Fatal Overdose, Acute Viral Hepatitis, and HIV Attributed to Injection Drug Use, Appalachian Region of the United States, 2000–2023

BACKGROUND: Appalachian states are disproportionately impacted by poverty, high rates of fatal overdose, hepatitis A, acute hepatitis B, acute hepatitis C, and human immunodeficiency virus (HIV). We evaluated trends for these syndemic conditions by Appalachian subregion to better inform prevention measures. METHODS: For the United States, non-Appalachian United States and Appalachian subregions, we calculated annual rates per 100 000 population for unintentional and undetermined fatal overdoses, hepatitis A, acute hepatitis B and acute hepatitis C during 2000-2023; and diagnoses of HIV for persons aged ≥ 15 years attributed to injection drug use (IDU) during 2008-2023. We calculated age and sex-specific rates during 2014-2023 for all diseases and conditions. RESULTS: During 2000-2023 in the central Appalachian subregions, age-adjusted rates of fatal drug overdose, hepatitis A, acute hepatitis B, and acute hepatitis C peaked at 985%, 2173%, 223% and 336% over the year 2000 rates. During 2008-2023, rates of new HIV infections attributable to IDU peaked at 380% over year 2008 rates. Rates of all conditions were higher in the Appalachian Region than in the non-Appalachian USA, especially in adults aged 25-44 years in Central and North Central Appalachian subregions. CONCLUSIONS: We documented elevated rates of infectious diseases and fatal drug overdose against a background of increased economic distress in the central Appalachian subregions, especially among working-age adults of reproductive age. Interventions to address social determinants of health and expand access to comprehensive integrated medical and substance use disorder treatment, overdose prevention, and syringe services are critical to control this syndemic.