Semin Liver Dis 2021; 41(02): 109-116
DOI: 10.1055/s-0040-1716343
Review Article

Alcohol Use Disorder and Hepatitis C Prevention and Care in People Who Inject Drugs: The State of Play

Fabienne Marcellin
1   Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
Antoine Jaquet
2   Univ. Bordeaux, Inserm, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
3   Inserm, ISPED, Bordeaux Population Health Research Center, UMR 1219, Bordeaux, France
Jeffrey V. Lazarus
4   Barcelona Institute for Global Health (ISGlobal), Hospital Clínic, University of Barcelona, Barcelona, Spain
Patricia Molina
5   Department of Physiology and Alcohol and Drug Abuse Center of Excellence, Louisiana State University Health Sciences Center, New Orleans, Louisiana
Patrizia Carrieri
1   Aix Marseille Univ, INSERM, IRD, SESSTIM, Sciences Economiques & Sociales de la Santé & Traitement de l'Information Médicale, Marseille, France
› Author Affiliations
Funding F.M. and P.C. were supported by the French National Agency for Research on AIDS and Viral Hepatitis (Agence Nationale de Recherches sur le Sida et les hépatites virales, ANRS) and the French National Institute of Health and Medical Research (Institut National de la Santé et de la Recherche Médicale, INSERM). A.J. was supported by a grant from the National Cancer Institute, the Eunice Kennedy Shriver National Institute of Child Health & Human Development, the National Institute of Allergy and Infectious Diseases, and the National Institute of Drug Abuse (grant no. 5U01AI069919). P.M. is supported by the National Institute of Health (NIH)/National Institute of Alcohol Abuse and Alcoholism (P60 AA009803). J.V.L. is supported by a Spanish Ministry of Science, Innovation, and Universities Miguel Servet grant (Instituto de Salud Carlos III/ESF, European Union [CP18/00074]) and further acknowledges support to ISGlobal from the Spanish Ministry of Science, Innovation, and Universities through the “Centro de Excelencia Severo Ochoa 2019-2023” Program (CEX2018–000806-S) and from the Government of Catalonia through the CERCA Program.


Safe and effective treatment with direct-acting antivirals (DAAs) has ushered in an era in which hepatitis C virus (HCV) elimination, as set out by the World Health Organization, is possible. However, alcohol use disorder (AUD) has the potential to reduce the benefits of prevention interventions and reduce access to and continuity of HCV care in at-risk populations, such as people who inject drugs (PWID). We review the literature on the consequences of AUD on the effectiveness of HCV prevention and the cascade of care in PWID and provide recommendations for future research in the field of alcohol use and HCV.

Author Contributions

F. M. and P. C. drafted the manuscript. A. J., P. M., and J. V. L., contributed to the full manuscript and provided critical reviewing and suggestions throughout the different versions of this manuscript. All authors revised the manuscript and approved the final draft for submission.

