Introduction

Infection with hepatitis C virus (HCV) is an increasing global health problem. In 2005, 184 million persons worldwide were estimated to have been infected with HCV, an increase from the estimated 122 million persons in 1990 (Mohd Hanafiah et al. 2013). In the USA, HCV is the most prevalent chronic blood-borne infection. An estimated 4.1 million persons have been infected with HCV, of whom approximately 3.2 million are chronically infected (Armstrong et al. 2006). The vast majority of those chronically infected are unaware of their infection (Smith et al. 2012). Furthermore, HCV infection is an increasing cause of morbidity and mortality. Chronic HCV infection is a major cause of liver cirrhosis and liver cancer and claims the lives of approximately 15,000 Americans each year (Ly et al. 2012). The number of deaths attributed to HCV infection now surpasses the number of deaths attributed to HIV (Ly et al. 2012).

In the current absence of an effective vaccine, primary prevention against infection with HCV focuses on reducing risks through blood safety and safe injection practices. In developing countries, HCV infection is primarily transmitted through exposure to infected blood and blood products in health care and community settings while injection drug use is the primary mode of transmission in developed countries (Maheshwari and Thuluvath 2010). In the USA, persons who inject drugs (PWID) are disproportionately infected with HCV (Aceijas and Rhodes 2007; Armstrong et al. 2006). Though the overall incidence of HCV has declined over the past 20 years, HCV incidence among young PWID in the range of 40 per 100 person-years has been reported (Klevens et al. 2012). In addition to the disproportionate number of new infections among PWID, the prevalence of HCV infection in studies among PWID ranges from 40 to 70 % (Amon et al. 2008; Hagan et al. 2011). PWID are also more likely to suffer from hepatitis-related health outcomes and comorbidities due to poor access to health care (Dore and Thomas 2005; Grebely et al. 2008).

On top of being disproportionately infected with HCV, PWID are at elevated risk for other viral infections including HIV. Among PWID, the prevalence of HIV and HCV coinfection ranges from 30 to 90 % (Miller et al. 2004; Vickerman et al. 2013). Among HIV-infected persons who receive antiretroviral therapy, chronic HCV infection is the leading cause of death after AIDS-related complications (Weber et al. 2006). Current prevention services recommended for PWID include testing for HCV infection, annual testing for HIV, receiving vaccinations for hepatitis A and B, treatment of substance use and mental disorders, and interventions for reduction of risk behavior (Centers for Disease Control and Prevention 2012a). However, PWID often lack access to preventative services and care due to myriad complex factors.

For the general population, health care coverage and access to preventative services varies widely across the USA. Nationwide, approximately 47 million Americans, or 15 % of the population, were uninsured in 2012 (Kaiser Commission on Medicaid and the Uninsured 2013). Federal programs, such as Medicaid, provide coverage for low-income individuals. A key goal of the Affordable Care Act legislation is to expand Medicaid coverage to millions of those currently uninsured. Estimates of health care coverage for PWID also vary and are mostly lower than the general population (Appel et al. 2004; Chitwood et al. 2002; Cronquist et al. 2001; Mehta et al. 2010). Across the USA, estimates of PWID range from 34 to 324 (median 91.5) per 10,000 persons (Tempalski et al. 2013). In an effort to help characterize current health care coverage and access to preventative services among PWID, we examined data from the National HIV Behavioral Surveillance System (NHBS) collected in Denver, Colorado and Seattle, Washington. Our objective was to compare health care coverage, HCV and HIV testing history, hepatitis A and B vaccination coverage, and co-occurring substance use among PWID in two cities with similar estimated numbers of PWID (136 per 10,000 population in Denver and 164 per 10,000 population in Seattle, Brady et al. 2008).

Methods

National HIV Behavioral Surveillance System

The NHBS system was established in 2003 by the Centers for Disease Control and Prevention (CDC) to monitor risk behaviors among three populations at the highest risk for HIV infection in the USA: men who have sex with men, injection drug users, and heterosexuals at increased risk for HIV. NHBS involves rotating 12-month cycles of surveillance activities in these three populations. Surveillance activities include ethnographic formative research, an in-depth behavioral survey, and HIV testing during each cycle. The analyses presented in the current paper are from the 2009 NHBS cycle among PWID in two of the participating NHBS sites, Denver, Colorado and Seattle, Washington (Centers for Disease Control and Prevention 2012b).

