MAJOR ARTICLE

Molecular Epidemiology of Hepatitis C Virus

in a Social Network of Injection Drug Users
Campbell K. Aitken,1 Rhonda F. McCaw,3 D. Scott Bowden,3 Samantha L. Tracy,3 Jenny G. Kelsall,1
Peter G. Higgs,1 Michael J. Kerger,1 Hoang Nguyen,1 and J. Nick Crofts2

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1
Epidemiology and Social Research Program and 2Centre for Harm Reduction, Macfarlane Burnet Institute for Medical Research
and Public Health, Melbourne, and 3Victorian Infectious Diseases Reference Laboratory, North Melbourne, Victoria, Australia

Background. We aimed to measure the overlap between the social networks of injection drug users (IDUs)
and the patterns of related hepatitis C virus (HCV) infections among IDUs.
Methods. A cohort of 199 IDUs (138 of whom were HCV RNA positive) was recruited from a local drug
scene in Melbourne, Australia, and was studied using social network analysis and molecular phylogenetic analysis
of 2 regions of the HCV genome.
Results. Eighteen clusters of related infections involving 51 IDUs (37.0% of HCV RNA–positive IDUs) were
detected; these clusters could be separated into 66 discrete pairs. Twelve (18.2%) of the 66 IDU pairs with related
infections reported having previously injected drugs together; conversely, only 12 (3.8%) of the 313 pairs of HCV
RNA–positive IDUs who were injection partners had strong molecular evidence of related infections. The social
and genetic distances that separated IDUs with identical genotypes were weakly associated. Significant clusters of
phylogenetically related sequences identified from core region analysis persisted in the analysis of the nonstructural
5a protein region. Genotyping and sequence analysis revealed 2 mixed-genotype infections.
Conclusions. Static social network methods are likely to gather information about a minority of patterns of
HCV transmission, because of the difficulty of determining historical infection pathways in an established social
network of IDUs. Nevertheless, molecular epidemiological methods identified clusters of IDUs with related viruses
and provided information about mixed-genotype infection status.

Molecular epidemiological techniques have brought a
new dimension to the study of the transmission and
evolution of disease. With respect to HIV and hepatitis
C virus (HCV), different combinations of genotyping,
sequencing, and phylogenetic methods have been used
to characterize historic epidemics [1, 2], to examine
virus evolution [3, 4], to establish links between pop-
ulations around the globe that have a high prevalence
of HIV and HCV infection [5, 6], to aid in investiga-
tions of outbreaks [7, 8], and to evaluate postulated
cases of transmission [9, 10]. Our understanding of the
Received 5 February 2004; accepted 17 May 2004; electronically published 23
September 2004.
Presented in part: National Scientific Workshop of the Australian Centre for
Hepatitis Virology (session 5: Epidemiology, Transmission and Immunity), Marys-
ville, Victoria, Australia, 13–15 June 2003 (abstract 5).
Financial support: National Health and Medical Research Council of Australia
(project grant 111701).
Reprints or correspondence: Dr. Campbell K. Aitken, Epidemiology and Social
Research Program, Macfarlane Burnet Institute for Medical Research and Public
Health, PO Box 2284, Melbourne, Victoria 3001, Australia (aitken@burnet.edu.au).
The Journal of Infectious Diseases 2004; 190:1586–95
 2004 by the Infectious Diseases Society of America. All rights reserved.
0022-1899/2004/19009-0008$15.00
epidemiology of HIV has also benefited, in recent years,
from the application of social network analysis, which
has generated new insights about transmission and as-
sociated behavior. Social network methods have been
used to demonstrate an association between the size
and the density of the risk networks of injection drug
users (IDUs) and the frequency of injection among IDUs
[11] and to explain the differences in patterns of HIV
infection between racial groups, on the basis of network
measurements [12]. The network study of Morris et al.
[13] showed that younger gay men with older partners
gave significant impetus to the epidemic of HIV infec-
tion among gay men in the United States. Network
methods have also been used to provide evidence that
relatively small subnetworks of HIV-negative individ-
uals may limit outbreaks in parent networks, allowing
the prevalence of HIV to remain high but stable [14],
and to show how specific network structures may fa-
cilitate HIV transmission [15].
Molecular epidemiological and social network meth-
ods, although stemming from vastly different scientific
disciplines, have in common an ability to identify and

1586 • JID 2004:190 (1 November) • Aitken et al.

