amongst these viruses, hepatitis C represents a growing concern for 

several reasons. Firstly, previous studies in the UK and Ireland suggest that its 

prevalence is extremely high among injecting drug users (IDUs) (between 60% and 

90%: Smythe et al.1998; Goldberg et al. 1998; Lamden et al. 1998; Best et al. 1999). 

Secondly, unlike for hepatitis A and B, no vaccine is as yet available, and the rapid 

mutation rate of the hepatitis C virus makes the imminent development of one 

unlikely (Liang et al. 2000). Thirdly, a high proportion of cases (around 80%) become 

chronically infected, and of these, around 20% go on to develop serious liver damage, 

such as cirrhosis or hepatic carcinoma (Theodore & Fried 2000). Finally, current 

treatment is often ineffective, with even the most advanced treatment available 

clearing the infection on only 40% of occasions (Liang et al. 2000). 

Key objectives in the Government's ten year drug strategy Tackling Drugs to Build a 

Better Britain (1998) include increasing the number of users entering treatment 

programmes, reducing the number of young people using drugs and reducing the 

levels of injecting and sharing of equipment. If these targets are met, the number of 

new hepatitis C infections would decrease. However, currently there are large numbers 

of users in the North West who share equipment who are either infected with hepatitis 

C or at risk of infection (see Section 1.4). The exact scale of the problem is difficult to 

assess as individuals typically have many years of asymptomatic infection before 

presenting to health services with chronic disease. What is clear though, is that the 

high prevalence among IDUs currently accessing drug treatment services suggests 

considerable future health care costs in treating the expected associated rise in liver 

failure and associated morbidity (Leal et al. 1999), as well as the health and social costs 

of prolonged morbidity and disability to those infected with hepatitis C (Dolan 1997). 

1.2 Transmission 

Hepatitis C is primarily transmitted through blood. Prior to screening of blood 

donations, recipients of blood transfusions or blood products were at risk of infection. 

As a result, an estimated 4000 haemophiliacs in the UK have been infected through 

blood products (The Haemophilia Society 1999) and the total number of people 

infected through blood or blood product transfusion and organ donation is estimated 

to be around 7500 (Syed & Snee 1997; CDSC North West 1999). The risk of infection 

through this route dropped dramatically with the introduction of effective heat 

treatment in 1986 (1987 in Scotland) (The Haemophilia Society 1999). The risk then 

dropped further with the introduction of hepatitis C antibody screening in 1991. 

The group now at the highest risk is IDUs. 

8 


The high prevalence of infection among IDUs means that, when sharing needles or 

other injecting equipment occurs, the probability of sharing with an infected individual 

is very high. Furthermore, infection among IDUs occurs very quickly; the risk of infection 

for each year of injecting has been estimated at between 15% and 30% (Rezza et al. 

1996; Hagan et al. 1999), but results of a recent Australian study suggest that the risk 

may be as high as 80% per year injecting in younger users (van Beek et al. 1998). 

Compared to HIV, hepatitis C is transmitted in blood relatively easily. For example, the 

probability of becoming hepatitis C positive following a needlestick injury (3% to 9%) 

is ten times higher than with needlesticks involving HIV (0.3%) (Coutinho 1998). Thus, 

although the length of time since onset of injecting behaviour is a strong predictor of 

hepatitis C infection, a large proportion of users get infected within a year or two of 

beginning injecting (e.g. Smythe et al. 1998; Lamden et al. 1998). Furthermore, 

because of its infectivity, it is not only sharing needles that poses a risk, but also 

syringes, spoons, filters, water; in other words any material used for the preparation of 

the drug and potentially shared between users (collectively called paraphernalia) 

(Renton & Main 1996). This ease of transmission and persistence of infective particles 

increases the probability that those injecting in the presence of other injectors will come 

into contact with the virus even if the user is taking fairly stringent precautions. 

There has been a degree of behaviour change (such as not sharing needles) among IDUs 

towards adopting safer injecting practice in order to avoid HIV infection (Stimson 1995). 

However, the same awareness and behavioural change is yet to be realised for other 

injecting equipment. Thus, many studies report a high prevalence of sharing injecting 

equipment: for example 94% of IDUs in Berlin had shared syringes more than one 

hundred times (Stark et al. 1996) and among British IDUs, 80% had shared some form of 

injecting equipment in the last month (Hunter & Stimson 1998). Even if the probability of 

contracting hepatitis C after a single occasion of sharing paraphernalia is relatively low, 

the likelihood of infection can become high if such sharing behaviour is frequent. 

Seventy percent of people currently living with hepatitis C have had their infections 

attributed to injecting drug use, 10% to blood products, 2% to occupational exposure 

(i.e. needlestick injuries), up to 2% to household contact, 1-2% to tattooing and related 

procedures and up to 1% to sexual contact, with many of the remaining cases having an 

unknown route of transmission (Dolan 1997). This high proportion of unattributed cases 

remains an enigma in the study of the epidemiology of hepatitis C. Unlike HIV and 

Hepatitis B, transmission of hepatitis C through sex appears to be relatively rare 

(Zylberberg et al. 1999). For example, spouses of haemophiliacs infected with hepatitis C 

do not appear to be infected at a higher rate than the general population (Brackmann et 

al. 1993; Thomas 2000). Hepatitis C virus particles have been isolated from the semen of 

infected men in some studies but not others (Semprini et al. 1998; Zylberberg et al. 

1999). Although case studies suggest that sexual transmission is possible, the actual risk 

appears too low to be accurately quantified (Renton & Main 1996). In the rare cases 


9

where sexual partners do get infected, it is hard to rule out the possibility that they 

were infected via other forms of contact, for example by regularly sharing toothbrushes 

or razors, or via unacknowledged injecting drug use (Zylberberg et al. 1999; Thomas 

2000). Population studies also indicate the relatively unimportant role of sexual 

transmission. In Thailand, where the prevalence of hepatitis C among IDUs is high 

(85%), the prevalence among high class sex workers is relatively low at 2% (Suganuma 

et al. 1998), although in part this low prevalence may be due to successful efforts to 

promote condom use. Studies in the USA (Osella et al. 1998) and Australia (Bodsworth 

et al. 1996) support the view that sexual behaviour is also not an important 

transmission route among homosexual men. 

For pregnant IDUs who are infected with hepatitis C, there is a 3-10% risk of passing 

on the infection to the child, with risk of infection increasing with increasing viral load 

of the mother (Resti et al. 1998; Garland et al. 1998) and with co-infection with HIV 

(Resti 1999). Mother to child infection may represent the fastest growing category of 

infection route (Dolan 1997). There may also be a risk of transmitting hepatitis C via 

breast feeding if the mother has a high viral load, either due to infected breast milk or 

traces of blood from cracked nipples (Kumar & Shahul 1998). Other factors that are 

known to damage the liver may be linked to the probability of contracting hepatitis C 

infection when exposed to the virus (e.g. excessive alcohol and drug use even in the 

absence of injecting) (Strugo et al. 1998; Rodriguez et al. 1998). Overall, however, now 

that blood products are routinely screened for the hepatitis C virus, forms of 

transmission other than the use of contaminated injecting equipment are comparatively 

rare. Consequently, extremely efficient transmission through blood and relatively low 

rates of transmission via sexual contact and other routes has led to a pool of infection 

being built up amongst injecting drug users. While generally this may pose a relatively 

small risk to other populations, in particular settings where incidental exposure to 

infected blood may occur, risks may be significant. One such setting is prisons. 

