The Relationship Between the Opioid Epidemic and the Transmission of Hepatitis C in Rural Areas and Prisons

By Manav Musunuru



The United States has been battling multiple waves of the opioid epidemic since the mid-1990s.1 In 2021, almost 26 deaths out of every 100,000 Americans were attributed to some type of opioid — whether it be prescription, heroin, or synthetic — a sharp rise from 3 deaths per 100,000 in 1999.1 Furthermore, Wang, Zhang, and Ho explain that people who inject drugs (PWID) are one of the largest reservoirs of hepatitis C (HCV) in the United States.2 This means that alongside a rise in opioid-related deaths, the United States is also battling a concurrent HCV epidemic spurred by the increasing use of opioids across the country. This conclusion is supported by a study conducted by Des Jarlais and others, who note that, while political will and publicization have led to a decrease in human immunodeficiency virus (HIV) cases among PWID, HCV cases continue to rise across the United States, especially among PWID affected by the opioid epidemic.3 This rising transmission rate has been flagged by researchers from the Centers for Disease Control and Prevention (CDC), who found that, between 2010 and 2016, rates of HCV transmission had tripled and there could have been over 2.4 million Americans unknowingly living with HCV in the late 2010s.4 Many of those affected may still be untreated and untested in the present day, potentially leading to higher rates of transmission in the future. This high transmission risk is likely compounded in high-risk areas, notably rural communities and prisons. However, to investigate the current pitfalls of the medical system in those high-risk areas, the mechanism of transmission of HCV between PWID and possible treatments must be discussed first.


Needle-sharing leads to HCV transmission among PWID using opioids

According to the CDC, HCV can be transmitted when the blood of an infected person enters the body of someone who is uninfected.5 HCV can also be transmitted through unprotected sex; however, this is a more uncommon transmission mechanism.5 Surratt, Kurtz, and Cicero report that around a quarter of opioid users are PWID.6 Furthermore, many PWID who use opioids, especially those who are younger, tend to share injection equipment, such as syringes.6,7 These used syringes are likely to have traces of HCV-infected blood, which can then infect PWID who use those syringes and then contaminate their own injection equipment as well, perpetuating the risk of transmission through needle-sharing.5 The CDC reports that HCV is 10 times more transmissible than HIV among PWID, further exacerbating the risk of transmission.8 Additionally, among PWID aged 18-30, around one-third are infected with HCV.8 This number may be as high as 90 percent among older PWID who shared needles in the 1970s and 1980s before adequate research surrounding bloodborne pathogens was conducted.8

The possibility of transmission through needles coupled with the high transmissibility of HCV prevents the inhibition of its transmission. A study by Mateu-Gelabert and others further adds that PWID, such as prescription opioids, assume that the people they frequently share injection equipment with are uninfected.7 On the contrary, the numbers above indicate that a high proportion of people are infected with HCV with an overwhelming majority of older PWID being infected, meaning that the aforementioned assumption only exacerbates the risks those who share injection equipment face and could expose them to HCV. Injection as a method of administration though, with its high risks of HCV transmission and infection, is starting to decline in popularity among opioid users due to the creation of therapy programs to help PWID. Tsui and others report that the use of opioid agonist therapy (OAT) helps combat opioid use disorder (OUD) overall, therefore decreasing the frequency of users injecting drugs and inhibiting the spread of HCV among PWID.9 Unfortunately, therapy methods such as these may be hard to find in high-risk areas, specifically rural communities and prisons, increasing the possibility of HCV transmission in those locations.


Rural communities have insufficient resources to combat the opioid epidemic and HCV

Schranz and others observe that the opioid epidemic has shifted from urban areas into rural communities in the United States.10 This is potentially devastating to these areas, as these rural communities likely have limited access to materials that combat the spread of the opioid epidemic and, in turn, the transmission of HCV. The University of Washington School of Medicine reports that only 3 percent of rural hospitals can prescribe buprenorphine,11 while Havens and others find that programs that prescribe methadone are not located in rural areas.12 These are the 2 main medications used in OAT13 and the absence of these prevention methods facilitates the rise of the opioid epidemic, perpetuating the transmission of HCV through needle-sharing in these areas, and putting people at a higher risk of contracting the disease. 

