Hepatitis C and injecting drug use in Latvia: findings from RSU research
Writer: Kārlis Rupainis (Graduate of RSU Public Health bachelor’s programme)
Although medicine has made major progress in recent years and hepatitis C is now an effectively treatable infection, it remains one of the most significant public health challenges in Latvia. The burden of infection is particularly high among people who inject drugs - it is within this population that the infection continues to spread most rapidly. Moreover, Latvia remains among the European countries with the highest incidence rates. 1, 3
Viral hepatitis C causes both acute and chronic liver damage. This infection is transmitted via blood, for example, through unsafe medical procedures, unscreened blood transfusions, the sharing of syringes and needles, or, less commonly, through sexual contact.
Although people who inject drugs are generally considered to be one of the main risk groups for hepatitis C, the likelihood of infection within this population is not the same for everyone. This is influenced by socioeconomic circumstances, drug-injection practices, and access to harm-reduction and healthcare services. I analysed these differences in my bachelor’s thesis at Rīga Stradiņš University (RSU) with the aim of identifying which groups of the people injecting drugs in Latvia are more frequently affected by hepatitis C and which factors are most closely associated with the spread of the infection. Developing risk profiles is necessary in order to plan more targeted prevention measures and to reach more effectively those who need this help the most.4
Situation in Latvia remains one of the most challenging in Europe
The World Health Organization (WHO) has set a goal of substantially reducing the prevalence of hepatitis C by 2030, but Latvia still has a long way to go to achieve it. International data show that between 2015 and 2021, the incidence of hepatitis C among people who inject drugs in Latvia was among the highest in Europe. To meet the WHO goals, this rate would need to fall by approximately 87%.5
This means that, although effective treatment is available, the infection continues to spread. Potentially, this may be explained not only by individual behaviours but also by social factors such as income level, stigma, limited access to healthcare, as well as difficulties to get tested in a timely manner.
Nowadays, hepatitis C can be completely cured. However, treatment alone cannot stop the spread of the infection - it is also important to identify people living with the infection at an early stage and provide prevention measures for those at the highest risk of infection.6
The focus of the study
The study was based on data from a cross-sectional ‘Study on the Prevalence of HIV and Associated Factors among People Who Inject Drugs’, commissioned by the Centre for Disease Prevention and Control and conducted by the DIA+LOGS association in 2023. It included 456 respondents, using respondent-driven sampling, a methodology, which is internationally recognised as one of the most suitable for studying hard-to-reach populations.7
However, to ensure, as accurately as possible, that the results obtained reflect the entire population of people who inject drugs in Latvia, rather than merely the respondents surveyed, the data were weighted as part of this study. The weighting was carried out using a respondent-driven sampling methodology and based on assumption that there were approximately 11,500 injecting drug users in Latvia. This figure was not chosen arbitrarily – it was calculated based on estimates by the European Union Drug Agency (EUDA) of the prevalence of injecting drug use in Latvia in 2023 (6.1 people per 1,000 inhabitants) and the population data from the Central Statistical Bureau of Latvia.8,9 This approach allows for results that are more representative for the entire target population.
The analysis was carried out across three major groups of factors: socioeconomic factors (place of residence, education, relationship status and ethnicity), drug-injecting practices (age at which injecting began, frequency of injecting and risky injecting practices, such as sharing or reusing syringes and needles etc.); and the third included the use of harm-reduction services – tests for hepatitis C in the past year, receiving support for reducing drug dependence, and the main sources of syringes and needles.
Hepatitis C prevalence varies across different groups of people who inject drugs
The analysis showed that hepatitis C prevalence was not evenly distributed across the population of people who inject drugs. In some groups, the infection is significantly more common than in others, influenced not only by individual drug-use practices but also by social circumstances.
One of the key factors was the level of education. Among people with basic education or lower, the prevalence of hepatitis C was significantly higher than for respondents with secondary or higher education.
This correlation is also consistent with trends described in the international literature, where a lower level of education is often associated with more limited access to healthcare, less health literacy and more challenging socioeconomic circumstances.10,11,12
The other significant socioeconomic factor associated with the prevalence of hepatitis C was ethnicity – hepatitis C prevalence was higher among people from ethnic minority groups. This finding does not in itself imply that ethnicity is a risk factor. Rather, it may imply possible social inequalities that can affect access to prevention and treatment services. This conclusion is also consistent with the correlations described in the international literature.13,14
Earlier initiation of injecting drug use is associated with a higher prevalence of hepatitis C
The study data revealed an alarming trend - 39% of respondents reported that they had started injecting drugs at the age of 18 or younger, and this was the largest of the analysed age groups for starting injecting drugs.
The highest hepatitis C prevalence was observed among the population who began injecting drugs at the age of 18 or younger. This finding can be explained relatively simply - the earlier a person starts injecting drugs, the longer they are exposed to the risk of infection. In addition, according to international literature sources, at a younger age people are more likely to lack knowledge about safer injecting practices, and the harm-reduction services are used less frequently.15,16
Particular attention should be paid to the fact that nearly four in ten respondents started injecting drugs before the age of 18.
