Viral Hepatitis

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Hepatitis is an inflammation of the liver. It can be caused by a variety of toxins (such as drugs or alcohol), autoimmune conditions, or pathogens (including viruses, bacteria, or parasites).1 Viral hepatitis is caused by a family of viruses labeled A, B, C, D, and E. To learn more about the route of transmission and prognosis for each virus, visit the Centers for Disease Control and Prevention’s Division of Viral Hepatitis. Hepatitis B (HBV) and hepatitis C (HCV) are the most common viral hepatitis infections transmitted through the sometimes risky behaviors of people who use drugs—particularly among people who inject drugs. An estimated 862,000 people are living with HBV chronic infections, with about 22,000 acute infections recorded in 2017. An estimated 2.4 million Americans are living with HCV based on 2013-2016 annual average, with an estimated 44,700 new cases of acute HCV in 2017. In fact, new cases of acute HCV have increased rapidly in the US since 2010, and have most often been associated with injection drug use.6 Three out of four people living with HCV are baby boomers born between 1945 and 1965.7

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Left untreated, hepatitis can lead to cirrhosis, a progressive deterioration and malfunction of the liver. It can also lead to a type of liver cancer called hepatocellular carcinoma. In fact, HBV and HCV infections are related to about 65 percent of liver cancers worldwide. Nearly 50 percent of the cases are caused by HCV alone.2 During the next 40 to 50 years, 1 million people with untreated chronic HCV infection will likely die from complications related to their HCV.3

Since 2012, there have been more deaths due to hepatitis C than all 60 of the other reportable infectious diseases combined.

In an effort to fight viral hepatitis in the United States, the U.S. Department of Health and Human Services developed the National Hepatitis Action Plan for 2017-2020. The plan outlines strategies to achieve the following goals:

  1. Prevent new viral hepatitis infections.
  2. Reduce deaths and improve the health of people living with viral hepatitis.
  3. Reduce viral health disparities (differences among ethnicities, race, income, gender, etc.).
  4. Coordinate, monitor, and report on implementation of viral hepatitis activities.

What is the relationship between drug use and viral hepatitis?

Drug and alcohol use places people at particular risk for contracting viral hepatitis. Engaging in risky sexual behavior that often accompanies drug use increases the risk of contracting HBV and, less frequently, HCV. People who inject drugs (PWID) are at high risk for contracting HBV and HCV from shared needles and other drug preparation equipment, which exposes them to bodily fluids from other infected people. Because drug use often impairs judgement, PWID repeatedly engage in these unsafe behaviors, which can increase their risk of contracting viral hepatitis. One study reported that each person who injects drugs infected with HCV is likely to infect about 20 others, and that this rapid transmission of the disease occurs within the first 3 years of initial infection.4 Drug and alcohol use can also directly damage the liver, increasing risk for chronic liver disease and cancer among those infected with hepatitis. This underscores that early detection and treatment of hepatitis infections in PWID and other people who use drugs is paramount to protecting both the health of the person and that of the community.

What are the other health challenges for people with hepatitis who inject drugs?

People with hepatitis who inject drugs often have several other health conditions at the same time, including mental illness and HIV/AIDS, thus requiring care from multiple health care providers. This is sometimes referred to as co-occurring disorders. Substance use disorder treatment is critical for PWID, as it can reduce risky behaviors that increase the chance of transmitting hepatitis. Research has shown that patients with hepatitis receiving medication-assisted treatment for their opioid addiction can be safely treated with antiviral medications.5

To enhance HCV care, NIDA is examining coordinated care models that utilize case managers to integrate HCV specialty care with primary care, substance use disorder treatment, and mental health services so that these patients get treatment regimens that address all of their health care needs. The Health Resources and Services Administration’s Ryan White HIV/AIDS Program developed a free, online curriculum about HIV/hepatitis C for healthcare providers and healthcare staff to increase knowledge about co-infection among people of color in the United States.

