SMOKE IT! Promoting a Change of Opiate Consumption Pattern - From Injecting to Inhaling,
Heino Johann Stöver and Dirk Schäffer, Harm Reduction Journal 2014, 11:18 doi:10.1186/1477-7517-11-18

The vast majority of the 165 respondents favoured using the foils from the ‘SMOKE-IT!’ packs (82.5%). The survey shows that two-thirds of the sample used the SMOKE-IT foils for inhaling instead of injecting. Almost six out of ten said that smoking was healthier than injecting.

Changing Patterns of First Injection Across Key Periods of the French Harm Reduction Policy: Priminject, A Cross Sectional Analysis,
Anne Guichard et al, Drug Alcohol Depend. (2013)

Monitoring of emerging modes of drug consumption in France has identified new patterns ofinjection among youths with diverse social backgrounds, which may explain the persistence of high ratesof hepatitis C virus infection. The circumstances surrounding the first injection have been poorly docu-mented in the group of heavy drug users and in the context of the French opioid substitution treatment (OST) policy that provides expanded access to high-dosage buprenorphine

Eradication of Hepatitis C Infection:
The Importance of Targeting People Who Inject Drugs, Hellard et al. Hepatology 2013

To achieve eradication, public health efforts must focus on PWID, the key drivers of HCV transmission. A sustained, multipronged approach could substantially reduce HCV infection in PWID over the next 10-20 years through a focus on HCV treatment as prevention, meaning improved access to more effective and well-tolerated HCV treatment. Other major elements include increasing coverage of opiate substitution therapy (OST), needle and syringe programs (NSPs), and regular HCV screening and counseling.

What is the Evidence for the Effectiveness of Interventions to Reduce Hepatitis C Infection and the Associated Morbidity?
Wright NMJ, Millson CE, Tompkins CNE, Copenhagen, WHO Regional Office for Europe 2005

This is a Health Evidence Network (HEN) synthesis report on effective interventions to reduce hepatitis C infection. HEN, initiated and coordinated by the WHO Regional Office for Europe, is an information service for public health and health care decision-makers in the WHO European Region. Cost-effectiveness analysis of current interventions aimed at primary prevention of hepatitis C infection shows additional benefits in reducing the prevalence of HIV.

Fibroscan Used in Street-Based Outreach for Drug Users is Useful for Hepatitis C Virus Screening and Management:
A Prospective Study, J. Foucher et al, Journal of Viral Hepatitis, 2009, 16, 121–131

Although hepatitis C virus (HCV) infection prevalence is high among drug users, they do not commonly receive regular care in academic centres. The aim of this prospective study was to assess the influence of FibroScan use on HCV screening and management in street-based outreach. From January 2006 to January 2007, all consecutive drug users were offered noninvasive evaluation of liver fibrosis with FibroScan.

Utilization of FibroScan in Clinical Practice,
Alan Bonder & Nezam Afdhal, Curr Gastroenterol Rep (2014) 16:372

The evaluation of liver fibrosis is critical, particularly to rule out cirrhosis. Novel non-invasive tests such as transient ultrasound elastography are widely used to stage liver fibrosis as an alternative to liver biopsy, and this technology has recently been approved in the US. In this review, we discuss the performance characteristics of elastography for a variety of liver diseases and highlight practical appropriate suggestions for how to incorporate this technology into clinical practice.

Transmission of Hepatitis C Virus Among People Who Inject Drugs:
Viral Stability and Association With Drug Preparation Equipment, Juliane Doerrbecker et al, The Journal of Infectious Diseases 2013;207:281–7

This study demonstrates the potential risk of HCV transmission among injection drug users who share water, filters, and water containers and will help to define public health interventions to reduce HCV transmission.

Hepatitis C Transmission and Injecting Drug Use:
Harm Reduction Responses, Eurasian Harm Reduction Network and Correlation Network 2010

This report outlines interventions for tackling hepatitis C in IDU populations in Europe and the surrounding area. These approaches are detailed in the context of the major common challenges faced across the region in addressing hepatitis C in IDU populations.

Hepatitis C Virus Maintains Infectivity for Weeks after Drying on Inanimate Surfaces at Room Temperature:
Implications for Risks of Transmission, Elijah Paintsil et al, Journal of Infectious Diseases, November 23, 2013

Healthcare workers may come into contact with fomites containing infectious HCV during preparation of plasma, or following placement or removal of venous lines. Similarly, injection drugs users may come into contact with fomites. The hypothesis of potential transmission from fomites was supported by the experimental results. The anti-HCV activity of commercial antiseptics varied.

Hepatitis C Virus Reinfection in Injection Drug Users,
Jason Grebely et al, Hepatology 2006;44:1139-1145.