Study Design and Protocol

Between July and December 2009, participants were recruited using respondent-driven sampling (RDS), a peer-referral sampling methodology (Heckathorn 1997). In RDS, initial “seed” participants are identified through key stakeholders and are recruited for participation. Seeds are then asked to recruit persons from their networks using referral coupons, who in turn recruit persons from their networks, and so on. Participation rates are calculated by dividing the number of referred eligible participants by the number of distributed coupons and typically range from 30 to 50 %. Each eligible participant was allowed to refer up to five persons from their network. Participants were instructed to recruit someone they knew who injects drugs and who they had seen in the past 30 days. RDS employs a dual incentive structure; thus, participants were compensated for their participation in addition to being compensated a smaller amount for each eligible person they successfully recruited.

Persons were eligible to participate if they were at least 18 years or older, had injected drugs during the preceding 12 months, resided in the Denver or Seattle metropolitan statistical area, had not previously participated in the 2009 NHBS cycle, and were able to provide informed consent. Additional eligibility criteria included having physical evidence of recent injection (fresh track marks) or having current knowledge of drug packaging, pricing, and locations where drugs are sold.

Verbal informed consent was obtained from eligible participants. Participants completed a standardized interviewer-administered behavioral risk survey using handheld computers. Participants were also offered a rapid HIV test and a follow-up confirmatory Western blot was performed on all tests with an initial reactive result. In addition, participants were offered a standard HCV antibody test. In Denver, participants were given US$25 for completing the survey, US$25 for providing specimens for testing, and US$10 for each eligible person they recruited. In Seattle, participants were given US$25 for completing the survey, US$15 for HIV testing, US$15 for HCV testing, and US$10 for each eligible referral. All NHBS activities were voluntary, and no names were collected. The study protocol was reviewed and approved by the Colorado Multiple and Washington State Institutional Review Boards.

HCV Testing

In Denver, a reference assay using the Ortho HCV Version 3.0 enzyme-linked immunosorbent assay was performed at the Colorado Department of Public Health and Environment’s laboratory (Ortho Clinical Diagnostics). In Seattle, the reference assay, performed at the laboratory at Public Health - Seattle & King County, was the Abbott AxSYM anti-HCV microparticle immunoassay (Abbott Laboratories). The reference assays used to detect HCV antibodies have specificities in 99 % range (Alter et al. 2003). At both sites, a third-generation recombinant immunoblot assay (RIBA) (Chiron RIBA HCV 3.0 SIA; Novartis Vaccines and Diagnostics) was used to confirm antibody positivity for reactive specimens with a signal-to-cutoff ratio below the CDC-recommended threshold. Results of the reference assays for HCV infection are reported.

HIV Testing

In Denver, participants provided an oral specimen for a rapid HIV test using OraQuick ADVANCE ® Rapid HIV-1/2 Antibody Test (OraSure Technologies Inc, Bethlehem, PA). In Seattle, participants provided a finger stick blood specimen for rapid testing using the OraQuick test or a blood specimen for standard EIA testing (Bio-Rad GS rLAV EIA, Human Immunodeficiency Virus Type 1) (Viral Lysate and E. coli Recombinant Antigen). At both sites, confirmatory testing was done by Western blot (Bio-Rad GS HIV-1 Western Blot Human Immunodeficiency Virus Type I).

Statistical Analysis

Descriptive frequencies are presented for each sample. Chi-square statistics were calculated to compare the two samples from Denver and Seattle. In addition, we used chi-square statistics to compare participants who were HCV antibody-positive to those who were antibody-negative within each site. Fisher’s exact test was calculated when minimum expected frequency requirements were not met. All analyses were conducted using Stata Version 12.0 (StataCorp, College Station, TX).