1.3 Prisons 

Previous studies have found that having been to prison is a significant risk factor for 

hepatitis C infection (Crofts et al. 1993; McBride et al. 1994; De Mercato et al. 1995; 

Stark et al. 1996; Weild et al. 2000). Many individuals who are dependent on drugs 

spend periods of time in prison because they commit crimes to support their habit 

(Eaton et al. 1998). Moreover, a considerable proportion of drug users entering prison 

have not previously been in contact with drugs treatment services and are therefore not 

in receipt of treatment for their drug addiction or information on harm minimisation 

(Birtles et al. 1998; Weild et al. 2000). In one prison in Merseyside, over a quarter of all 

new prisoners reported ever having injected drugs (Bellis et al. 1997). Of those who had 

been imprisoned previously, 16% had injected drugs in prison, and over half of those 

had shared equipment in prison (Bellis et al. 1997). In a recent survey of prisons in 

10 


England and Wales, over a quarter of inmates were found to have previously injected 

drugs, 31% of whom had injected in prison, and of those, three quarters had shared 

injecting equipment (Weild et al. 2000). In Scottish prisons, over a third of prisoners had 

a history of injecting drug use (Gore et al. 1999). Correspondingly, the prevalence of 

hepatitis C in prisons is high. In England and Wales, 9% of all adult prisoners (20% of 

adult males on remand) were hepatitis C positive (Weild et al. 2000). In Scotland, 20% 

of all prisoners were hepatitis C positive (Gore et al. 1999). Once in prison, evidence 

suggests that half of drug users continue to use and injecting equipment, when 

available, is likely to be shared by a lot of people (Eaton et al. 1998). 

Prisons are confined environments where the prevalence of hepatitis C is likely to be 

high (Gore et al. 1999; Weild et al. 2000). Even in the absence of sharing injecting 

equipment, occurrences of blood to blood contact, such as sharing of razors and other 

personal items, or involvement in fights, are likely to be frequent. Although in isolation 

each individual event may present a relatively low risk of hepatitis C exposure, several 

such events over time may account for additional cases of infection. Thus, in Scottish 

prisons 3% (Gore et al. 1999) and in English and Welsh prisons 2% (Weild et al. 2000) 

of the non-injectors were positive, a higher prevalence than that estimated for the 

general population, at less than 1% (Renton & Main 1996; Dolan 1997). 

1.4 Drug use in the North West 

The North West has the second highest rate of problematic drug users accessing drug 

treatment services in the UK at 73 per 100,000 according to the national monitoring 

system, the Drugs Misuse Database (DMD) (Birtles et al. 1999). This provides a national 

comparison of drug use, but hugely underestimates the number of individuals even in 

treatment, let alone those using other services, such as agency based syringe exchange 

schemes (SES), pharmacy-based SES and outreach. More injectors again will not be in 

contact with any service at all (Hardi & Bellis 1999) and are thus ommitted from 

monitoring. In those areas of the North West (i.e. Merseyside and Cheshire) for which 

the actual numbers of users attending drugs agencies has been ascertained, the 

numbers of individuals reported to the DMD each year underestimates actual 

attendance by around one third (Birtles & Bellis 2000). In fact, approximately 9,000 

drug users attend Specialist Drugs Agencies each year with 3,500 attending agency 

based SES and 4,500 attending pharmacy based SES in Merseyside and Cheshire. 

Some people use more than one agency type, giving a total of 14,670 individuals 

accessing some form of treatment in Merseyside and Cheshire alone (Birtles & Bellis 

2000). If this rate of drug use is assumed to apply to the rest of the North West 

(although DMD data suggest that rates in the rest of the North West are higher), then a 

crude extrapolation on a population basis gives a conservative estimate of 40,200 drug 

users in contact with services in the North West. Not all of these will have injected 

drugs: around three quarters of users reporting to the DMD have disclosed injecting 


11

ehaviour at some stage in their drug using career (although the rates of injecting 

among those attending SES and pharmacy SES are likely to be higher), giving a 

conservative estimate of 30,200 IDUs. However, statistical estimations of the hidden 

population of drug users in Merseyside (based on the overlap between the number of 

people contacting drugs agencies and those arrested by the police for drug crime) 

suggest that only about half of problematic heroin users are in contact with services 

(Hardi & Bellis 1999). Although this would suggest that there may be twice as many 

problematic drug users in the North West than we have estimated, the proportion of 

the hidden population of drug users who are injectors cannot be determined. 

In the North West of England, 67% of IDUs requesting a hepatitis test tested positive 

for hepatitis C (Lamden et al. 1998). Since the sample was drawn from those requesting 

a test, only a subset of the total population of IDUs was included. Little is known about 

potential differences in patterns of injecting and sharing between groups attending 

different agencies or none at all. A Scottish survey found little difference between 

prevalence of hepatitis C among IDUs recruited from SES, treatment centres and on the 

street (Taylor et al 2000). However, a survey of HIV prevalence among female IDUs in 

London found a higher prevalence in those recruited from the community than in those 

attending treatment agencies (Judd et al. 1999). Therefore, the assessment of the levels 

of hepatitis C in the wider drug using communities requires sampling individuals 

attending different services as well as those not in contact with services at all (Aim 1 of 

this study). 

Of the new agency episodes reported to the DMD, 73% were clients who reported 

having injected at some stage previously, and of those, 48% reported ever having 

shared injecting equipment (Birtles et al. 1999). A high proportion of those using drugs 

have periods of imprisonment, where continued drug use and levels of sharing are 

high (Eaton et al. 1998; section 1.3). However, estimations of sharing behaviour often 

rely on a single question on sharing behaviour that may not measure the extent of 

sharing (Hunter & Stimson 1998). In depth questions on sharing behaviour of IDUs in 

the North West revealed that around 80% of IDUs had shared injecting equipment in 

the previous four weeks (Speed & Bennet 1997). Moreover, there was a lack of 

knowledge among IDUs as to the risks of sharing injecting paraphernalia compared to 

the more well known risks of sharing needles and syringes (Speed & Bennett 1997). 

The number of people in contact with services who share injecting equipment in the 

North West can be estimated, assuming 80% of the estimated 30,200 IDUs share. 

This leads to the prediction that there are around 24,100 current drug users who have 

shared injecting equipment. Conservatively, this ignores those that have used drugs in 

the past but now abstain from drugs and do not use drugs services. 

12 


1.5 Harm reduction policies 

Compared to the high prevalence of hepatitis C, the prevalence of HIV among IDUs in 

the UK has remained low at under 1% (Unlinked Anonymous Surveys Steering Group 

1999). This low prevalence has often been attributed to the prompt introduction in the 

UK of harm reduction strategies such as syringe exchange schemes (SES) (Stimson 

1995). In contrast, in the USA, where such schemes were not adopted very rapidly, 

there is a large pool of IDUs infected with HIV (Stimson 1995). However, the high 

prevalence of hepatitis C infection suggests that this pragmatic approach to decreasing 

the spread of blood borne infections has been less successful at preventing hepatitis C. 

Several studies report no decline in incidence or prevalence of hepatitis C after 

adoption of harm reduction policies such as methadone treatment and SES (Lamden et 

al. 1998; Hagan et al. 1999; Crofts et al. 1997) and where effects are reported the 

reduction is rather small (Rezza et al. 1996). However, the decline in hepatitis C 

prevalence among IDUs in Scotland has been attributed to the introduction of SES 

(Goldberg et al. 1998; Taylor et al. 2000). Similarly, in Switzerland, Broers et al. (1998) 

found a decrease in prevalence from 91% to 30%. These mixed findings on the effect 

of harm reduction measures are difficult to interpret. 

Studies evaluating harm reduction policies need to take into account many factors 

such as the advice given and the desire of the clients to change their behaviour as well 

as established trends prior to the intervention. Relevant to this study however, factors 

that could lead to harm reducing behaviour need to be identified in order to measure 

any effect they may have on hepatitis C infection. One potential factor still in need of 

study is whether having a hepatitis C test, and consequently knowledge of serostatus, 

has an effect on behaviour (Aim 4 of this study). 

1.6 Screening 

Due to the limited success of treatment, the benefits of screening or even offering 

tests for hepatitis C have been questioned from a clinical perspective. At present 

treatment is not offered routinely to anyone with hepatitis C, and there are no 

nationally agreed guidelines for managing hepatitis C infections and no screening 

programmes for drug users, leaving health authorities to respond individually (Syed & 

Snee 1997; CDSC North West 1999). Calculations show that, despite the high cost of 

treatment, screening and treatment may be cost effective in the long term (Leal et al. 

1999; Dusheiko & Roberts 1995). In addition, a screening programme would allow 

monitoring and counselling of infected individuals. Such counselling may also 

discourage other risk behaviours that may aggravate hepatitis C infection, for example 

alcohol use (Datz et al. 1999; Theodore & Fried 2000). Moreover, individuals' 

knowledge of hepatitis C status may encourage safer injecting behaviour, either to 

avoid infection or to avoid infecting others ('the altruistic response'). In a study of IDUs 

infected with HIV in several European countries, those knowing their status were more 


13

likely to use a condom and less likely to pass on used injecting equipment to others 

(Schlumberger et al. 1999). However, this response is only likely if individuals who have 

been tested perceive and understand their result correctly. In a study of IDUs in 

London, over half of people who had previously been for a hepatitis C test either did 

not know their status or incorrectly thought themselves to be negative (Best et al. 