A study from the University of Michigan about rural physicians complements this information by stating that only 9 percent of physicians feel comfortable treating patients with chronic HCV regardless of whether or not they are opioid users.14 Furthermore, only 15 to 30 percent of HCV-infected persons are symptomatic,10 creating a more dire situation in an area that is already medically disadvantaged, as people may be unaware they have HCV and unknowingly spread it through needle-sharing. In addition to rural areas already having high rates of needle-sharing (44.4 percent) and equipment sharing (62.2 percent), they also have a higher percentage of people at high risk of contracting HCV (due to behaviors or other factors) compared to non-rural areas (38.5 percent vs. 15.5 percent).15 This has the potential to exacerbate outbreaks of HCV, as PWID infected with HCV may perpetuate the spread of the disease to others through needle-sharing and sexual intercourse.5 This further exemplifies how rural areas are inadequately equipped to combat the opioid epidemic and, in turn, are also unprepared to prevent the transmission of HCV between PWID.


The incarceration of PWID has increased the risk of HCV transmission

Prisons are another location associated with high-risk opioid usage and HCV transmission. Similar to rural areas, prisons exacerbate the opioid crisis and HCV epidemic by offering inadequate care for those with OUD, while also being a location for opioid usage and HCV transmission. Josiah D. Rich from Brown University and others report that, in the United States, the number of people incarcerated for drug-related offenses has increased from 40,000 to 450,000 between 1985 and 2005 and people with OUD comprise around 20 percent of state prison populations.16 Furthermore, more recent data suggest that 85 percent of the total prison population in the United States either has an active substance use disorder or was incarcerated for a crime concerning substances and substance use.17 

Although there is an increasing number of people with OUD in prisons, there has not been any substantial improvement in the treatments they are provided. Although 90 percent of state prison systems, according to a study conducted by Chestnut Health Systems, have some type of medication for OUD (MOUD) available in at least one prison in the system, the distributions of MOUD among individual prisons reveal gaps in coverage.18 Naltrexone was the most prevalent MOUD, with 36 percent of prison systems offering it, while 15 percent offered buprenorphine, 9 percent offered methadone, and all 3 by only 7 percent.18 Additionally, buprenorphine and methadone were primarily only given to those who were pregnant or were already receiving the medication before being incarcerated,18 meaning that those with untreated OUD continued to be untreated while incarcerated. The National Academy of Sciences expanded on this information by stating that only about 5 percent of those with OUD in prisons receive medication treatment and those who do not, only receive behavioral therapy or detoxification without any follow-ups.17 Therefore, upon release, many people with OUD will return to using opioids. Similar to those with OUD without any involvement with the criminal justice system, those released from prison with untreated OUD may also be PWID, making them vulnerable to the same HCV transmission risks.19 However, those involved with the criminal justice system are especially vulnerable due to the aforementioned lack of adequate OUD treatment and care in prison settings.19

Furthermore, interactions between people within prison settings may also spark HCV outbreaks. Unsafe practices in prisons, such as “injection drug use, tattooing, and unprotected sex” cause the risk of HCV infection and transmission to be disproportionately higher among those who are incarcerated.20 Additionally, some people who are incarcerated begin to inject substances, such as opioids, to cope with the violent environments in prisons, while those who were PWID at the time of incarceration continue to inject throughout their time in prison.21 Combined with the scarcity of injection equipment within prisons, this leads to widespread needle-sharing21 and, in turn, a heightened risk of exposure to HCV. This is worsened by the lack of widespread HCV testing in U.S. prisons,22 which leads to the underreporting of HCV cases within prisons. Nevertheless, the current prevalence of HCV infections in U.S. prisons is estimated to be at least 23 percent.20 The prevalence of HCV within U.S. prisons is estimated to be around 10 times greater than the prevalence of HCV in the general population23 but may be even higher. This further illustrates the disproportionately high risks of HCV transmission within prison populations, a matter that is only worsened by the lack of adequate screening for HCV and appropriate treatment options for OUD. 