Results

Demographics

A total of 3,356 RDS coupons were distributed, 2,044 in Denver and 1,312 in Seattle. To begin the RDS recruitment chains, 16 initial seed participants were identified, ten in Denver and six in Seattle. A sufficient number of recruitment waves was reached in both cities for the samples to reach equilibrium (i.e., the point at which sample characteristics no longer change and are not biased by seed participants). A total of 935 eligible persons were recruited via RDS, 428 (21 % of distributed coupons) from Denver and 507 (39 % of distributed coupons) from Seattle. Of the 428 persons recruited in Denver, 295 (68.9 %) were male, a little over half (51.6 %) identified as non-Hispanic white, and one-fifth (21.7 %) were 55 years or older (Table 1). In Seattle, 330 (65.1 %) of participants were male, 60 % identified as non-Hispanic white, and approximately 18 % were 55 or older. There were significant differences in the racial distribution of the Denver and Seattle populations. In particular, more participants in Denver identified as Hispanic compared to participants in Seattle (26.5 vs. 5.7 %, p < 0.001). In both cities, approximately one quarter of participants reported having less than a high school education, 27.3 % in Denver and 25.6 % in Seattle. Participants differed by employment status between the two cities. More participants in Denver reported being unemployed (44.2 vs. 34.8 %, p < 0.001), while significantly more participants in Seattle, 50 %, reported being disabled for work. In both cities, approximately 45 % of participants, 43.2 % in Denver and 44.5 % in Seattle, reported being currently homeless. While heroin was the drug most frequently injected in both cities (Denver 72.4 %; Seattle 81.7 %), higher proportions of Denver participants reported injecting methamphetamine, speedball, and cocaine as their primary drug compared to Seattle participants.

Table 1 Sociodemographic characteristics of a sample of injection drug users, National HIV Behavioral Surveillance (NHBS), Denver, Colorado and Seattle, Washington, 2009
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Health Care and Access to Testing

In Denver, a total of 196 (45.8 %) participants reported having current health insurance or coverage with the biggest proportion of coverage provided by Medicaid (20.6 %; Table 2). In Seattle, a total of 341 (67.4 %) participants reported current health care coverage with almost half reporting Medicaid coverage (46.1 %). In both cities, the majority of participants had seen a health care provider in the past 12 months though significantly more participants in Seattle had seen a provider compared to Denver (83.4 vs. 75.2 %, p = 0.002). Among those who had seen a provider in the past 12 months, a slightly higher proportion of participants in Seattle (43 %) were offered an HIV test compared to Denver participants (41 %). We examined testing offered during stays in detention, jail, or prison and found that approximately 8 % of participants in Denver were offered both HIV and HCV tests while incarcerated during the past 12 months. In Seattle, 6.7 % of participants had been offered an HIV test and 3.6 % had been offered an HCV test during their last detention, jail, or prison stay.

Table 2 Health care and access to HIV and HCV testing variables in a sample of injection drug users, National HIV Behavioral Surveillance (NHBS), Denver, Colorado and Seattle, Washington, 2009
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HCV History

Participants were asked about their prior HCV testing experiences and HCV history. Overall, fewer participants in Denver had a prior blood test for HCV compared to Seattle participants (79.7 vs. 86.2 %, p = 0.034, Table 3). Participants from both sites were similar in terms of self-reported hepatitis C status, time since diagnosis, and ever having taken medication to treat their HCV infection.

Table 3 HCV history, HCV and HIV serology results, and reported male-male sexual behavior in a sample of injection drug users who were tested for HCV, National HIV Behavioral Surveillance (NHBS), Denver, Colorado and Seattle, Washington, 2009
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HIV History

Participants were also asked about their prior HIV testing experiences and HIV history. Similar to prior HCV testing, fewer participants in Denver reported having a prior HIV test compared to Seattle participants (87.0 vs. 92.7 %, p = 0.022, Table 3). However, more participants in Denver reported the result of their prior HIV test with 3.8 % reporting a positive result, 92.7 % reporting a negative result, and 3.5 % reporting they never obtained their result. This is compared to 10.0 % of Seattle participants reporting they never obtained their HIV result, 5.4 % reporting a positive result, and 84.6 % reporting a prior HIV-negative test result.

HCV and HIV Infection

There were no significant differences between Denver and Seattle in HCV prevalence, HIV prevalence, or HCV-HIV coinfection. This is true for the PWID population as a whole, among males who inject and report sexual activity with males, and among males who inject and report no male sexual activity (Table 3). A total of 395 participants in Denver and 260 participants in Seattle provided a blood specimen to test for HCV and HIV antibody. In Denver, 289 (73.2 %) were HCV antibody-positive while 189 (72.7 %) were antibody-positive in Seattle. In terms of HIV infection, 4.6 % of Denver participants and 5.8 % of Seattle participants tested positive. We also examined HCV and HIV coinfection among those who were screened for both infections. In Denver, 3.8 % of participants were coinfected, 69.4 % were mono-infected with HCV, and 0.8 % of participants were HIV mono-infected. In Seattle, 4.2 % of participants were coinfected, 68.5 % were HCV infected, and 1.5 % HIV infected.