1999), although some of these could have had correct recall of their test result and 

subsequently become infected. To understand the potential impact of wider screening 

it is necessary to determine whether correct perceptions of test results are related to 

risk taking behaviour IDUs (Aim 4 of this study). 

1.7 Tests for hepatitis C 

A hepatitis C infection can be detected through the identification of specific 

antibodies. However, this does not distinguish past from present infection: the 20% 

who have naturally removed the infection, or those who have had successful 

treatment, will still test positive. Current infection is confirmed by the presence of the 

virus in the blood (by detecting viral RNA) using polymerase chain reaction (PCR) tests. 

As the disease progresses, the virus and / or the cellular immune response to hepatitis 

C virus damages the liver cells and liver enzymes are released into the blood. 

Measurement of the level of enzymes in the blood can provide information on the 

course of the disease and the effectiveness of treatment. However, the most accurate 

way to measure the progression of damage to the liver is to take a biopsy of the liver 

and perform microscopic investigation of its structure (Dusheiko et al. 1996). 

1.8 Disease course and treatment 

The outcome of infection by hepatitis C is very variable (Theodore & Fried 2000). Initial 

acute infection with hepatitis C may be accompanied by transient flu-like symptoms, 

but in many cases the infection passes unnoticed. Calculations based on those infected 

with the virus via blood transfusions indicate that of those with acute infection, the 

majority (around 80%) develop chronic hepatitis C infection and remain infectious to 

others, with 20% of those progressing to cirrhosis over a 20 year period (Theodore & 

Fried 2000). After development of cirrhosis, approximately 1% per year go on to 

develop liver cancer (Tong et al. 1995). When severe liver damage occurs, a liver 

transplant can be given but the new liver will eventually become infected. However, 

progression to severe disease is very variable and is influenced by gender (males are 

more susceptible), alcohol use, the genotype of the virus and the genes of the host's 

immune system (Datz et al. 1999; Theodore & Fried 2000). The consequences for 

those acquiring the infection via injecting drug use are even less well known. 

Because IDUs tend to contract the infection at a younger age (on average), and may 

be exposed on more than one occasion to different strains of the virus, the risk of 

serious liver disease may be higher (Renton & Main 1996; Dolan 1997). 

14 


A course of treatment usually comprises injections of interferon alpha three times a 

week for a year. This treatment successfully clears the virus in only 20% of cases 

(Liang et al. 2000), with some individuals simply not responding and some relapsing 

after treatment finishes. Failed treatment may increase the severity of the eventual liver 

disease (Dusheiko et al. 1996). However, the latest treatment, combination therapy 

with interferon and ribavirin, increases the success rate to 40% (Liang et al. 2000). 

Combination therapy is expensive, at around £6,000 per patient (but the cost of this 

may be considerably less than the social and medical costs of letting the disease 

progress untreated: Leal et al. 1999). Treatment is associated with unpleasant side 

effects such as nausea and depression and requires a high level of compliance 

(Liang et al. 2000). In contrast, the behavioural characteristics of IDUs can be chaotic 

and consequently the demands of the treatment regime have been considered by 

some to make it unsuitable for this group of patients (Renton & Main 1996). 

Furthermore, since the risk of re-infection is high (immunity is not obtained even if the 

infection is cleared from the body: Liang et al. 2000), it is generally only recommended 

for individuals who are definitely drug free. 

Although there is no evidence that continued drug use increases progression to severe 

liver disease, alcohol use and co-infection with other viral infections such as HIV and 

hepatitis B do appear to increase the risk of serious disease (Pol et al. 1998; Tagger et 

al. 1999; Allory et al. 2000). Conversely, hepatitis C infection appears not to accelerate 

the course of HIV disease (Haydon et al. 1998; Staples et al. 1999), although this may 

depend on the genotype of the hepatitis C virus (Dieterich 1999). The management of 

treatment in cases of co-infection with HIV is complex (Dusheiko et al. 1996) and there 

is an increased risk of transmission of hepatitis C from mother to child (Resti 1999). 


15

2. AIMS AND O BJECTIVES 

Reviewing current knowledge about hepatitis C epidemiology reveals a number of 

factors that are at present unmeasured but necessary to implement effective and 

economic policies for hepatitis C prevention and treatment. Key amongst these is the 

level of infection in wider drug injecting communities in the North West (not just those 

requesting a test or in treatment at specialist drug agencies). Equally however, 

additional data are needed on the risk behaviours associated with infection and 

information is required on whether and how individuals change such behaviour once 

aware of their hepatitis C serostatus. Consequently, a group of IDUs in the North West 

were recruited in order to: 

1. compare the prevalence of hepatitis C among drug users accessing different types 

of service, and among drug users not accessing services 

2. establish the extent of co-infection of hepatitis C and hepatitis B 

3. elucidate risk factors for hepatitis C infection 

4. explore the effect of knowledge of previous hepatitis test results on behaviour 

5. identify factors that predict sharing of equipment 

6. establish a cohort for follow up and establish feasibility of monitoring hepatitis C 

infection among drug using populations using saliva samples (results not covered 

in this report). 

16 


3. METHODS 

3.1 Subjects 

Study participants were recruited and laboratory analyses of samples undertaken 

between 1997 and 1999 for the Wirral sample and between 1998 and 1999 for the 

Manchester sample. The aims of the study necessitated drawing drug users from a 

wide variety of services as well as attracting groups of users not currently in contact 

with services. Consequently, subjects were either in contact with treatment agencies in 

Drugs North West and Wirral Drugs Service or not in contact with any drugs services. 

There were 110 people recruited through community drug teams, 112 from syringe 

exchange schemes and 23 through outreach. Forty five people were recruited on their 

first ever visit to a drugs agency, and 60, who were not in contact with treatment 

agencies, were recruited via a snowballing technique through the existing service 

users. Forty eight people presented at Wirral Drugs service specifically to request either 

an HIV, hepatitis B or C test and were invited to join the study (referred to as 'self 

presenters'). Nine further drug users were recruited through other sources (for 

example, some were resident in an in-patient facility). 

3.2 Questionnaire 

Subjects completed a questionnaire ascertaining drug taking, sharing of needles and 

other equipment, previous hepatitis B and C test history and sexual behaviour. Drug 

taking history elicited information on whether the subject had ever used or injected 

each of 14 named drugs, and whether they had used or injected these same drugs in 

the previous four weeks. Participants were also given the opportunity to identify any 

drug other than those on the list that they had used or injected. Sharing questions 

identified whether the subject had ever, or in the previous four weeks, shared needles, 

spoons, syringes, filters or other injecting equipment (such as water used in the 

preparation of drugs). The age of first use of drugs, the age of first injecting behaviour 

and the size of the group of fellow users on the previous occasion that the subject had 

injected was determined. Subjects were also asked if they had ever been to prison, and 

if so, on how many occasions. Sexual behaviour questions determined how many male 

and female partners the subjects had ever had, and had in the previous four weeks, 

and what their usual method of contraception had been. Questions on previous test 

history asked whether subjects had ever taken tests for hepatitis C or hepatitis B, and 

if so, what their results had been. 

Questionnaires were self-administered, but a drug worker was present if any clarification 

of questions was needed. Participants had a choice of named or anonymous participation. 

Those who were named were notified of their test result and consequently formed part of 

a cohort for follow up (see Aim 6). Two hundred and fifty nine (64%) volunteered to be 

part of the follow up group and therefore provided identifying details. 


17

3.3 Testing 

Subjects gave blood and saliva samples 1 . Blood samples were tested by the Liverpool 

and Manchester Laboratories of Public Health Laboratory North West for hepatitis B 

core antibodies and antibodies to hepatitis C. These measures give an indication of 

infection at some point (previous or current) with the hepatitis viruses. In the case of 

hepatitis B, only around 5% become chronic carriers of the virus, so many of the 

positives will be the result of previous infection. For hepatitis C, around 80% of the 

positive results are likely to be people with chronic infection. In this study, having ever 

been infected was used as the best measure of risk factors for infection. Consequently 

all analyses refer to whether hepatitis C or B antibodies were detected in samples. 