What treatments are available for viral hepatitis?

Many medications are available for the treatment of chronic HBV and HCV infection. For chronic HBV infection, there are several antiviral drugs. People who are chronically infected with HBV require consistent medical monitoring to ensure that the medications are keeping the virus in check and that the disease is not progressing to liver damage or cancer.

There are also antiviral medications available for HCV treatment and new treatments have been approved in recent years. Many antiviral HCV treatments can cure more than 90 percent of people who take them within 8 to 12 weeks. HCV treatment dramatically reduces deaths, and people who are cured are much less likely to develop cirrhosis or liver cancer. However, not everyone infected with HCV needs or can benefit from treatment. NIDA researchers have identified genes that are associated with spontaneous clearance of HCV. These genes also enable people who are unable to clear HCV on their own to respond more favorably to treatment medications. This new information can be used to determine which patients can benefit most from HCV treatment. More studies must be done, but this is a first step to personalized medicine for the treatment of HCV. 

How do I know if I am infected with viral hepatitis?

The number of new HBV and HCV infections has been declining in recent years, but the number of people living with chronic hepatitis infections is considerable, and deaths associated with untreated, chronic hepatitis infections have been on the rise. This is because most people don’t know they are infected until the disease has begun to damage the liver, highlighting why screening for viral hepatitis is so important. People with a history of drug use are generally at higher risk, and should discuss their substance use with their health care provider.

Initial screening for HBV or HCV involves antibody tests, which show whether you have been exposed to the hepatitis virus, although not necessarily whether you are still infected. A positive antibody test should then be followed up with a test that measures the amount of virus in your blood. If this follow-up test is positive, then you should seek advice from a physician that specializes in viral hepatitis treatment. Because screening for hepatitis is so critical for linking people who test positive to the care they need, NIDA is studying new rapid HCV antibody tests that can be used in drug treatment settings.

The CDC recommends that people who inject drugs be tested for hepatitis B and C as part of routine medical care. To determine if you are at risk for contracting hepatitis, HHS has created an online assessment tool to help you find out.

What do I do if I find out I have viral hepatitis?

After learning from your doctor that you have hepatitis, your first step will be to learn more about the virus. Read government resources, like the websites listed below, to find current, scientific information. Adopting a healthy lifestyle is important to prevent the virus from becoming serious. Don’t drink or misuse drugs because they are hard on your liver. Get plenty of rest, eat healthy foods, and exercise. Work to protect others by not donating blood or participating in risky behaviors, including sharing needles when using drugs or having unprotected sex.

  1. Hardtke-Wolenski, M., et al., Genetic predisposition and environmental danger signals initiate chronic autoimmune hepatitis driven by CD4+ T cells.Hepatology, 2013.
  2. Centers for Disease Control and Prevention. Viral Hepatitis and Liver Cancer Fact Sheet. Accessed April 6, 2018.
  3. Rein, D.B., et al., Forecasting the morbidity and mortality associated with prevalent cases of pre-cirrhotic chronic hepatitis C in the United States.Dig Liver Dis, 2011. 43(1): p. 66-72.
  4. Magiorkinis, G., et al., Integrating phylodynamics and epidemiology to estimate transmission diversity in viral epidemics.PLoS Comput Biol, 2013. 9(1): p. e1002876.
  5. Bruce, R.D., et al., A review of pharmacological interactions between HIV or hepatitis C virus medications and opioid agonist therapy: implications and management for clinical practice.Expert Rev Clin Pharmacol, 2013. 6(3): p. 249-69.
  6. Centers for Disease Control and Prevention. Surveillance for Viral Hepatitis – United States, 2017 Report. Accessed July 31, 2020.
  7. S. Department of Health and Human Services, Office of Infectious Disease and HIV/AIDS Policy. Viral Hepatitis in the United States: Data and Trends. Accessed July 31, 2020.