Given the higher prevalence of HIV among men who have sex with men (MSM), we examined HIV and HCV coinfection by report of MSM activity (Table 3). Significantly, more male participants in Seattle reported oral or anal sex with a man in the past 12 months compared to Denver participants (19.9 vs. 4.8 %, p < 0.001). Among males who reported MSM activity in Denver, 23.1 % were HCV and HIV coinfected, 38.4 % were mono-infected with HCV, and 15.4 % were HIV mono-infected. In Seattle, 18.2 % of males reporting MSM activity were HCV and HIV coinfected, 39.4 % were mono-infected with HCV, and 12.1 % were HIV mono-infected.

Injection History, Vaccination Status, and Other Substance Use by HCV Antibody Status

Within each site, we compared participants who were HCV antibody-positive (anti+) to those who were antibody-negative (anti−) by injection history, vaccination status, and non-injection substance use. In both sites, the median age at first injection was significantly lower among participants who were HCV anti+ compared to those who were HCV anti− (19.9 vs. 24.8 in Denver and 21.6 vs. 27.2 in Seattle, Table 4). Similarly, there were significant differences in HCV infection status by the number of years since first injection in both sites. In Denver, slightly more participants who were HCV anti+ had hepatitis A and/or B vaccinations compared to those who were HCV anti− (43.2 vs. 28.3 %, p = 0.052). In Seattle, HCV anti+ participants actually had lower hepatitis A and/or B vaccination coverage compared to HCV anti− participants (34.3 vs. 47.9 %, p = 0.181), though the difference was not significant.

Table 4 Drug use-related variables in a sample of injection drug users who were tested for hepatitis C virus (HCV), National HIV Behavioral Surveillance (NHBS), Denver, Colorado and Seattle, Washington, 2009
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Alcohol and marijuana use can exacerbate the effects of HCV, so we examined the use of these substances. There did not appear to be substantial differences in behavior based on HCV infection status in either site. In Denver, slightly more participants who were HCV anti+ reported not binge drinking in the past 12 months compared to HCV anti− participants (48.3 vs. 41.5 %, p = 0.038). In Seattle, the pattern was similar with slightly more HCV anti+ participants reporting that they had not engaged in binge drinking during the past 12 months (50.5 vs. 43.7 %, p = 0.495). Frequency of marijuana use did not differ by HCV infection status in either site. In Denver, fewer participants who were HCV anti+ reported never having participated in an alcohol or drug treatment program compared to HCV anti− participants (17.3 vs. 29.3 %, p = 0.101).

Discussion

This study characterizes current health care coverage, HCV and HIV seroprevalence, HCV testing history, hepatitis A and B vaccination coverage, and co-occurring substance use among PWID in two urban areas in the USA. Our results provide evidence that persons who inject drugs in both Denver and Seattle have substantial unmet needs for health care coverage and access to medical preventative services. The vast majority of participants were at or below the federal poverty threshold in 2009 (US$10,830 for a family of one and US$14,570 for a family of two), either unemployed or disabled for work, and in unstable housing situations. Despite this, most participants (75 % in Denver and 83 % in Seattle) reported seeing a health care provider in the past 12 months. However, the visit with a health care provider was most likely to address an acute medical need and not to receive preventative medical care, such as screening for HCV and HIV infection or vaccinations for hepatitis A and B.

In our samples of PWID, substantially, more participants reported being uninsured in Denver (54 %) compared to Seattle (33 %). However, when we examined the number of uninsured persons in the general population during the same time frame, the difference was not as substantial with 18 % uninsured in Denver and 12 % in Seattle (US Census Bureau 2014). In both cities, the majority of participants report Medicaid as their source of health care coverage. The difference in coverage observed between the two samples of PWID may be due, in part, to the substantial difference in the number of persons reporting being disabled for work (30 % in Denver vs. 50 % in Seattle) given that Medicaid is also the federal government’s mechanism for providing health care to persons with disabilities.

Though Seattle has higher Medicaid coverage compared to Denver (46 vs. 21 %), there is still ample room for expanded coverage to those currently eligible but uncovered. While not all 50 states opted to participate in Medicaid expansion as part of the Affordable Care Act, Colorado and Washington are two states moving forward with Medicaid expansion. As such, identifying those most in need of health care coverage and better access to preventative services is essential. Our findings are similar to other studies that have documented the high prevalence of health care needs among PWID. In San Francisco, 82 % of homeless PWID reported needing health care during the preceding 6 months while 75 % of the sample reported having no health insurance (Robbins et al. 2010). Restricting our samples to those PWID who reported being currently homeless, 66 % of those in Denver and 44 % of those in Seattle reported being uninsured. In Miami, the prevalence of unmet health care need among PWID was similarly high at 76 % (Chitwood et al. 1999).