All samples testing positive for hepatitis C antibody were re-tested with a second enzyme 

linked immunosorbent assay (ELISA) test in order to confirm the positive hepatitis C 

antibody test. Samples remaining inconclusive were analysed using recombinant 

immunoblot assay (RIBA-III) and polymerase chain reaction (PCR). Individuals testing 

positive for hepatitis C were referred to local clinical services for full clinical examination 

and appropriate assessment for treatment, counselling and monitoring. 

3.4 Statistics 

Comparisons were made using chi-square tests and t tests between those who had 

ever been or never been hepatitis B and C positive, between sharers of equipment and 

non-sharers, and between those taking previous hepatitis B and C tests and those not. 

Univariate results are presented as means and odds ratios (OR) with 95% confidence 

intervals (CI). Then, significant variables were entered into multivariate logistic 

regression models to identify which were independent predictors of hepatitis B and C 

infection, sharing injecting equipment and taking a hepatitis B or C test. Results of 

multivariate analyses are presented as adjusted OR and 95% CI. 

1 The saliva samples were retained for comparison with the blood test results to ascertain the potential of saliva 

testing as a method of detecting hepatitis C infection in this type of survey. Results will be presented elsewhere. 

18 


4. RESULTS 

A basic breakdown of results, split by those who had injected at some stage during 

their life and those who claimed never to have injected, is given in Table 1. 

4.1 Comparison of injectors and non injectors 

There were 407 completed questionnaires, 21 of which were excluded because their 

matching hepatitis C results were equivocal or there was insufficient blood sample for 

analysis (5 and 17 respectively). Of the remaining 386, 45 claimed never to have 

injected. A comparison of those who have never injected with those who have is 

shown in Table 1a. Injectors were more likely to be male, were more likely to have 

been in prison, had been to prison on more occasions, and were more likely to have 

taken a prior hepatitis C test. Injectors were over four times more likely to be infected 

with hepatitis C (odds ratio and confidence intervals, OR = 4.45, CI 1.73-11.4). 

Table 1a: Basic results: characteristics of injecting & non-injecting drug users 

Injectors Non injectors P 

Number 341 45 

Mean Age (years) 29.5 27.9 NS 1 

Percent (number) male 72.3% (245) 42.2% (19) 3 sexual partners 

in previous 12 months 

4.1% (14) 13.3% (6) 0.009 2 

15.0% (51) 31.1% (14) 0.023 2 

NS non significant, 1 t test, 2 chi-square test, 3 of those who had been to prison at least once, 

4 other than HIV, hepatitis B or C 


19

Table 1b: Basic results: behaviours of injecting drug users 

Sharing in previous 4 weeks 

Needles 7.3% (25) 

Syringes 7.3% (25) 

Spoons 34.6% (118) 

Filters 27.6% (94) 

Other 5.0% (17) 

Any 37.8% (129) 

Sharing ever 

Needles 53.7% (183) 

Syringes 53.1% (181) 

Spoons 82.1% (280) 

Filters 71.6% (244) 

Other 23.2% (79) 

Any 85.0% (290) 

Size of group when injecting 

Alone 24.6% (82) 

One other 40.5% (135) 

2 - 5 others 30.9% (103) 

More than 5 others 3.9% (13) 

Age at first injection 

Of the 45 who claimed never to have injected, eight had been or were currently 

infected with hepatitis C. These infected non-injectors were nearly 20 times more likely 

to have been in prison than non infected non-injectors (seven out of eight compared 

to nine out of 25: odds ratio OR = 19.4, CI 2.1-180.7, X 2 = 10.23, P = 0.001), and 

were over twenty times as likely to have taken heroin in the previous four weeks 

(seven out of eight compared to nine out of 28; OR = 21.8, CI 2.4-201.7; X 2 = 11.46, 

P = 0.001). However, two of the individuals were recruited through SES which could 

suggest that some of these eight did not identify their real injecting status (although 

attendance at SES to access other services or accompany an injecting friend could not 

be ruled out). 

Subsequent analysis was limited to the 341 who claimed to have injected a drug at 

some stage in their life. Among this group, the prevalence of hepatitis C was 53.1% 

(181 people), 26.6% (89 people) had been infected with hepatitis B and 19.0% 

(65 people) had been infected with both hepatitis C and B. People who were positive 

for antibodies to one virus were over four times as likely to also be positive for the 

other (OR = 4.25, CI 2.42-7.46; P

Table 2: Hepatitis C and B status as determined during this study and recall of 

testing history in relation to contact type 

Hepatitis C 

SES Outreach CDT Self New Not in Other p 2 

presenting 1 (first contact) contact 

Number 104 17 88 42 41 40 9 

% hepatitis C antibody 

positive (this study) 

48.1 58.8 61.4 61.9 48.8 45.0 33.0 0.255 

% previously taken test 28.3 29.4 24.0 25.6 33.3 23.3 55.6 0.488 

% not previously taken test 65.1 64.7 63.0 67.4 50.0 65.1 44.4 

% do not know 6.6 5.9 13.0 7.0 16.7 11.6 0.0 

Number having taken a 

test previously 

30 5 24 11 14 10 5 

% positive (previous test) 36.7 40.0 37.5 45.5 21.4 50.0 20.0 0.782 

% negative (previous test) 46.7 40.0 50.0 27.3 50.0 50.0 40.0 

% don’t know (previous test) 16.7 20.0 12.5 27.3 28.6 0.0 40.0 

Hepatitis B 

Number 106 17 100 43 42 43 9 

% hepatitis B positive 

(this study) 24.0 6.7 33.0 41.0 20.0 22.5 11.1 0.067 

% previously taken test 42.5 41.2 42.0 39.5 42.9 34.9 55.6 0.066 

% not previously taken test 53.8 58.8 40.0 55.8 47.6 58.1 33.3 

% do not know 3.8 0.0 18.0 4.7 9.5 7.0 11.1 

Number having taken a 

test previously 

45 7 42 17 18 15 5 

% positive (previous test) 24.4 0.0 23.8 17.6 16.7 13.3 0.0 0.145 

% negative (previous test) 68.9 85.7 59.5 64.7 44.4 80.0 60.0 

% don’t know (previous test) 6.7 14.3 16.7 17.6 38.9 6.7 40.0 

1 People presenting at Wirral Drugs Service specifically to request either an HIV, hepatitis B or C test who were 

invited to join the study, 2 chi-square P values 

22 


4.3 Predictors of hepatitis C and hepatitis B infection 

Using basic univariate analyses similar risk factors were found to predict both hepatitis 

B and C infections, as shown in Table 3. The most important factors were being in 

prison (and the number of occasions in prison: Figure 1), the length of time since the 

onset of injecting behaviour (Figure 2) and polydrug use (i.e. ever having injected more 

than one type of drug: Figure 3). 

Figure 1: Percentage of injecting drug users with hepatitis C and B infection 

against number of times individuals have been in prison 

% INFECTED 

80 

70 

60 

50 

40 

30 

20 

10 

0 

HEPATITIS C + HEPATITIS B + 

Never 1 2-5 6-9 10+ 

NUMBER OF TIMES IN PRISON 

H EPATITIS C IN INJECTING DRUG USERS IN THE N ORTH W EST 23

Table 3: Effects of risk factors on the prevalence of hepatitis C and hepatitis B 

infection 

CHARACTERISTIC Hepatitis C Hepatitis B 

+ ve (n=181) -ve (n=160) P 1 +ve (n=89) -ve (n=245) P 1 

Being male 72.9% (132) 71.5% (113) NS 80.9% (72) 70.4% (171) * 

Being from Wirral 69.6% (126) 65.0% (124) NS 69.7% (62) 64.5% (158) NS 

Been in prison 72.4% (131) 51.3% (82) **** 77.5% (69) 56.7% (139) **** 

Lived abroad 14.4% (26) 12.5% (20) NS 13.5% (12) 13.9% (34) NS 

Shared equipment abroad 4.4% (8) 1.3% (2) * 3.4% (3) 2.9% (7) NS 

Length of injecting career **** **** 

Up to 5 years 9.4% (17) 20.6% (43) 8.0% (9) 17.9% (43) 

