Rachel Gonzales: My background is in looking at ways to assess hepatitis C accurately and in identifying outcomes that may have been affected by the combination of hepatitis C and continuous drug use. For example, we have begun to look at whether methamphetamine may be a particularly risky drug to abuse because of its association with high-risk sexual practices. For those of us who don’t have a medical background, Dr. Sylvestre’s article (2007) is an excellent clinical overview. From a research perspective, the article points to several areas where studies may contribute to more effective clinical management and outcomes. David Perlman: I’m an infectious disease physician and have done a lot of work in the health service aspects of infections in drug abusers—for example, we are currently studying how best to screen methadone participants for hepatitis A, B, and C and then link them to vaccinations or appropriate care. Dr. Sylvestre’s main point bears repeating: Despair is unwarranted. There is a lot of hype about this disease, and people can get very scared. However, as she points out, a significant percentage of patients have spontaneous remissions; treatment can be highly effective; and even infections that do not respond to treatment do not always progress to advanced liver disease. Gonzales: Ideally, substance abuse clinicians’ attention to hepatitis C should commence at the time the patient first enters treatment. You want to find out if the patient has hepatitis C so that you can provide appropriate additional screening, education, referral, and monitoring. Perlman: As Dr. Sylvestre says, hepatitis C screening should be standard for people at risk—which includes most people entering substance abuse treatment. The sooner you find out a patient has hepatitis C infection, the sooner you can begin managing it. Alternatively, the sooner you know someone is not infected, the sooner you can reinforce behaviors to keep them that way. Gonzales: I agree absolutely. It’s terribly important to include messages for drug users who aren’t yet infected in our models for preventing hepatitis C. Perlman: Along with warning patients about the risk of injections with nonsterile or reused equipment, the messages might discuss heightened risks that are associated with the specific places and contexts in which people inject drugs. For example, data indicate that injecting drugs outdoors is generally riskier than injecting drugs indoors and that infection rates are especially high among people who inject drugs in shooting galleries. The reasons may have to do with the sharing of paraphernalia or other behaviors that occur in these settings. Whatever the reasons, this is good information to share with patients. Gonzales: The issue of whether continuing drug abuse affects the potential toxicities of hepatitis medications or the progress of the disease is obviously very significant for clinicians. One key to answering this and many other issues will be getting accurate assessments of the time of onset of hepatitis C, especially in long-term drug abusers. That information will enable us to untangle all these relationships—what’s due to the drugs, the infectious disease, the medication, or any of these together. Perlman: The question of reinfection as a potential consequence of drug abuse or risky sexual practices comes up sometimes. Dr. Sylvestre cites data showing that this has not been an overwhelming problem in study populations so far. Clearly, there is a potential for reinfection, but just as clearly and more importantly, the fact that someone may relapse is no reason not to give all the care he or she needs. After all, we don’t deny treatment to substance abusers with HIV infection, even though reinfection is possible there, too.