Publication History

Article published online:
26 August 2020

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  • References

  • 1 American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders (DSM-5). 5th ed.. Washington, DC: American Psychiatric Association; 2013
  • 2 GBD 2016 Alcohol and Drug Use Collaborators. The global burden of disease attributable to alcohol and drug use in 195 countries and territories, 1990-2016: a systematic analysis for the Global Burden of Disease Study 2016. Lancet Psychiatry 2018; 5 (12) 987-1012
  • 3 Alavi M, Janjua NZ, Chong M. et al. The contribution of alcohol use disorder to decompensated cirrhosis among people with hepatitis C: an international study. J Hepatol 2018; 68 (03) 393-401
  • 4 Schwarzinger M, Baillot S, Yazdanpanah Y, Rehm J, Mallet V. Contribution of alcohol use disorders on the burden of chronic hepatitis C in France, 2008-2013: a nationwide retrospective cohort study. J Hepatol 2017; 67 (03) 454-461
  • 5 Fuster D, Sanvisens A, Bolao F, Rivas I, Tor J, Muga R. Alcohol use disorder and its impact on chronic hepatitis C virus and human immunodeficiency virus infections. World J Hepatol 2016; 8 (31) 1295-1308
  • 6 Larney S, Randall D, Gibson A, Degenhardt L. The contributions of viral hepatitis and alcohol to liver-related deaths in opioid-dependent people. Drug Alcohol Depend 2013; 131 (03) 252-257
  • 7 Ward JW, Hinman AR. What is needed to eliminate hepatitis B virus and hepatitis C virus as global health threats. Gastroenterology 2019; 156 (02) 297-310
  • 8 World Health Organization. Access to hepatitis C testing and treatment for people who inject drugs and people in prisons - a global perspective: policy brief. Accessed May 27, 2020 at:
  • 9 Doyle JS, Aspinall EJ, Hutchinson SJ. et al. Global policy and access to new hepatitis C therapies for people who inject drugs. Int J Drug Policy 2015; 26 (11) 1064-1071
  • 10 Martin NK, Vickerman P, Grebely J. et al. Hepatitis C virus treatment for prevention among people who inject drugs: modeling treatment scale-up in the age of direct-acting antivirals. Hepatology 2013; 58 (05) 1598-1609
  • 11 American Association for the Study of Liver Diseases. Guidance HCV: Recommendations for Testing, Managing, and Treating Hepatitis C. Accessed May 27, 2020 at:
  • 12 Razavi H, Sanchez Gonzalez Y, Yuen C, Cornberg M. Global timing of hepatitis C virus elimination in high-income countries. Liver Int 2020; 40 (03) 522-529
  • 13 Dore GJ, Martinello M, Alavi M, Grebely J. Global elimination of hepatitis C virus by 2030: why not?. Nat Med 2020; 26 (02) 157-160
  • 14 Lazarus JV, Safreed-Harmon K, Thursz MR. et al. The micro-elimination approach to eliminating hepatitis C: strategic and operational considerations. Semin Liver Dis 2018; 38 (03) 181-192
  • 15 Lazarus JV, Pericàs JM, Colombo M, Ninburg M, Wiktor S, Thursz M. Viral hepatitis: “E” is for equitable elimination. J Hepatol 2018; 69 (04) 762-764
  • 16 Larney S, Peacock A, Leung J. et al. Global, regional, and country-level coverage of interventions to prevent and manage HIV and hepatitis C among people who inject drugs: a systematic review. Lancet Glob Health 2017; 5 (12) e1208-e1220
  • 17 Smith DJ, Combellick J, Jordan AE, Hagan H. Hepatitis C virus (HCV) disease progression in people who inject drugs (PWID): a systematic review and meta-analysis. Int J Drug Policy 2015; 26 (10) 911-921
  • 18 Safreed-Harmon K, Blach S, Aleman S. et al. The consensus hepatitis C cascade of care: standardized reporting to monitor progress toward elimination. Clin Infect Dis 2019; 69 (12) 2218-2227
  • 19 Siu L, Foont J, Wands JR. Hepatitis C virus and alcohol. Semin Liver Dis 2009; 29 (02) 188-199
  • 20 Meyer JP, Isaacs K, El-Shahawy O, Burlew AK, Wechsberg W. Research on women with substance use disorders: reviewing progress and developing a research and implementation roadmap. Drug Alcohol Depend 2019; 197: 158-163
  • 21 Dillon JF, Lazarus JV, Razavi HA. Urgent action to fight hepatitis C in people who inject drugs in Europe. Hepatol Med Policy 2016; 1: 2
  • 22 Degenhardt L, Peacock A, Colledge S. et al. Global prevalence of injecting drug use and sociodemographic characteristics and prevalence of HIV, HBV, and HCV in people who inject drugs: a multistage systematic review. Lancet Glob Health 2017; 5 (12) e1192-e1207