The opioid epidemic has helped foster the transmission of HCV across the United States. The main mechanism of HCV transmission is through contact with the blood of an infected person, which occurs when PWID share needles when using injecting equipment. However, this method of transmission is declining in some areas due to the use of OAT which helps PWID treat their OUD and inhibits the spread of HCV. However, there are still high-risk areas where OAT is not or cannot be effectively utilized. Rural areas are inadequately prepared for HCV outbreaks and opioid epidemics, as many clinics do not have the resources to treat OUD or hinder HCV transmission. Prisons are dealing with increasing numbers of PWID being incarcerated, but are unable to offer them adequate treatments for their OUD. Therefore, when these PWID are released from prison, they are likely to use opioids again and needle-share, making them especially vulnerable to HCV. There must be more done to combat the opioid epidemic and the concurrent HCV outbreaks, directly.

Fortunately, there have been some recent changes surrounding methadone dispensing guidelines that make it easier for patients to receive their medications. These February 2024 revisions allow for an increased amount of take-home medication, more frequent care after telehealth appointments, and enable nurses and physician assistants working at opioid treatment programs (OTPs) to order methadone.24 However, the major barrier hindering the effectiveness of these new rules is that methadone will still only be available at the 2,000 federally approved OTPs nationwide, failing to expand access into underserved areas adequately.24

To truly close the gaps in opioid care, both federal and state governments must do more to expand coverage for everyone. Pew suggests that state governments should reduce legal restrictions, such as zoning, to enable the establishment of new OTPs across the country.25 Additionally, Medicaid does not cover all MOUD in all states. For example, although buprenorphine is widely covered by Medicaid programs in all states, methadone is only covered under the programs of 80 percent of states, while the extended-release buprenorphine injection is covered by just over 60 percent of state Medicaid programs.26 Both Congress and state governments can remedy this issue, however, by expanding coverage for different types of MOUD under the Medicaid program.25

Prisons and jails, on the other hand, should shift their focus to rehabilitation and expand access to MOUD to those with OUD. Pew recommends that state health agencies should combat this issue by establishing medication units and extending OTPs into underserved areas, such as prisons and rural communities.25 Altogether, the recommended changes above will help combat OUD in the United States, therefore decreasing the transmission of HCV among people with OUD. Furthermore, federal and state governments should also increase the funding of rural and prison healthcare systems to allow them to access essential resources and respond to HCV outbreaks when they happen.  For this to happen, however, the stigma surrounding drugs and opioids must be challenged and there must be a focus on helping people rather than punishing them, from both the general public and elected officials.