Similar to other studies among PWID, we also found high prevalence of HCV antibody in our two samples (Amon et al. 2008; Fisher et al. 2006; Havens et al. 2013; Mehta et al. 2011). Though a large proportion of participants were aware of their HCV status, approximately 30 % were unaware of their infection. Our estimate of those unaware of their HCV infection is lower than some estimates of other at-risk populations. For example, in a study among homeless adults in Los Angles, nearly half of those who were HCV infected were unaware of their infection (Gelberg et al. 2012). Among young PWID in five US cities, 72 % of those who were HCV antibody-positive were unaware of their infection (Hagan et al. 2006).

Among persons who were HCV antibody-positive, approximately 40 % reported being vaccinated for hepatitis A and/or B. Surprisingly, our vaccination coverage rates are slightly higher than those reported in a cohort study of HCV-infected patients enrolled in private health insurance plans and population-based estimates (Centers for Disease Control and Prevention 2006; Kanwal et al. 2010; Wong et al. 1996). One study of PWID aged 15 to 30 found that only 10 % had been vaccinated for hepatitis B (Kuo et al. 2004a, b). In an earlier study conducted between 1999 and 2002, the same investigators demonstrated that the validity of self-reported hepatitis B vaccination was poor with 52 % of those claiming to be vaccinated actually being susceptible to HBV as measured by serological markers (Kuo et al. 2004a, b). Our vaccination coverage rates should be interpreted with caution given that they are based on participant self-report and were not confirmed by examination of medical record, or serological verification of immunity status, for those who most likely received the vaccines as adults. Furthermore, our data does not capture the number of doses an individual received. A study evaluating the uptake of free hepatitis B vaccinations among PWID in the Netherlands suggests that perceived behavioral control related to vaccination was predictive of vaccine uptake (Baars et al. 2008). While hepatitis B vaccination does not provide biological protection against HCV, it may help create stronger pro-health attitudes among PWID (Quaglio et al. 2003). Most importantly, because infection with hepatitis A and/or B creates serious complications for those with chronic liver disease, ensuring that persons with HCV infection are vaccinated for both hepatitis A and B is a critical prevention issue.

Given that excessive alcohol consumption is also an important factor affecting the progression of liver disease among those infected with HCV, we compared the frequency of “binge” drinking between those who were HCV infected and those who were not. There was no evidence that HCV-positive participants reported less binge drinking than HCV-negative participants. In both sites, roughly half of those who were HCV infected reported abstaining from alcohol during the preceding 12 months. Still, we found that approximately 20 % of participants reported binge drinking at least weekly during the past 12 months. A recent analysis of the National Health and Nutrition Examination Survey (NHANES III) examined the long-term outcomes among those with chronic hepatitis C. The authors found that chronically infected patients with excessive alcohol use had a dramatically increased risk of all-cause mortality with a hazard ratio of 5.12 (95 % CI 1.97–13.28), in addition to increased liver-related mortality (Younossi et al. 2013). In a cohort study of HIV-infected patients, reporting being told that they were HCV infected was associated with greater abstinence from alcohol with an adjusted odds ratio of 1.60 (95 % CI 1.13–2.27). The authors suggest that it is being told of one’s hepatitis C diagnosis, rather than actually having infection, that is linked to the effect on drinking (Tsui et al. 2007).

Several studies have documented the association between moderate to severe fibrosis and daily cannabis use among HCV-infected individuals (Dore and Thomas 2005; Hezode et al. 2008; Ishida et al. 2008). In both cities, we did not see significant differences in marijuana use between those who were HCV infected and those who were not, with approximately 15 % of participants reporting daily cannabis use in both cities. Cannabis use may also be related to syringe sharing among PWID which has obvious implications for HCV and HIV transmission. In a study of PWID of which 236 (36.6 %) were regular cannabis users and 227 (35.2 %) were non-regular cannabis users, cannabis use was associated with a fivefold increased risk of sharing syringes in non-regular users compared to regular users (Jutras-Aswad et al. 2010).