  • 23 Grebely J, Tran L, Degenhardt L. et al. Association between opioid agonist therapy and testing, treatment uptake, and treatment outcomes for hepatitis C infection among people who inject drugs: a systematic review and meta-analysis. Clin Infect Dis Off Publ Infect Dis Soc Am 2020; (e-pub ahead of print) DOI: 10.1093/cid/ciaa612.
  • 24 World Health Organization. WHO, UNODC, UNAIDS: technical guide for countries to set targets for universal access to HIV prevention, treatment and care for injecting drug users. Accessed May 27, 2020 at:
  • 25 Platt L, Minozzi S, Reed J. et al. Needle and syringe programmes and opioid substitution therapy for preventing HCV transmission among people who inject drugs: findings from a Cochrane Review and meta-analysis. Addiction 2018; 113 (03) 545-563
  • 26 Welch-Lazoritz M, Hautala D, Habecker P, Dombrowski K. Association between alcohol consumption and injection and sexual risk behaviors among people who inject drugs in rural Puerto Rico. J Subst Abuse Treat 2017; 82: 34-40
  • 27 Poudel KC, Poudel-Tandukar K, Yasuoka J, Joshi AB, Jimba M. Correlates of sharing injection equipment among male injecting drug users in Kathmandu, Nepal. Int J Drug Policy 2010; 21 (06) 507-510
  • 28 Stein MD, Hanna L, Natarajan R. et al. Alcohol use patterns predict high-risk HIV behaviors among active injection drug users. J Subst Abuse Treat 2000; 18 (04) 359-363
  • 29 Roux P, Fugon L, Jones JD, Comer SD. Hepatitis C infection in non-treatment-seeking heroin users: the burden of cocaine injection. Am J Addict 2013; 22 (06) 613-618
  • 30 Evans JL, Hahn JA, Lum PJ, Stein ES, Page K. Predictors of injection drug use cessation and relapse in a prospective cohort of young injection drug users in San Francisco, CA (UFO Study). Drug Alcohol Depend 2009; 101 (03) 152-157
  • 31 Gyarmathy VA, Neaigus A. The association between social marginalisation and the injecting of alcohol amongst IDUs in Budapest, Hungary. Int J Drug Policy 2011; 22 (05) 393-397
  • 32 Mehta SH, Srikrishnan AK, Noble E. et al. Emergence of cocaine and methamphetamine injection among HIV-positive injection drug users in northern and western India. Drug Alcohol Depend 2014; 135: 160-165
  • 33 Hillebrand J, Marsden J, Finch E, Strang J. Excessive alcohol consumption and drinking expectations among clients in methadone maintenance. J Subst Abuse Treat 2001; 21 (03) 155-160
  • 34 Chaudhry AA, Botsko M, Weiss L. et al; BHIVES Collaborative. Participant characteristics and HIV risk behaviors among individuals entering integrated buprenorphine/naloxone and HIV care. J Acquir Immune Defic Syndr 2011; 56 (Suppl. 01) S14-S21
  • 35 Tross S, Hanner J, Hu MC, Pavlicova M, Campbell A, Nunes EV. Substance use and high risk sexual behaviors among women in psychosocial outpatient and methadone maintenance treatment programs. Am J Drug Alcohol Abuse 2009; 35 (05) 368-374
  • 36 Arasteh K, Des Jarlais DC. At-risk drinking and injection and sexual risk behaviors of HIV-positive injection drug users entering drug treatment in New York City. AIDS Patient Care STDS 2009; 23 (08) 657-661
  • 37 Roux P, Le Gall JM, Debrus M. et al. Innovative community-based educational face-to-face intervention to reduce HIV, HCV and other blood-borne infectious risks in difficult-to-reach people who inject drugs: results from the ANRS-AERLI intervention study. Addiction 2016; 111 (01) 94-106
  • 38 Bush K, Kivlahan DR, McDonell MB, Fihn SD, Bradley KA. The AUDIT alcohol consumption questions (AUDIT-C): an effective brief screening test for problem drinking. Ambulatory Care Quality Improvement Project (ACQUIP). Alcohol Use Disorders Identification Test. Arch Intern Med 1998; 158 (16) 1789-1795
  • 39 Roux P, Rojas Castro D, Ndiaye K. et al. Increased uptake of HCV testing through a community-based educational intervention in difficult-to-reach people who inject drugs: results from the ANRS-AERLI study. PLoS One 2016; 11 (06) e0157062
  • 40 Chirikov VV, Shaya FT, Howell CD. Contextual analysis of determinants of late diagnosis of hepatitis C virus infection in Medicare patients. Hepatology 2015; 62 (01) 68-78
  • 41 Papatheodoridis GV, Tsochatzis E, Hardtke S, Wedemeyer H. Barriers to care and treatment for patients with chronic viral hepatitis in Europe: a systematic review. Liver Int 2014; 34 (10) 1452-1463