6-10 years 24.3% (44) 39.4% (90) 21.6% (19) 37.5% (90) 

11-15 years 27.1% (49) 23.1% (59) 27.3% (24) 24.6% (59) 

16-20 years 19.9% (36) 11.3% (34) 21.6% (19) 14.2% (34) 

21-25 years 13.3% (24) 1.9% (10) 15.9% (14) 4.2% (10) 

26+ years 4.4% (8) 1.9% (4) 5.7% (5) 1.7% (4) 

Number of drugs 

ever injected 

**** **** 

One 7.9% (14) 21.5% (34) 5.7% (5) 18.2% (44) 

2-5 44.4% (79) 60.1% (95) 49.4% (43) 54.1% (131) 

More than 5 48.8% (85) 18.4% (29) 44.8% (39) 27.7% (67) 

Sexual Behaviour 

More than 2 partners 

in 4 weeks 2 

3.9% (7) 4.4% (7) NS 4.5% (4) 3.7% (9) NS 

Number of partners 

in year 2 

* NS 

One 64.6% (117) 56.3% (90) 57.3% (51) 61.2% (150) 

2-3 24.3% (44) 24.4% (39) 29.2% (26) 23.3% (57) 

More than 3 11.0% (20) 19.4% (31) 13.5% (12) 15.5% (38) 

Sex with non UK resident 23.8% (43) 19.4% (31) NS 23.6% (21) 19.2% (47) NS 

Using contraception 49.7% (90) 50.6% (81) NS 50.6% (45) 49.0% (120) NS 

Using a condom 42.0% (72) 42.5% (68) NS 44.9% (40) 58.8% (144) NS 

Using pill 6.1% (11) 12.5% (20) ** 10.1% (9) 8.6% (21) NS 

1 univariate chi-square analysis, 2 analysis repeated on females only (because some females in this sample may 

use prostitution to support their drug use); however, there was no significant effect of multiple partners on 

hepatitis C or B infection. NS is non significant, * P

When non-injectors are included in the analysis (see Figure 2), the increase in infection 

occurs near to the onset of injecting, with those with five or fewer years of injecting 

having a prevalence of 34%. The prevalence of hepatitis C rose to 84% for those who 

had injected for over 20 years. 

Imprisonment, length of injecting career and polydrug use all remained independently 

significant in logistic regression analysis to predict hepatitis C infection: having been in 

prison corresponded with a 70% increase in risk (OR =1.71, CI 1.02-2.86, p = 0.041); 

injecting for 21 to 25 years corresponded with a seven-fold increase in risk compared with 

those who had injected for up to five years (OR =7.59, CI 1.91-30.17 p = 0.0376); and a 

history of injecting multiple types of drugs (compared with having injected only one drug) 

quadrupled the risk (OR = 4.16, CI 1.81-9.54, p25yr 

TIME SINCE ONSET OF INJECTING 


Figure 3: Percentage of injecting drug users with hepatitis C and B infection 

against number of different drugs injected during lifetime 

% INFECTED 

80 

70 

60 

50 

40 

30 

20 

10 

0 

HEPATITIS C + HEPATITIS B + 

1 2-5 >5 

NUMBER OF DIFFERENT DRUGS EVER INJECTED 

The proportion of IDUs sharing injecting equipment ever and in the last four weeks is 

shown in Table 1b. Whether the subject had ever shared needles or syringes was 

associated with hepatitis C infection in the univariate analyses (Table 4). However, sharing 

variables did not remain significant after multivariate adjustment for imprisonment, 

length of injecting history and polydrug use. This is discussed further in Section 5. 

For hepatitis B, sharing needles and syringes was associated with infection (Table 4). 

However, after multivariate adjustment, only sharing spoons (a two-fold increase in risk 

of infection) remained significant (OR = 2.13, CI 1.01-4.52, p = 0.048). In addition, 

having used (without injecting) or injected most of the named drugs, except Temgesic 

(buprenorphine) and crack, was related to hepatitis C infection (Table 5). However, in the 

case of heroin and anabolic steroids there was too little variation to use in statistical 

analyses, with too many subjects using heroin and too few using steroids (Table 5). 

26 


Use of any particular drug is likely to be related to use of the other drugs. Therefore, a 

backwards stepwise logistic regression was carried out to identify which drugs were 

independently related to hepatitis C infection. Compared to not having used the drug at 

all, having injected methadone (OR = 3.62, CI 1.38 - 9.48), DF 118 (dihydrocodeine 

tartrate) (OR = 3.92, CI 1.12 - 13.75), Diconal (dipipanone hydrochloride) (OR = 3.09, CI 

1.42 - 6.69) and morphine (OR = 3.48, CI 1.71 - 7.08) all resulted in higher risk of 

hepatitis C infection. Compared to not using the drug, those who used (but not injected) 

amphetamines and those who had used or injected Temgesic were at lower risk of 

infection (using amphetamine: OR = 0.33, CI 0.14 - 0.78; using Temgesic OR = 0.32, CI 

0.14 - 0.75, injecting Temgesic OR = 0.32 CI 0.13-0.75). For hepatitis B, having used or 

injected Diconal tripled the risk (compared to not using: OR = 3.76, CI 1.32-10.71 and 

OR = 3.34, CI 1.74-6.42 respectively) while those using (but not injecting) amphetamines 

were about a third as likely to be infected (OR = 0.3, CI 0.1-0.82). These patterns of drug 

use, as measures of chaotic behaviour, are examined further in the discussion. 

Table 4: Percentage of individuals sharing injecting equipment (ever and in the 

previous four weeks) by current serostatus and test history 

Hepititis C 

Needle Syringe Spoon Filter Paraphernalia 1 Any 

n ever last 4 ever last 4 ever last 4 ever last 4 ever last 4 ever last 4 

weeks weeks weeks weeks weeks weeks 

Current +ve 181 61.3** 5.5 59.7* 6.1 81.8 32.6 74.0 29.3 82.9 35.4 86.2 37.6 

Serostatus -ve 160 45.0 9.4 46.6 8.8 82.5 36.9 68.8 25.6 83.1 37.6 83.8 38.1 

Previously yes 99 64.6* 5.1 61.6* 5.1 87.9 28.3 81.8* 28.3 84.6 32.3 90.9 33.3 

Tested no 225 49.3 8.4 46.7 7.1 80.4 38.7 68.9 29.8 82.1 40.4 82.7 41.3 

Previous +ve 36 69.4 5.6 58.3 2.8 86.1 33.3 83.3 36.1 88.9 38.9 94.4 41.7 

Test Result -ve 45 55.6 6.7 60.0 8.9 88.9 28.9 77.8 22.2 88.9 28.9 88.9 28.9 

Hepititis B 

Current +ve 89 64.0* 4.5 61.8* 5.6 87.6 33.7 77.5 27.0 87.6 34.8 91.0 36.0 

Serostatus -ve 245 49.4 8.6 48.2 7.8 79.2 35.1 69.0 28.2 80.8 37.6 82.9 39.2 

Previously yes 149 58.4 6.0 55.0 5.4 86.6 30.9 77.9 26.8 87.9* 33.6 88.6 34.2 

Tested no 179 47.5 7.8 46.9 7.3 78.8 38.5 68.2 30.7 79.3 40.8 81.6 41.3 

Previous +ve 29 58.6 3.4 51.7 3.4 89.7 34.5 79.3 24.1 89.7 34.5 89.7 34.5 

Test Result -ve 96 56.3 6.3 55.2 5.2 86.5 31.3 79.2 30.2 87.5 35.4 88.5 35.4 

1 Injecting equipment other than needles or syringes. *p

Table 5: Percentage (number) of subjects using 1 and injecting each type of drug 

Hepatitis C 

Hepatitis B 

+ ve (n=181) -ve (n=160) P 2 +ve (n=89) -ve (n=245) P 2 

Heroin NS 3 

Used 4.4% (8) 5.0% (8) 5.6% (5) 4.5% (11) 

Injected 93.9% (170) 92.5% (148) 94.4% (84) 92.7% (227) 

Methadone **** ** 

Used 43.1% (78) 58.1% (93) 42.7% (38) 53.9% (132) 

Injected 52.5% (95) 28.1% (45) 51.7% (46) 35.9% (88) 