Despite the recommendation that PWID be tested annually for HIV, less than half of participants who had seen a health care provider in the past 12 months were offered an HIV test. Our findings are similar to those from a study of PWID in two Mexico-US border cities which showed that 65 % of those who had never been tested for HIV experienced at least one missed opportunity for testing (Moyer et al. 2008). Detention, whether in jail or prison, often offers an opportunity to screen for HIV and HCV for detention facilities where medical services are available. In our study, we found that approximately 20 % of those who had been incarcerated during the past 12 months had been offered an HIV and/or HCV test. However, we did not ask if vaccinations for hepatitis A and B were offered during the last detention stay.

While we observed differences between the two cities related to medical coverage and potential access to preventative medical services, it is also important to note a key difference between the two cities related to harm reduction services for PWID. Since 1989, Seattle has had legally operating syringe programs that offer HIV/HCV testing and counseling, hepatitis A and B vaccinations, and abscess treatment and care in addition to the provision of sterile syringes. In contrast, Denver did not legalize syringe programs until 2012. Prior to that, harm reduction services for PWID were limited to the provision of clean cookers, cottons, and water and HIV/HCV testing and counseling. We compared several indicators related to harm reduction between the two cities. Significantly, more PWID in Seattle (33 %) reported always using a sterile syringe compared to Denver participants (20 %, p < 0.001). Similarly, fewer participants in Seattle reported sharing syringes with others compared to Denver (31.5 vs. 40.7 %, p < 0.01). Despite this, the overall prevalence of HIV and HCV in our samples is comparable between the two cities.

Our findings are subject to several limitations. First, because the survey was administered by an interviewer, some participants might not have reported their behaviors accurately. Second, we did not run HCV RNA tests on samples from participants who were HCV antibody-positive so our HCV+ results may include some individuals who have cleared the infection Third, because of logistics related to the premarket evaluation of the rapid HCV antibody assays, there was a delay in initiating HCV testing resulting in not all NHBS participants being offered an HCV test. Fourth, though participants were recruited using RDS, we do not present RDS-weighted estimates. Finally, our results are limited to respondents in two urban cities in the Western part of the USA and may not be generalizable to PWID in other parts of country or to other countries.

Not only are PWID disproportionately affected by HIV and HCV infection, they are also disproportionately affected by limited access to health care and other social and preventative services they so desperately need. An analysis of population-based data demonstrated that HCV infection was an independent predictor of being uninsured (Stepanova et al. 2011). Our findings underscore the need to improve access to preventative services and care, such as hepatitis A and B vaccination, for PWID. Previous studies have shown that providing on-site vaccination at locations where PWID access other services can increase adherence to vaccination (Burr et al. 2014; Campbell et al. 2007; Des Jarlais et al. 2001). While access to preventative services is essential, ensuring that PWID utilize services once they are accessed is also critical. As recently demonstrated in a randomized control trial of methadone maintenance patients, the provision of coordinated care which includes on-site screenings, motivational-enhanced education and counseling, on-site vaccination, and case management services is efficacious in increasing hepatitis A and B vaccinations and HCV evaluation (Masson et al. 2013). Given how marginalized PWID can often be, providing comprehensive preventative services at locations where they may feel more comfortable accessing other services, such as syringe exchange programs or community-based organizations, is essential.

Whereas PWID account for a substantial proportion of the HIV epidemic, their burden of the HCV epidemic is enormous. With a new generation of highly effective interferon-free direct-active antivirals for the treatment of HCV on the horizon, coupled with the expansion of health coverage in the USA, a real opportunity to achieve substantial reductions in prevalent HCV now exists. However, juxtaposed against the promise of making a significant public health impact, we are confronted by the challenge of a “re-emerging HCV epidemic” among adolescent and young PWID. In both cities, the mean age of first injection was significantly lower among those who were HCV infected indicating an increased risk for younger PWID. As recently summarized by recommendations from the US Office of HIV/AIDS and Infectious Disease Policy, “embracing a perspective that recognizes the syndemic nature of emergent HCV infection among adolescent and young IDUs requires a commitment to simultaneously address substance use and its social antecedents as well as to confront the ongoing and powerful stigma associated with substance use disorders and persons who inject drugs (Valdiserri et al. 2014).” Prevention science has a critical role to play in addressing this syndemic as developmentally appropriate interventions to prevent substance use upstream could have a tremendous impact on mitigating the downstream effects.