Individuals with previous HCVinfection and viral clearance were 4 times less likely to develop infection than those infected for the first time (adjusted odds ratio, 0.23; 95% CI, 0.10-0.51, P < .001). In conclusion, individuals with clearance of HCV infection may have a lower risk of acquiring HCV than individuals who have never been infected, despite ongoing exposure to HCV.

Healthcare Workers and Prevention of Hepatitis C Virus Transmission:
Exploring Knowledge, Attitudes and Evidence-Based Practices in Hemodialysis Units in Italy, Aida Bianco et al, BMC Infectious Diseases 2013, 13:76


Evidence exists regarding the full prevention of HCV transmission to hemodialysis patients by implementing universal precaution. However, little information is available regarding the frequency with which hospitals have adopted evidence-based practices for preventing HCV infection among hemodialysis patients. A cross-sectional survey has been conducted among nurses in Calabria region (Italy) in order to acquire information about the level of knowledge, the attitudes and the frequencies of evidence-based practices that prevent hospital transmission of HCV.

Rapid Decline in HCV Incidence among People Who Inject Drugs Associated with National Scale-Up in Coverage of a Combination of Harm Reduction Interventions,
Norah E. Palmateer et al. PLOS ONE 2014

This is the first study to demonstrate that impressive reductions in HCV incidence can be achieved among PWID over a relatively short time period through high coverage of a combination of interventions.

Lack of Behavior Change after Disclosure of Hepatitis C Virus Infection among Young Injection Drug Users in Baltimore, Maryland,
Danielle C. Ompad et al, Clinical Infectious Diseases 2002; 35:783–8

We evaluated behavior change after disclosure of a positive hepatitis C virus (HCV) antibody test result among a cohort of young injection drug users (IDUs). Participants underwent semiannual interviews, HIV and HCV antibody testing, and pretest and posttest counseling. We used x2 statistics to study changes in the frequencies of high-risk behaviors from baseline to a 6-month follow-up visit among 46 IDUs who had a positive HCV test result and among 60 IDUs who did not have a positive HCV test result or who were unaware of their test result. No significant differences were detected between the 2 groups. Both groups continued to share syringes, needles, and other injection paraphernalia.

Management of Accidental Exposure to HCV, HBV and HIV in Healthcare Workers in Romania,
Eyal Malka et al, GERMS December 2012

Accidental blood exposure in healthcare workers is an important issue worldwide. We present a study which analyzed the route of exposure, the source of infection and the post-exposure prophylaxis treatment administered.

Models of Care for the Management of Hepatitis C Virus Among People Who Inject Drugs:
One Size Does Not Fit All, Philip Bruggmann1 and Alain H. Litwin, Clinical Infectious Diseases 2013;57(S2):S56–61

One of the major obstacles to hepatitis C virus (HCV) care in people who inject drugs (PWID) is the lack of treatment settings that are suitably adapted for the needs of this vulnerable population. Models may be integrated in primary care—all under one roof in either addiction care units or general practitioner–based models—or can occur in secondary or tertiary care settings. Additional innovative models include directly observed therapy and peer-based models. A high level of acceptance of the individual life circumstances of PWID rather than rigid exclusion criteria will determine the level of success of any model of HCV management.

Prevention And Control Of InfectiousDiseases Among People Who Inject Drugs, ECDC 2011

This evidence-based joint guidance by ECDC and the EMCDDA identifies good practice for prevention and control of infectious diseases among people who inject drugs.

Projecting Severe Sequelae of Injection-Related Hepatitis C Virus Epidemic in the UK. Part 1:
Critical Hepatitis C and Injector Data, Bird SM, Goldberg DJ, Hutchinson SJ., J Epidemiol Biostat. 2001;6(3):243-65; discussion 279-85.

Incubation periods from HCV infection to cirrhosis and hepatocellular carcinoma are even longer than from HIV infection to AIDS, being counted in decades; they depend on age, gender, alcohol consumption and co-infection with other viruses. We identify 25 data sources that are available, or required, for projecting the severe sequelae of the injection-related hepatitis C epidemic.

Projecting severe sequelae of injection-related hepatitis C virus epidemic in the UK. Part 2:
Preliminary UK estimates of prevalent injection-related hepatitis C carriers, and derivation of progression rates to liver cirrhosis by gender and age at hepatitis C virus infection, Bird SM, Goldberg DJ, Hutchinson SJ., J Epidemiol Biostat. 2001;6(3):243-65; discussion 279-85

In Part 2, we illustrate how available data can be used to obtain preliminary estimates for Scotland of prevalent injection-related hepatitis C carriers and of maternally hepatitis C virus (HCV)-infected infants. Novel approaches to reducing uncertainty about the number of Scotland's HCV infected children of injector parents are discussed in brief. Three approaches, one direct and two indirect, to estimating the number of current and ever-injectors are presented for England and Wales.