Cocaine **** NS 

Used 13.8% (25) 23.1% (37) 11.2% (10) 21.2% (52) 

Injected 74.6% (135) 57.5% (92) 73.0% (65) 63.3% (155) 

Amphetamine **** ** 

Used 9.9% (18) 25.6% (41) 9.0% (8) 22.4% (55) 

Injected 72.4% (131) 56.3% (90) 73.0% (65) 59.6% (146) 

Temgesic NS NS 

Used 12.7% (23) 15.6% (25) 13.5% (12) 13.9% (34) 

Injected 18.2% (33) 11.9% (19) 20.2% (18) 12.2% (30) 

Temazepam **** **** 

Used 26.0% (47) 40.0% (64) 19.1% (17) 38.0% (93) 

Injected 52.5% (95) 29.4% (47) 56.2% (50) 34.7% (85) 

DF118 **** *** 

Used 51.4% (93) 51.3% (82) 47.2% (42) 51.8% (127) 

Injected 13.8% (25) 3.1% (5) 15.7% (14) 4.9% (12) 

Dicanol **** **** 

Used 4.4% (8) 8.8% (14) 9.0% (8) 5.3% (13) 

Injected 34.3% (62) 9.4% (15) 37.1% (33) 15.1% (37) 

Cyclizine **** *** 

Used 2.8% (5) 6.3% (10) 5.6% (5) 3.7% (9) 

Injected 25.4% (46) 6.3% (10) 24.7% (22) 10.2% (25) 

Diazepam *** * 

Used 55.8% (101) 61.3% (98) 50.6% (45) 60.4% (148) 

Injected 22.1% (40) 8.8% (14) 22.5% (20) 12.2% (30) 

Morphine **** **** 

Used 9.4% (17) 14.4% (23) 7.9% (7) 12.7% (31) 

Injected 42.5% (77) 13.8% (22) 42.7% (38) 22.4% (55) 

Crack NS NS 

Used 32.0% (58) 41.9% (67) 33.7% (30) 37.6% (92) 

Injected 31.5% (57) 23.8% (38) 23.6% (21) 29.8% (73) 

Dalmane *** NS 

Used 8.3% (15) 6.3% (10) 6.7% (6) 6.1% (15) 

Injected 5.5% (10) 0.0% (0) 3.4% (3) 1.6% (4) 

Steroids 4 4 

Used 1.7% (3) 3.1% (5) 1.1% (1) 2.9% (7) 

Injected 2.8% (5) 2.5% (4) 0.0% (0) 2.9% (7) 

1 Used refers to taking but not injecting. 2 Numbers using (but not injecting), numbers injecting and numbers not 

using each drug (percentages of those not using are not shown) are compared by infection status (chi-square 

analysis). NS is non significant, * P

4.4 Previous hepatitis C test history 

People who had been for previous hepatitis C tests were nearly three times more 

likely to have shared needles or other equipment at some point in their lives 

(adjusted OR = 2.63, CI 1.23-6.17) and were twice as likely to have been in prison 

(adjusted OR = 1.94, CI 1.23-3.31). Since these are both risk factors for hepatitis C 

infection itself (see Section 4.3), it follows that those presenting for previous tests 

were about 70% more likely to be hepatitis C positive (OR =1.68, CI 1.03-2.75, 

chi square p = 0.01). 

Table 4 shows that those who have ever shared needles or any item of injecting 

paraphernalia were more likely to have presented for a hepatitis C test. Thus, over 

90% of those previously tested for hepatitis C had shared at least some item of 

injecting equipment (needles or paraphernalia) at some time compared to 83% of 

those who had not been tested. However, when examining recent sharing behaviour 

(last four weeks), importantly this trend was reversed. Here, of those having taken a 

hepatitis C test only 33% had shared in the past four weeks compared with 41% of 

those who had not previously been tested. 

This was examined further by dividing the study sample into those who had shared in 

the past but not in the four weeks prior to taking part in the study ('reformed sharers') 

and those who disclosed sharing in the previous four weeks ('current sharers'). 

Analyses indicate that those having previously taken a hepatitis C tests were 1.69 

times more likely than previously untested individuals to be reformed sharers (i.e. no 

longer sharing; CI 1.01-2.85, p = 0.045). In other words, taking a test was associated 

with a small but significant change in sharing behaviour. 

Length of time being an injector was not related to having taken a hepatitis C test. 

Of the people who had been tested previously, 63 (66%) knew their correct status 

(32 positive, 31 negative). For fifteen (16%), their present test result was not the same 

as that recalled from the previous test: 14 stated that they had tested negative but 

were found to be positive during this study. Either these individuals were in fact 

negative at the time of their previous test and have been infected subsequently, 

or their recall of their test result was incorrect. The remaining person mistakenly 

thought himself or herself to be positive. Seventeen people did not know their 

status following their previous test, of those, over half (11, 65%) were positive at the 

current test. 


4.5 Predicting sharing behaviour 

People who believed themselves to be positive (by a previous test) did not differ 

significantly in their recent (previous four weeks) sharing behaviour from those who 

believed themselves to be negative, with around 6% having shared needles and 

about a third having shared any paraphernalia (Table 4). However, the size of the 

group within which the individual most recently injected their drugs was an important 

predictor of recent sharing behaviour (Figure 4). Of those whose previous injecting 

occasion was with one other person, 54% had shared some form of injecting 

equipment in the previous four weeks, whereas only 35% of those who injected 

with a larger group (two to five others) had recently shared. Compared to those 

who injected alone on their most recent injecting occasion, people who injected 

with one other person were nearly five times more likely to have shared equipment 

in the previous four weeks (p

A history of polydrug use was another significant predictor of recent sharing of 

equipment (p = 0.019) with those having used five or more drugs being over three 

times more likely to share (adjusted OR = 3.31, CI 1.40-7.79). Importantly, 

sharing was also more likely among those who had started injecting drugs within the 

previous 5 years (Figure 5, p = 0.014), with people who took up the habit recently 

being between two and seven times more likely to share equipment than those with 

longer histories of injecting behaviour (6-10 years, adjusted OR = 0.41, CI 0.2-0.85; 

11-15 years, adjusted OR = 0.30, CI 0.14-0.67; 16-20 years, adjusted OR = 0.26, 

CI 0.11-0.61; 21-25 years, adjusted OR = 0.14, CI 0.04-0.42; and over 25 years, 

adjusted OR = 0.21, CI 0.05-0.92). 

Figure 5: The percentage of injecting drug users sharing any form of injecting 

equipment in the previous four weeks (needles, syringes or other 

paraphernalia), categorised by time since first injected 

60 

% SHARING ANY EQUIPMENT 

IN PREVIOUS 4 WEEKS 

50 

40 

30 

20 

10 

0 

0-5yr 6-10yr 11-15yr 16-20yr 21-25yr >25yr 

YEARS SINCE FIRST INJECTING 


4.6 Blood donation 

Of those who had ever injected drugs, 15% had donated blood at some stage 

(Table 1a). Although we did not ascertain when blood donation had occurred, at least 

five individuals gave blood after commencing injecting, since they first injected before 

the age of 17 (the permitted age for blood donation is 17 years). Three of these five 

were hepatitis C positive in this study. A further 23 blood-donating individuals (13 of 

whom were hepatitis C positive) had commenced injecting before the age of 20; 

around the same time as they would be permitted to give blood. For the remaining 

27 individuals, the relative timing of blood donation and onset of injecting behaviour 

could not be ascertained. 

32 


5. DISCUSSION 

5.1 Contact Groups 

Across the whole sample the prevalence of hepatitis C (current or previous infection) 

was 49% rising to 53% (with 95% confidence intervals of 47% to 58%) when 

considering injectors alone. Those approaching services specifically for tests (here called 

self-presenters) and those in treatment through community drugs teams had higher 

levels of hepatitis C (see Table 2) than those contacted through other settings. However, 

these differences failed to reach significance (see Section 4.2). A previous study to 

determine the hepatitis C prevalence in the North West found a higher prevalence of 

67% (with 95% confidence intervals of 63% to 70%) based on a sample of 545 IDUs 

presenting for hepatitis C testing (Lamden et al. 1998). Perhaps not surprisingly, this 

figure (67%) was closest to the prevalence found in CDT recruited participants for this 

study (61.4%) and those again presenting to services to request a test (61.9%). In our 

study, those who came forward for a previous test are those who are more likely to 

have shared, more likely to have been in prison (both risk factors for hepatitis C) and 

more likely to be hepatitis C positive. Similarly, Best et al. (1999), in their study of IDUs 

in London, found that those attending for previous tests were more likely to be hepatitis 

C positive. Combined therefore, these studies suggest caution should be used when 

interpreting prevalence of hepatitis C infection in studies where people have come 

forward for testing, since these prevalence estimations cannot necessarily be 

meaningfully extrapolated to the general population of injecting drug users. 