At the same time, in Latvia, sterile injecting equipment is only available at HIV prevention centres once a person has reached adulthood. This means that some young people who are already at high risk of infection may not have access to one of the key hepatitis C prevention services.17,1 8,19,20
One of the most unexpected findings, however, was that no statistically significant differences in hepatitis C prevalence were found between respondents who reported risky injecting practices and those who reported safer practices. This may be explained by several factors. First, the behavioural indicators used in the study reflected only a specific period of time, whereas hepatitis C infection may have been acquired long before that. Second, self-reports are always subject to the possibility that risky behaviour may be underestimated or not fully disclosed.
Frequency of injecting remains one of the key risk factors
The highest hepatitis C prevalence was observed among people who injected drugs six or seven days a week. Meanwhile, the lowest prevalence was found among those who injected only once a week.
Similar trends have also been described in the international literature. More frequent injecting means more opportunities for exposure to infected blood or non-sterile injecting equipment. Even if a person mostly uses sterile needles and syringes, a higher number of injections increases the overall lifetime risk of infection.
At the same time, this means that prevention measures should not be solely limited to the provision of sterile injecting equipment. Equally important is the access to addiction treatment, as reducing the frequency of injecting also reduces the likelihood of infection transmission.21,22
Why hepatitis C was more commonly diagnosed among users of harm-reduction services
One of the most interesting findings of the study was related to harm-reduction services.
The study found that respondents who had undergone hepatitis C testing in the past year had a lower prevalence of infection than among those who had not been tested. Although the study does not allow causal relationship to be established, this association may indicate that people who regularly use healthcare and prevention services are also more likely to engage in other health-promoting activities.23
The study found that the prevalence of hepatitis C was higher among respondents who obtained syringes and needles mainly from syringe and needle exchange centres or mobile units than among those who purchased syringes from pharmacies.
At first glance, it might seem paradoxical that respondents who had used this harm-reduction service were found to have the infection more frequently than those who had not used the service. Based on these results, it should not be concluded that syringe and needle exchange programmes contribute to infection. On the contrary - these services most often reach people with the most complex risk profiles, whose likelihood of infection is already higher to begin with.24
This is also a key aspect in public debate. There is often a public perception that harm-reduction services “cause the problem”, but the study’s findings suggest quite the opposite – these services reach people who, without such support, might not come to the attention of healthcare services at all.
Treatment alone will not suffice
In recent years, significant progress has been made in hepatitis C treatment. Nowadays, in the majority of cases, the infection can be completely cured, which significantly reduces both the risk of complications and the likelihood of passing the infection on to others. However, treatment alone cannot solve the problem if people do not even reach diagnosis in the first place. It is important to emphasise that harm-reduction services are not an alternative to treatment – they are essential to ensure that treatment reaches those who need it most.
The results of my study once again demonstrate that the prevalence of hepatitis C is not random. It is concentrated in certain social groups, which often also face social difficulties and limited access to healthcare. Controlling hepatitis C is not solely the responsibility of infectious disease specialists and hepatologists – it requires a much broader approach, encompassing social support, health care literacy and access to prevention measures.
At the same time, the study shows that harm-reduction services reach people at the highest risk of infection.
These services are often viewed controversially by the public, yet the study’s findings indicate that they are reaching precisely the population with the greatest need for prevention. People who use needle and syringe exchange programme services have not become a risk group because these services are available; on the contrary, the services reach people who are already in the highest-risk category. At HIV prevention centres, it is possible not only to obtain sterile injecting equipment but also undergo testing, receive counselling and support, and, in the event of a positive test result, be referred to the relevant healthcare specialists for further examination and treatment.25
The study helps to identify where the greatest investment is needed
One of the most important benefits of this type of research is the ability to make data-based decisions. When we know which groups are more likely to be affected by hepatitis C, prevention measures can be planned much more precisely. This allows for a more efficient use of healthcare resources and reach the people who need support the most.
One of the most important benefits of this type of research is the ability to make data-based decisions.
When we know which groups are more likely to be affected by hepatitis C, prevention measures can be planned much more precisely. This allows for a more efficient use of healthcare resources and reach the people who need support the most.
The article has been published on LSM.lv
- Atsauces
1 World Health Organization. Hepatitis C. World Health Organization. Published July 25, 2025. Accessed July 9, 2026.
2 World Health Organization. Hepatitis C. World Health Organization. Published July 25, 2025. Accessed July 9, 2026.
3 Artenie, A., Trickey, A., Looker, K. J., Stone, J., Lim, A. G., Fraser, H., Degenhardt, L., Dore, G. J., Grebely, J., Cunningham, E. B., Hazarizadeh, B., Low-Beer, D., Luhmann, N., Webb, P., Hickman, M., & Vickerman, P. Global, regional, and national estimates of hepatitis C virus (HCV) infection incidence among people who inject drugs and number of new annual HCV infections attributable to injecting drug use: a multistage analysis. Lancet Gastroenterol Hepatol. 2025; 10(4), 315-331
https://doi.org/10.1016/S2468-1253(24)00442-44 Chen, YJ., Lin, YC., Wu, MT., Kuo, JY., Wang, CH. Prevention of Viral Hepatitis and HIV Infection among People Who Inject Drugs: A Systematic Review and Meta Analysis. Viruses. 2024. 16(1):142. doi:10.3390/v16010142
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