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Hepatitis C in Women: Updated Guidance on Screening and Management

Tatyana Kushner, MD, MSCE
Released: December 1, 2020

Epidemiology of HCV in the United States

Incidence of Acute HCV Is Increasing in the United States

This slide documents a concerning recent trend in the United States: an increase in the incidence of acute HCV infection. This increase has been largely driven by the opioid epidemic. The graphic on the left panel of the slide shows that starting in 2011, new cases of acute HCV began to increase each year.[1] Of importance, both male and female cases increased, and they were almost equivalent in terms of incidence and rate of increase.

In the graph on the right panel, CDC data show a breakdown by age, demonstrating which age groups are most affected by acute HCV.[1] The important observation is that new cases of acute HCV increased among the younger population—the highest incidence being in the group 20-29 years of age. This of course, includes women of childbearing age. As previously noted, this rise in acute HCV infection is related to the opioid epidemic. 

New HCV Infections in the US: Emerging Epidemic Among Young People Who Use Heroin

This slide demonstrates the increase in HCV incidence from 2006-2012 and that the largest increase has been in rural—as opposed to urban—areas, paralleling the burgeoning opioid epidemic.[2] During this period, there has been a regional doubling of heroin use.[3] In an analysis from Kentucky, Tennessee, Virginia, and West Virginia, 3 of 4 people who inject drugs had a history of prescription opioid use before initiating injection-drug use.[3] This demonstrates what we now understand about the opioid epidemic: It often starts with misuse of prescription medications, which then leads to injection-drug use. Many of the individuals who are affected began taking opioid medications at young ages—often before 20 years of age.[2]

In a separate meta-analysis, it was found that HCV incidence was 17% higher in women who inject drugs compared with men who inject drugs.[4]

HCV in Women of Childbearing Age

In this study, which specifically looked at HCV in women, investigators retrospectively pooled data from 2 databases: the National Notifiable Diseases Surveillance System and the Quest Diagnostics laboratory database.[5] The graph depicting trends over time shows that starting in 2012, women 15-44 years of age had higher rates of acute HCV infection compared with women 45-64 years of age. Before that time, the baby boomer age group (ie, those 45-64 years of age) was at highest risk of HCV infection, but these data tell us that risk has become higher in younger people and, in particular, women of reproductive age. 

Why Might Women Be at Higher HCV Risk?

Why might women be at higher risk? Studies have shown that women who inject drugs have higher incidence of HIV and higher rates of injection-related risk behaviors compared with men who inject drugs; these same injection risk behaviors put them at risk for HCV.[4] They also have higher rates of equipment and syringe sharing.[4] More women use injection equipment after their male partners than males after their female partners, and more women are injected by others, as opposed to injecting themselves.[4]  

Women are more likely than men to participate in injection-drug behavior with their sexual partners, and these overlapping sexual and injecting partnerships may increase their risk behaviors.[6] Finally, women who inject drugs may face stigma and may be less likely to participate in harm-reduction services.[4]  

Because of these patterns, women of childbearing age may be at increased risk of acquiring HCV infection. Therefore, it is critical to counsel women on harm-reduction services and safe injection practices to avoid HCV infection and reinfection.

HCV in Pregnant Women, 2009-2017

Paralleling the rise in HCV incidence among younger women, there also has been an increase in HCV infections among women during pregnancy. On the slide are data from a large, retrospective study of live births in the United States from 2009-2017.[7] The panel on the left documents a significant increase in HCV prevalence during pregnancy, particularly among non-Hispanic White women. Reported prevalence of maternal HCV infection increased by 161% over this period.

It is important to note that, although there is a clear recognition of how the opioid epidemic has led to increased HCV infections among young women during this period, the increases may also in part reflect increased testing of this population and identification of more cases. 

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