Based on the crude estimations of the number of current injecting drug users in 

contact with services in the North West (30,200: section 1.4) and the prevalence of 

hepatitis C found in this study (53%), we would expect 16,000 current drug users to 

be infected with hepatitis C. Studies on the disease progression (Section 1.8) suggest 

that 80% of these will go on to develop chronic hepatitis (i.e. 12,800), 20% of whom 

will go on to develop cirrhosis of the liver after a period of around 20 years (around 

2,600 cases). Having developed cirrhosis, the risk of developing hepatic carcinoma is 

estimated to be 1% per year (Tong et al. 1995), leading to around 26 cases per year. 

However, the prognosis of individuals infected by injecting drug use may be worse 

than that for transfusion patients (on whom the calculations of disease progression 

have been made), because IDUs may be exposed to multiple strains of the virus on 

more than one occasion (Renton & Main 1996). These numbers are based on estimates 

of the current drug using population assessing services. However, statistical estimates 

of the hidden population of drug users suggest that half of drug users may not be in 

contact with services. Also there are unknown numbers of former users exposed to the 

virus, and the addition of new users to the drug using population will increase the 

number of people with hepatitis C. This underlines the importance of the Government 

drug strategies to reduce the number of young people starting to use drugs, and 

reduce levels of injecting and equipment sharing. 


5.2 Co-infection between hepatitis B and hepatitis C 

Nineteen percent of the IDUs in this study were co-infected with hepatitis B and hepatitis 

C. People who had been infected with one virus were over four times as likely to also 

have been infected with the other. Results suggest that similar risk factors are associated 

with both infections such as prison, length of time since starting injecting and polydrug 

use (see Section 4.3). Co-infection represents a serious problem: the outcomes of the 

disease are more severe (Pol et al. 1998; Tagger et al. 1999); treatment is more difficult to 

manage (Dusheiko et al. 1996) and the risk of mother to child transmission of hepatitis C 

is increased (Resti 1999). Moreover, those infected with both viruses appear to be more 

infectious, possibly because they have higher viral loads in their body fluids (Dolan 1997). 

In this sense, continued pressures to increase levels of hepatitis B immunisation are 

essential both to reduce hepatitis B but also to potentially reduce the morbidity 

associated with hepatitis C and the levels of hepatitis C transmission. 

5.3 Risk factors 

In common with many other studies (e.g Garfein et al. 1998; Smythe et al. 1998; 

Lamden et al. 1998), a major risk factor for hepatitis C infection among IDUs was time 

since onset of injecting behaviour. In this study, prevalence increases from 18% among 

those who claim never to have injected to 34% in those injecting for up to five years, 

and 89% in those injecting for 21 to 25 years (Figure 2). The consequences for 

prevention programmes of the increase in hepatitis C infection that begins early in 

injectors’ careers are discussed in section 5.5. 

Having been in prison and the number of prison stays (Figure 1) were also important 

predictors of hepatitis C. The prison environment is one in which drug use is prevalent 

and, because clean equipment is difficult to obtain, when injecting occurs sharing is 

likely to happen (Bellis et al. 1997). Because such a large number of drug users find 

themselves in prison, the prevalence of hepatitis C among all prisoners is much higher 

than in the general population (for example, estimated as 20% in Scottish prisons: 

Gore et al. 1999). Moreover, within the confined environment of a prison, individuals 

may frequently be exposed to less common routes of transmission, for example, by 

sharing razors and other personal items or by being involved in fights that draw blood 

(De Mercato et al. 1995). Although transmission of infection is unlikely from a single 

such event, a high number could add up to a significant risk. Eight individuals in this 

study were infected with hepatitis C despite claiming never to have injected. Around 

15% of hepatitis C infections cannot be attributed to any cause and these may fall into 

this category but, of the eight, a disproportionate number (88%) had been in prison 

(P

azors should not be shared and should be made aware of the risk to both staff and 

prisoners posed by blood shed in the environment. At present, there is no centrally 

co-ordinated education programme on hepatitis C for prisoners although individual 

prisons may have arrangements with local services, for example drugs agencies. 

Type of drug injected had a strong statistical relationship with probability of ever 

having been hepatitis C infected. It is probable that the injecting or illegal use of 

certain drugs acts as a proxy for chaotic behaviour and that chaotic behaviour rather 

than a specific drug of use is directly related to increased chances of infection. 

Thus, having injected methadone, DF 118, Diconal and morphine all resulted in a 

higher risk of hepatitis C infection. The greater the number of different drugs used or 

injected, the more likely the individual was to be positive. Despite the probability of 

only an indirect link, polydrug use can still be used as a risk factor for hepatitis C and a 

marker for those most at risk. Other studies find a relationship between types and 

combinations of drugs used and infection: for example, the use of cocaine in addition 

to heroin increases the risk of hepatitis C infection (Garfein et al. 1998). In contrast, 

steroid injectors have been found to have a very low prevalence of hepatitis B and HIV 

compared to heroin users, which has been attributed to steroid users’ injecting 

practices being more hygienic and less likely to share (Crampin et al. 1998). Steroid 

users are also likely to inject relatively infrequently (Lenehan & McVeigh 1998). 

5.4 Effects of testing on risk behaviour 

In this study, subjects' perception of their hepatitis C status was not directly 

ascertained; instead, their history of previous tests was recorded. Thus, the 17 

individuals who were hepatitis C positive but claimed that their previous test was 

negative may have had an incorrect recollection of their status or could have become 

infected (or passed through the incubation period) since their previous test. However, 

both alternatives are causes for concern. Either individuals had forgotten or not 

understood their result in which case the value of the test was reduced or they have 

continued with risk behaviour despite a negative test result. In fact, in our sample an 

individuals' previous test result did not affect current sharing behaviour: regardless of 

whether a previous test was negative or positive, around 6% had shared needles in 

the previous four weeks, and up to 40% had shared some form of injecting 

equipment over the same time period (Table 4). Importantly however, there was some 

indication that individuals who had taken a test (regardless of the result) may be less 

likely to be currently sharing. Table 4 shows that, although those who took a previous 

test were more likely to have shared all forms of equipment in the past (i.e. ever 

shared), they were less likely to have shared in the previous four weeks (although this 

just failed to reach significance). Furthermore, when the data were grouped into 

current (those who admitted sharing in the previous four weeks) and reformed sharers 

(those who had shared in the past but not in the previous four weeks), reformed 


sharers were significantly more likely to be people who had taken a test (P = 0.045). 

Therefore, taking a test per se but not the result of the test appears to have some 

relationship with changing behaviour. In the case of sero-negative individuals this may 

be to retain their negative status. For sero-positives it may act to prevent infection of 

fellow users, or to prevent multiple infection with different strains or co-infection with 

hepatitis B or HIV. 

It is difficult to distinguish cause and effect. Presenting for the test in the first place 

may mean individuals have already made a decision to improve and protect their 

health or the test may allow intervention by a drugs worker to encourage behaviour 

change. Certainly, the test procedure presents an opportunity for the drugs worker to 

provide holistic appraisal of risk behaviour, for example to counsel about safer injecting 

behaviour, and encourage uptake of the hepatitis B vaccine and abstinence from 

alcohol abuse. Further research should address whether changes in risk behaviour 

identified in the study occur just prior to or just after testing. 