  • 42 European Association for the Study of the Liver, Electronic address:; European Association for the Study of the Liver. EASL recommendations on treatment of hepatitis C 2018. J Hepatol 2018; 69 (02) 461-511
  • 43 Tsui JI, Williams EC, Green PK, Berry K, Su F, Ioannou GN. Alcohol use and hepatitis C virus treatment outcomes among patients receiving direct antiviral agents. Drug Alcohol Depend 2016; 169: 101-109
  • 44 Jonas DE, Amick HR, Feltner C. et al. Pharmacotherapy for Adults With Alcohol-Use Disorders in Outpatient Settings. Rockville, MD: Agency for Healthcare Research and Quality; 2014
  • 45 Klimas J, Tobin H, Field C-A. et al. Psychosocial interventions to reduce alcohol consumption in concurrent problem alcohol and illicit drug users. Cochrane Database Syst Rev 2014; (12) CD009269 pub3
  • 46 Doyle JS, Hunt D, Aspinall EJ. et al. A systematic review of interventions to reduce alcohol consumption among individuals with chronic HCV infection. J Hepatol 2014; 60 (01) S314-S315
  • 47 Stein MD, Anderson B, Charuvastra A, Maksad J, Friedmann PD. A brief intervention for hazardous drinkers in a needle exchange program. J Subst Abuse Treat 2002; 22 (01) 23-31
  • 48 Testino G, Leone S, Borro P. Treatment of alcohol use disorder patients affected by liver cirrhosis and/or hepatocellular carcinoma awaiting liver transplantation. Minerva Med 2016; 107 (04) 223-238
  • 49 Lazarus JV, Baker L, Cascio M. et al; Nobody Left Outside initiative. Novel health systems service design checklist to improve healthcare access for marginalised, underserved communities in Europe. BMJ Open 2020; 10 (04) e035621
  • 50 World Health Organization. The Alcohol Use Disorders Identification Test - Guidelines for use in primary care. 2nd ed. Accessed May 27, 2020 at:
  • 51 Pilowsky DJ, Wu LT. Screening for alcohol and drug use disorders among adults in primary care: a review. Subst Abuse Rehabil 2012; 3 (01) 25-34
  • 52 Jin J. Screening and counseling to reduce unhealthy alcohol use. JAMA 2018; 320 (18) 1948
  • 53 De Bruijn A. Alcohol marketing practices in Africa - Findings from the Gambia, Ghana, Nigeria and Uganda - MAMPA Project. Accessed May 27, 2020 at:
  • 54 Vinikoor MJ, Zyambo Z, Muyoyeta M, Chander G, Saag MS, Cropsey K. Point-of-care urine ethyl glucuronide testing to detect alcohol use among HIV-hepatitis B virus coinfected adults in Zambia. AIDS Behav 2018; 22 (07) 2334-2339
  • 55 O'Keefe D, Scott N, Aitken C, Dietze P. Longitudinal analysis of change in individual-level needle and syringe coverage amongst a cohort of people who inject drugs in Melbourne, Australia. Drug Alcohol Depend 2017; 176: 7-13
  • 56 Gibson EK, Exner H, Stone R, Lindquist J, Cowen L, Roth EA. A mixed methods approach to delineating and understanding injection practices among clientele of a Victoria, British Columbia needle exchange program. Drug Alcohol Rev 2011; 30 (04) 360-365
  • 57 Tsui JI, Ko SC, Krupitsky E. et al. Insights on the Russian HCV care cascade: minimal HCV treatment for HIV/HCV co-infected PWID in St. Petersburg. Hepatol Med Policy 2016; 1: 13
  • 58 Read P, Lothian R, Chronister K. et al. Delivering direct acting antiviral therapy for hepatitis C to highly marginalised and current drug injecting populations in a targeted primary health care setting. Int J Drug Policy 2017; 47: 209-215
  • 59 Woodrell C, Weiss J, Branch A. et al. Primary care-based hepatitis C treatment outcomes with first-generation direct-acting agents. J Addict Med 2015; 9 (05) 405-410
  • 60 Bazzi A, Saitz R. Screening for unhealthy alcohol use. JAMA 2018; 320 (18) 1869-1871
  • 61 US Department of Health and Human Services, National Institutes of Health, National Institute on Alcohol Abuse and Alcoholism. Helping Patients Who Drink Too much: A Clinician's Guide. Updated 2005 Edition. Bethesda, MD: National Institutes of Health; 2007
  • 62 World Health Organization. Guidelines for the care and treatment of persons diagnosed with chronic hepatitis C virus infection. Accessed May 27, 2020 at:
  • 63 Reus VI, Fochtmann LJ, Bukstein O. et al. The American Psychiatric Association Practice guideline for the pharmacological treatment of patients with alcohol use disorder. Am J Psychiatry 2018; 175 (01) 86-90
  • 64 O'Connor EA, Perdue LA, Senger CA. et al. Screening and behavioral counseling interventions to reduce unhealthy alcohol use in adolescents and adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA 2018; 320 (18) 1910-1928