  1. Understanding the opioid overdose epidemic. Centers for Disease Control and Prevention. August 8, 2023. Accessed January 10, 2024. 
  2. Wang X, Zhang T, Ho W-Z. Opioids and HIV/HCV infection. Journal of Neuroimmune Pharmacology. 2011;6(4):477-489. doi:10.1007/s11481-011-9296-1 
  3. Des Jarlais DC, Cooper HL, Arasteh K, Feelemyer J, McKnight C, Ross Z. Potential Geographic “hotspots” for drug-injection related transmission of HIV and HCV and for initiation into injecting drug use in New York City, 2011-2015, with implications for the current opioid epidemic in the US. PLOS ONE. 2018;13(3). doi:10.1371/journal.pone.0194799 
  4. Hofmeister MG, Rosenthal EM, Barker LK, et al. Estimating prevalence of hepatitis C virus infection in the United States, 2013‐2016. Hepatology. 2018;69(3):1020-1031. doi:10.1002/hep.30297 
  5. What is Hepatitis C – FAQ. Centers for Disease Control and Prevention. October 31, 2023. Accessed January 10, 2024. 
  6. Surratt H, Kurtz SP, Cicero TJ. Alternate routes of administration and risk for HIV among prescription opioid abusers. Journal of Addictive Diseases. 2011;30(4):334-341. doi:10.1080/10550887.2011.609805 
  7. Mateu-Gelabert P, Guarino H, Jessell L, Teper A. Injection and sexual HIV/HCV risk behaviors associated with nonmedical use of prescription opioids among young adults in New York City. Journal of Substance Abuse Treatment. 2014;48(1):13-20. doi:10.1016/j.jsat.2014.07.002 
  8. Access to clean syringes. Centers for Disease Control and Prevention. August 5, 2016. Accessed January 10, 2024. 
  9. Tsui JI, Evans JL, Lum PJ, Hahn JA, Page K. Association of opioid agonist therapy with lower incidence of hepatitis C virus infection in young adult injection drug users. JAMA Internal Medicine. 2014;174(12):1974. doi:10.1001/jamainternmed.2014.5416 
  10. Schranz AJ, Barrett J, Hurt CB, Malvestutto C, Miller WC. Challenges facing a rural opioid epidemic: Treatment and prevention of HIV and hepatitis C. Current HIV/AIDS Reports. 2018;15(3):245-254. doi:10.1007/s11904-018-0393-0 
  11. Rosenblatt RA, Andrilla CH, Catlin M, Larson EH. Geographic and specialty distribution of us physicians trained to treat opioid use disorder. The Annals of Family Medicine. 2015;13(1):23-26. doi:10.1370/afm.1735 
  12. Havens JR, Walsh SL, Korthuis PT, Fiellin DA. Implementing treatment of opioid-use disorder in rural settings: A focus on HIV and hepatitis C prevention and treatment. Current HIV/AIDS Reports. 2018;15(4):315-323. doi:10.1007/s11904-018-0402-3 
  13. Jin H, Marshall BD, Degenhardt L, et al. Global opioid agonist treatment: A review of clinical practices by country. Addiction. 2020;115(12):2243-2254. doi:10.1111/add.15087 
  14. Thomson M, Konerman MA, Choxi H, Lok AS. Primary care physician perspectives on hepatitis C management in the era of direct-acting antiviral therapy. Digestive Diseases and Sciences. 2016;61(12):3460-3468. doi:10.1007/s10620-016-4097-2 
  15. Barranco MA, Rosenberg ES, Flanigan C, et al. A cross‐sectional study of hepatitis C prevalence and correlates among persons who inject drugs in rural and non‐rural communities. Journal of Viral Hepatitis. 2022;29(11):994-1003. doi:10.1111/jvh.13735 
  16. Rich JD, Boutwell AE, Shield DC, et al. Attitudes and practices regarding the use of methadone in US state and Federal Prisons. Journal of Urban Health: Bulletin of the New York Academy of Medicine. 2005;82(3):411-419. doi:10.1093/jurban/jti072 
  17. Criminal Justice DrugFacts. National Institutes of Health. March 23, 2023. Accessed January 10, 2024. 
  18. Scott CK, Dennis ML, Grella CE, Mischel AF, Carnevale J. The impact of the opioid crisis on U.S. State Prison Systems. Health & Justice. 2021;9(1). doi:10.1186/s40352-021-00143-9 
  19. Spaulding AC, Anderson EJ, Khan MA, Taborda-Vidarte CA, Phillips JA. HIV and HCV in U.S. prisons and jails: The Correctional Facility as a bellwether over time for the community’s infections. Aids Reviews. 2017;19(3). doi:10.24875/aidsrev.m17000006 
  20. Ocal S, Muir AJ. Addressing hepatitis C in the American incarcerated population: Strategies for nationwide elimination. Current HIV/AIDS Reports. 2020;17(1):18-25. doi:10.1007/s11904-019-00476-z 
  21. Armstrong-Mensah E, Dada D, Rupasinghe R, Whately H. Injecting substance use in prisons in the United States: A case for needle exchange programs. The American Journal of Drug and Alcohol Abuse. Published online February 17, 2021:1-7. doi:10.1080/00952990.2021.1872587
  22. Beckwith CG, Kurth AE, Bazerman L, et al. Survey of US correctional institutions for routine HCV testing. American Journal of Public Health. 2015;105(1):68-71. doi:10.2105/ajph.2014.302071 
  23. Sadacharan R, Rich J. Opioid use disorder, infectious diseases, and the Criminal Justice System. The Opioid Epidemic and Infectious Diseases. Published online 2021:39-50. doi:10.1016/b978-0-323-68328-9.00004-7 
  24. Mann B. With opioid deaths soaring, Biden administration will widen access to methadone. NPR. February 2, 2024. Accessed February 13, 2024. 
  25. Opioid treatment programs: A key treatment system component. The Pew Charitable Trusts. July 16, 2021. Accessed February 13, 2024. 
  26. O’Brien P, Alikhan S, Cummings N, et al. Medicaid Coverage of Medication-Assisted Treatment for Alcohol and Opioid Use Disorders and of Medication for the Reversal of Opioid Overdose. Substance Abuse and Mental Health Services Administration. 2018. Accessed February 13, 2024.