The intricate relationships between the epidemics of drug abuse, HIV/AIDS, and hepatitis C were the focus of discussion at "Drug Use, HIV, and Hepatitis: Bringing It All Together," a conference sponsored jointly by NIDA, the Center for Substance Abuse Treatment (CSAT), and the Centers for Disease Control and Prevention (CDC) held in Baltimore in May.

"The connection between drug abuse and HIV has been recognized for some time," said NIDA Director Dr. Alan I. Leshner. "It's unfortunate that it has taken us this long to take on hepatitis C as a related issue, because the reality is that these three diseases are intertwined." Dr. Leshner emphasized that a logical approach to preventing the spread of HIV and hepatitis C is treatment for drug addiction.

Like HIV, the hepatitis C virus (HCV) is spread through contact with an infected individual's blood and-although this is less common than with HIV-through sexual contact. According to CDC, approximately 4 million Americans have been infected with HCV, of whom 2.7 million are experiencing chronic symptoms. At least 60 percent of the estimated 36,000 individuals infected each year will contract the disease through the use of contaminated injection drug equipment. Eight thousand to 10,000 Americans are expected to die of HCV-related liver disease this year. (See "Facts About Drug Abuse and Hepatitis C" for additional information.)

NIDA Director Dr. Alan I. Leshner and CSAT Director Dr. Westley Clark at the conference. (Photo courtesy of Danya International, Inc.)

At workshops during the conference, scientists from NIDA and CDC discussed ways to prevent the spread of HCV, as well as ways to assess and treat patients with both HCV and HIV. Attendees participated in skills building workshops that were led by NIDA researchers and other experts and that focused on topics such as the problem of HCV in the prison system; the role of microbicides in prevention; prevention strategies for high-risk populations; the epidemiology of HIV and hepatitis infections among young adults and recently initiated injection drug users; prevention of opportunistic infections; improving adherence to prevention and treatment strategies; integrating treatment into public health settings; methods for conducting patient needs assessments; drug interactions; integrating mental health care into comprehensive treatment planning; and more.

At a press conference held during the meeting, Dr. Leshner announced the release of NIDA's new Community Drug Alert Bulletin on Hepatitis C and also announced that NIDA is publishing the first science-based guide for HIV outreach, entitled The NIDA Community-Based Outreach Model: A Manual to Reduce the Risk of HIV and Other Blood-Borne Infections in Drug Users.

Dr. Leshner noted that NIDA, CSAT, and CDC all are working with the scientific community, substance abuse treatment programs, and the HIV community to increase knowledge of these diseases among people at risk and the general public. "Substance abuse prevention and treatment practitioners are on the front lines of preventing and treating HIV, HCV, and other sexually transmitted diseases (STDs) but need to focus on the whole problem-not just one aspect of it," added Dr. Westley Clark, director of CSAT. This means developing and implementing comprehensive approaches that integrate ways to reduce the risk of contracting and spreading these diseases, he noted.

Dr. Leshner noted that although drug abuse and addiction affect everyone in the United States either directly or indirectly, most people deal with the issue based on their individual ideologies and cultural myths. "Advances in science have fundamentally revolutionized the way we look at the brain and at drug addiction as a brain disease," he said. "We now know that drug abuse is a preventable behavior but addiction is a disease." Treatment is essential because "drug abuse is a major vector for transmission of other diseases, including HIV, HCV and other types of hepatitis, other STDs, and tuberculosis." The challenge not only will be getting drug-abusing and drug-addicted individuals into treatment, but also will be getting those who have not yet entered treatment to change their behaviors, he said.

"We now have the science base we need to understand how these diseases work alone and together, and this must be the foundation of our work," Dr. Leshner said. "What we have learned through the scientific study of the brain helps explain why most addicts can't just stop taking drugs. But this does not mean that they cannot reduce their risk behaviors for related diseases."

Dr. Henry Francis, director of NIDA's Center on AIDS and Other Medical Consequences of Drug Abuse (CAMCODA), emphasized to participants that drug abusers tend to be as willing to participate in treatment as anyone else if they have regular contact with a primary care doctor. "CAMCODA's goal is to expand NIDA's treatment portfolio from a focus on how the disease and infection process works to a focus on why and how people are exposed to risk and what is needed to treat and prevent the disease," he said. Because HCV is a significant problem in the drug-injecting population, treatment provided to individuals who have both HIV and HCV must be carefully planned and monitored. Interferon-the standard treatment for HCV-can cause mood disorders and other symptoms that may encourage drug abuse or interfere with treatment for HIV. Drug use should not be considered a contraindication for treatment of either HIV or HCV, he said.

In panel discussions, experts from CDC's Division of HIV/AIDS Prevention told conference participants that HIV infection rates among injection drug users remain high and that Hispanics and African Americans are disproportionately affected by the disease. Since 1992, death rates among AIDS-infected persons have declined dramatically due to the introduction of highly effective antiretroviral medications. However, the infection rate for hepatitis C in this population has risen as the number of deaths from HIV has declined.