Practice Pearl 1: Preventing Transmission With Syringe Exchange Programs

Experts in the management of hepatitis C discuss transmission of the hepatitis C virus by sexual transmission and by tattoo parlors.

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Christian B. Ramers, MD, MPH, AAHIVS: What are some measures that are out there that we know work to prevent ongoing transmission of hepatitis C? Chris?

Christopher Hulstein, PharmD, CSP: Being aware that you are actively infected with hepatitis C, so you can prevent the transmission to close contacts. Any spilled blood that you might have in your home, cleaning that up and following it with bleach. Making sure that you're not sharing toothbrushes or razors, until you do have that actual cure under your belt.

Being very aware of the safety from where you're getting tattooed, for example, recommending for IV [intravenous] drug users using sterile needles. It may be very difficult to prevent a patient from using drugs. That's kind of a long-term addiction, but we can at least try to encourage using them in a safer manner that might prevent them transmission of the disease itself.

Christian B. Ramers, MD, MPH, AAHIVS: Speaking about misinformation, there are really a lot of different views on syringe-exchange services. We all practice in different parts of the country. One of the main misperceptions is that starting a syringe-exchange program is going to tempt people to use more drugs. I'm curious about all 3 of you—your opinion on syringe exchanges, whether they're available in your location. I'll start with you, Caroline.

Caroline Derrick, PharmD, BCPS: Syringe exchange is not something that is truly there to promote drug use. It's there to create a safety net in a way to provide clean equipment to patients. In South Carolina, we don't have any syringe-exchange programs that are legalized. That's not something we are actively doing in South Carolina. I'm an advocate for education on syringe-exchange programs and making sure that it's done the right way—and having that as an available option for those who will be using needles to make sure that they're clean—is something that's important.

Christian B. Ramers, MD, MPH, AAHIVS: In Massachusetts?

Bhavesh Shah, RPh, BCOP: We are heavily faced with opioid crisis and really heavily involved in this space, so we definitely have a program where patients can come in to get needle exchange from the pharmacy from the treatment centers that we have. We have the opioid addiction treatment center. We do have that facilitation for it. We haven't seen an increase in incentivizing patients to do that.

Christian B. Ramers, MD, MPH, AAHIVS: In Colorado?

Christopher Hulstein, PharmD, CSP: Directly within my practice we don't have a direct needle or syringe-exchange program, but I am in the same school of thought of providing that education to patients to try to prevent and reduce transmission from patient to patient.

Christian B. Ramers, MD, MPH, AAHIVS: From California the answer is that it's complicated. I've been impressed with the efforts at the federal level to get to 0 new HIV infections, as well as the response to the opioid crisis. There's been much more of an accepting view of what we call syringe service programs. Because they're not just there to hand out syringes and encourage drug use. They're actually a place where we can get people into care much more easily. For people who have opioid use disorder, getting them into Suboxone or a medication-assisted treatment program is much easier when they're engaged in a syringe program.

There are a lot of local laws that need to be looked at in terms of whether this is legal or allowed or not. I know that Health and Human Services agency at the federal level has endorsed syringe exchange as a very important prevention activity. Until we have a vaccine, we need to use every other tool we have. Knowing your status, getting tested. What we didn't talk about it just aggressively treating everybody who has hepatitis C. Because anybody who has hepatitis C is going to be a reservoir for ongoing infections. The more people we treat, the more we will drive down incidence.

One other specific point on that is that we traditionally have avoided treating the hard-to-treat people who are more likely to transmit. That's mainly people who inject drugs. There's been a real move within the field to try to treat more of those "harder-to-treat" patients, because they're the ones involved in the new infections.