Recommendations for the Management of Hepatitis C Virus Infection Among People Who Inject Drugs,
Geert Robaeys et al. Clinical Infectious Diseases 2013;57(S2):S129–37

Among PWID, there are a number of barriers to care that should be considered and systematically addressed, but these barriers should not exclude PWID from HCV treatment. Furthermore, it has been clearly demonstrated that HCV treatment is safe and effective across a broad range of multidisciplinary healthcare settings. Given the burden of HCV-related disease among PWID, strategies to enhance HCV assessment and treatment in this group are urgently needed. These recommendations demonstrate that treatment among PWID is feasible and provides a framework for HCV assessment, management, and treatment.

A Systematic Review and Meta-Analysis of Interventions to Prevent Hepatitis C Virus Infection in People Who Inject Drugs, Holly Hagan et al.,
The Journal of Infectious Diseases 2011;204:74–83

The meta-analysis included 26 eligible studies of behavioral interventions, substance-use treatment, syringe access, syringe disinfection, and multicomponent interventions. Interventions using strategies that combined substance-use treatment and support for safe injection were most effective at reducing HCV seroconversion.

Screening for Hepatitis C Virus Infection in Adults,
Comparative Effectiveness Review Number 69, Agency for Healthcare Research and Quality, U.S. Department of Health and Human Services

Many patients with chronic hepatitis C virus (HCV) infection are unaware of their status. Screening could identify patients at earlier stages of disease, when interventions might be effective in improving clinical outcomes or reducing transmission risk. The purpose of this report is to systematically review the evidence on screening for HCV infection in asymptomatic adults without known liver enzyme abnormalities, including pregnant women.

Reductions in HIV/STI Incidence and Sharing of Injection Equipment among Female Sex Workers Who Inject Drugs:
Results from a Randomized Controlled Trial, Steffanie A. Strathdee et al., PLOS ONE,, June 2013, Volume 8, Issue 6

We evaluated brief combination interventions to simultaneously reduce sexual and injection risks among female sex workers who inject drugs (FSW-IDUs) in Tijuana and Ciudad Juarez, Mexico during 2008–2010, when harm reduction coverage was expanding rapidly in Tijuana, but less so in Juarez.

Sustained Drug Use Changes Following Hepatitis C Screening and Counseling among Recently Infected Persons who Inject Drugs:
A Longitudinal Study, Bruneau, J. et al., Clinical Infectious Diseases, December 20, 2013

Our results indicate that notification of HCV-positive status is associated with reduced injection drug use among seroconverters. Amongst PWIDs deemed seronegative after screening, there is no sustained trend for change in risk behavior.

Hepatitis C: Urgency to Fight Viral Foe Grows in the Suburbs and on the Streets,
Jeffery Norris, UCSF June 2012

With funding from the U.S. Centers for Disease Control and Prevention, UCSF epidemiologist Kimberly Page is developing guidelines so that other cities can adopt the San Francisco model of outreach, education, counseling and care developed and practiced at the Tenderloin Clinical Research Center. The model is tailored to young injection drug users, who are at highest risk for hepatitis C.

Injection Drug Use and Hepatitis C Virus Infection in Young Adult Injectors:
Using Evidence to Inform Comprehensive Prevention, Page K,C. et al., Clin Infect Dis. 2013 Aug;57 Suppl 2:S32-8. doi:10.1093/cid/cit300.

This paper discusses some key HCV prevention strategies that to date have not been widely researched or implemented, and wherein future HCV prevention efforts may be focused: (1) reducing sharing of drug preparation equipment; (2) HCV screening, and testing and counseling; (3) risk reduction within injecting relationships; (4) injection cessation and "breaks"; (5) scaled-up needle/syringe distribution, HCV treatment, and vaccines, according to suggestions from mathematical models; and (6) "combination prevention.

Injection Drug Use And Hepatitis C Virus Infection In Young Adult Injectors:
Using Evidence To Inform Comprehensive Prevention, Page K,C. et al., Clin Infect Dis. 2013 Aug;57 Suppl 2:S32-8. doi:10.1093/cid/cit300.

This paper discusses some key HCV prevention strategies that to date have not been widely researched or implemented, and wherein future HCV prevention efforts may be focused: (1) reducing sharing of drug preparation equipment; (2) HCV screening, and testing and counseling; (3) risk reduction within injecting relationships; (4) injection cessation and "breaks"; (5) scaled-up needle/syringe distribution, HCV treatment, and vaccines, according to suggestions from mathematical models; and (6) "combination prevention.

Working With Heroin Sniffers: Clinical Issues in Preventing Drug Injection.
Cathy Casriel et al., Journal of Substance Abuse Treatment, Vol. 7, pp. 1-10, 1990

This paper reports on clinical issues that arose in a program for intranasal (“sniffer”) heroin users who were at high risk of injecting drugs.