5.5 Sharing behaviour 

This study identified an important link between the size of the group within which an 

individual injects and sharing behaviour. Sharing of needles and all types of 

paraphernalia was much more likely to happen if the user was injecting with just one 

other person present (Figure 4). Of those whose previous injecting occasion was with 

one other person, 54% had shared some form of injecting equipment in the previous 

four weeks, compared with 35% of those who injected with a larger group (two or 

more others). Many of the occasions of sharing with just one other person may be 

between sexual partners, in which case, sharing equipment may be seen as a sign of 

trust and intimacy (Rhodes & Quirk 1998). Harm reduction messages already explain 

the dangers of sharing but such messages on safer injecting practices should reiterate 

the fact that sharing with anybody else who injects drugs, be it friends or sexual 

partners, is a high risk activity for hepatitis C infection and other blood borne viruses. 

Of equal importance was the finding that sharing is more likely among those who 

have taken up injecting recently (i.e. within previous five years; Figure 5). This supports 

the importance of intercepting young users at the beginning of their drug taking 

careers to educate them in safer injecting behaviour. Harm minimisation policies 

should consider whether those not injecting, but who are progressing towards such 

drug use, need safer injecting information in order to reduce the increase in hepatitis C 

that occurs soon after injecting begins (Figure 2; Smythe et al. 1998; Lamden et al. 

1998). Consequently, it is especially important that efforts are made to reach 

vulnerable groups of young drug users. 

Overall, it appears that while IDUs may have changed their behaviour regarding 

sharing of needles (in response to the HIV crisis), messages about the danger of other 

36 


forms of sharing have not necessarily been received. Around 40% of this study sample 

had either shared spoons, filters or other paraphernalia in the previous four weeks 

(Table 4) possibly because sharing paraphernalia is still not viewed as risky by many 

users. Speed & Bennett (1997), in an audit of sharing behaviour in the North West, 

reported a low awareness among IDUs of the risk of such indirect sharing: only around 

a third knew that such behaviour could lead to infections. Clearly, attempts to educate 

users that all forms of sharing are dangerous should be continued and the debate 

around whether syringe exchange schemes could also provide other clean equipment 

in addition to needles and syringes needs to be re-addressed. 

5.6 Blood donation 

In countries where donors are paid for giving blood there is an increased probability of 

blood being infected because drug users may give blood to supplement their income. 

Studies of infected blood donors in the USA show that having injected drugs is by far 

the largest single risk factor for being hepatitis C positive (Murphy et al. 2000). In fact, 

many Canadian haemophiliacs are infected with hepatitis C from blood collected in US 

prisons, even after the high risk nature of the prison setting was known (The Hepatitis 

Information Network 2000). Blood donors in the UK are not paid (and therefore not 

financially motivated), and the introduction of effective heat treatment of blood in 

1986 has made infection through transfusions or blood products very rare. However, 

no screening procedure can be 100% effective and hepatitis C (and HIV) cannot be 

detected in the 'window period' before antibodies are made. To further minimise the 

risk, potential donors are asked not to give blood if they have a history of injecting 

drugs. It is important to know to what extent injecting drug users donate blood. 

The results of this study show that 15% of those who had ever injected drugs had 

donated blood at some stage. Although we did not ascertain when blood donation 

had occurred, at least five individuals gave blood after commencing injecting, since 

they first injected before the age of 17 (the permitted age for blood donation is 17 

years). New blood borne infections emerge periodically, with IDUs always being a key 

risk group. The screening process should therefore place more emphasis on identifying 

drug users prior to donation, since tests for potential pathogens can only identify 

known disease organisms. The proportion of IDUs (or ex-IDUs) that currently donate 

blood is unknown, and this should be a topic for future research. 

5.7 Further research 

Sixty four percent of the individuals recruited to this study volunteered to be included 

as part of the cohort for follow up. This group provides the opportunity for a 

controlled study of test results on behavioural change. Levels of treatment uptake and 

the effects of such treatment could also be effectively monitored using this group. 

Such information is essential in order to inform policy around the costs and benefits of 

screening, counselling and treatment. 


5.8 Conclusions and Recommendations 

This study has identified the following key findings and recommendations: 

• Among the 341 injecting drug users in this study, the prevalence of hepatitis C 

was 53.1% (181 people), hepatitis B 26.6% (89 people) and 19.0% (65 people) 

were co-infected with hepatitis C and B (Section 4.1). Although the study was 

relatively small, different areas of study recruitment provided different levels of 

hepatitis C infection, with those presenting to drugs services requesting a test or 

those in treatment with community drugs teams having the highest prevalence. 

Those who had been for a hepatitis C test before this study were 1.68 times more 

likely to be hepatitis C positive in this study, again suggesting that people 

presenting for tests are more likely to be hepatitis C positive (Section 4.4). 

Models of health impact of hepatitis C should consider potential variations in 

prevalence rates between settings and recognise that most studies to date have 

assessed those most at risk of infection. 

• We crudely estimate that there are around 30,200 drug users currently in contact 

with services in the North West. Using estimates of the proportion of these 

injecting drugs and applying the hepatitis C prevalence of 53% found in this study, 

we estimate that there are 12,800 people currently chronically infected with 

hepatitis C. Of these, 2,600 will go on to develop serious liver damage (cirrhosis or 

hepatic carcinoma) (Section 5.1). This figure does not include the hidden 

population of drug users, previous or new users entering the drug-using population. 

Health Authorities should anticipate the increase in treatment costs associated with 

treating this high number of patients with liver damage over the next twenty years. 

• Those who are infected with hepatitis C are four times more likely to also be infected 

with hepatitis B (Section 4.1). Co-infection increases the risk of progression to serious 

disease. 

Current hepatitis B vaccination programmes should attempt to protect people 

early in their drug injecting career before exposure to hepatitis C. 

• Having ever visited prison, and the number of prison stays, were both strong 

predictors of hepatitis C infection (Figure 1). Prison represents a potential injecting 

and non-injecting risk for hepatitis C. For example sharing of personal items such 

as razors may lead to infection, and those few study participants infected but not 

identified as injectors were more likely to have been in prison. 

More awareness of these other, albeit low risk, activities is needed generally but in 

particular in prisons. 

38 


• Chaotic behaviours such as polydrug use (Figure 3), use of less commonly misused 

drugs (Section 4.3) and a longer history of injecting (Figure 2) all predicted hepatitis 

C infection. 

Harm reduction measures can be targeted at such high risk groups and predictors 

identified in this study can be used as indicators as to which populations or 

individuals are at most risk of infection or most likely to be infected. 

• Significant levels of sharing were revealed. Almost 40% had shared some form of 

injecting equipment over the previous four weeks, and 7% had shared needles 

(Table 4). Consistent with more chaotic behaviour, sharing injecting equipment is 

more likely to occur in those with polydrug use (Section 4.5). Also, sharing injecting 

equipment is most common in new injectors (those who have been injecting for up 

to five years) (Figure 5). 

Work is urgently needed to reach young vulnerable groups of drug users who 

have recently begun injecting or may progress to injecting drugs. Such work 

requires education on the risks of injecting to reduce high risk behaviours or 

ideally prevent them even before they begin. 

• A previous positive result for hepatitis C did not appear to result in a change in 

sharing behaviour (Section 4.4). However, those who had presented for previous 

tests were more likely to be reformed sharers (i.e. not currently sharing). This may 

be because counselling received at the time of the test was successful in reducing 

subsequent risk behaviour regardless of the actual results of the test. However, it 

may relate to those asking for a test already having decided to protect their 

health. 

Further work should examine in more detail the links between hepatitis C testing 

and the identified reduction in sharing behaviour. 

• Sharing injecting equipment is more likely to occur in smaller groups of fellow 

users (Figure 4), possibly because the user feels safe among friends or with a 

partner. The high prevalence of hepatitis C in drug users in the North West means 

sharing with anyone carries a high risk of hepatitis C infection. 

Information about the risks of sharing should stress this includes close friends and 

sexual partners. Health information should also help users address the problems 

around refusing to share with a partner. 


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44 






Penny A. Cook, Jim McVeigh, Apurva Patel, Qutub Syed, Ken Mutton and Mark A. Bellis 

Published by 

Public Health Sector 

School of Health and Human Sciences 

Liverpool John Moores University 

70 Great Crosshall Street 

Liverpool L3 2AB 

Tel: +44 (0151) 231 4301 

Fax: +44 (0151) 231 4320 

e-mail: p.a.cook@livjm.ac.uk 

© JULY 2000 ISBN 1-902051-19-X

9261 HEPATITIS C REPORT GALLEY - North West Public Health ...

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