 Table 1. Genotype distribu- a suburb of Melbourne, Australia, and we compare the risk
tion among blood samples ob- network data for these IDUs with the patterns of HCV infection
tained from 138 hepatitis C virus delineated by molecular epidemiological methods. The primary
(HCV) RNA–positive injection
objective of the present study was to establish the degree to
drug users.
which the genetic relatedness of HCV infection corresponded
No. (%) to the epidemiological map of potential routes of transmission
HCV genotype of samples represented by the risk networks of the IDUs. If the risk net-
1a 19 (13.8) works of the IDUs correspond well with patterns of infection,
1a 40 (29.0) then the social networks should be capable of being exploited
1b 13 (9.4) as loci for interventions aimed at reducing HCV transmission.
2b 3 (2.2)
3a 50 (36.2)
PARTICIPANTS, MATERIALS, AND METHODS
6a 7 (5.1)

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7a 4 (2.9) Data collection. The setting of the present study was Mari-
1a/3ab 1 (0.7)
byrnong (2001 population, 59,770 [16]), an inner municipality
3a/7ac 1 (0.7)
of Melbourne (2001 population, 3,366,542 [16]), which is the
a
Could not be further differentiated state capital of Victoria, Australia. Maribyrnong is home to one
as genotype 1a or genotype 1b.
b
Mixture of genotypes 1a and 3a. of the city’s largest illicit-drug (principally, heroin) markets.
c
Mixture of genotypes 3a and 7a. The needle and syringe program in Maribyrnong is the only
such dedicated service in the western suburbs of Melbourne,
elucidate patterns in complex arrangements of humans (the registering 4000–5000 visits/month in 2001. Our researchers
former with respect to transmission of infection and the latter spent 10 months (November 2000–August 2001) interacting
with respect to relationships and behaviors that permit trans- with and observing IDUs on the streets of Maribyrnong, to
mission of infection). In the present article, we report a study learn about the nature of the street-drug scene and to document
in which social network methods were used to recruit IDUs in its social environment. This initial observation period also al-

Table 2. Significant clusters identified by hepatitis C virus core and nonstructural 5a protein (NS5a) region
phylogenetic analysis (bootstrapped ⫻1000).

No. of trees
No. of In the In the
Genotype sequences Groupingsa core region NS5a region
b
1a 61 MK08, JK01, MK23, and JK04 825 788
HN26 and HN28 718 971
MK31 and JK39 908 1000
MK58 and MK56 979 933
JK32 and JK07 975 980
1bb 31 HN35 and HN03 743 …
JK43 and JK14 876 …
MK10, MK16, JK50, and JK25 719 …
MK53, JK09, MK05, MK13, HN38, HN03, and HN35 1000 …
2b 3 None
3a 51 JK54 and PH17 995 993
MK54, MK52, JK58, MK04, JK35, and MK27 912 422c
JK55 and PH25 774 711
MK57 and MK55 908 999
HN05 and MK37 973 761
MK59 and MK65 994 583c
MK41, JK28, and JK44 888 340c
6a 7 None
7a 5 HN22, HN12, and HN10 852 …
HN43 and PH22 999 …
a
Groupings shown are identification codes given to the blood samples/study participants and are based on interviewers’ initials
and interview numbers.
b
Includes samples genotyped as genotype 1 or genotype 1a/b.
c
Not statistically significant.

Social and Molecular Epidemiology of HCV • JID 2004:190 (1 November) • 1587


Figure 1. A, Hepatitis C virus (HCV) core gene tree for genotype 1a. B, HCV nonstructural 5a protein region gene tree for genotype 1a.
lowed for the identification of individuals who were judged to
be well connected in the local drug scene and for the eventual
invitation extended to these individuals to become “seed cases”
for the recruitment phase of the networks.
During the next 11 months (September 2001–July 2002), our
researchers recruited 199 IDUs by following the social networks
initially described by seed cases (recruitment ended in July
2002, to ensure that sufficient funds remained for data analysis).
The criterion for the nomination of IDUs as network members
was that they had injected drugs with the interviewee (at the
1588 • JID 2004:190 (1 November) • Aitken et al.
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same time and in the same location) at least once during the
previous 6 months. Participants were reimbursed in Australian
dollars (Au$30 [∼US$18 in early 2002]) for the time (typically,
30–40 min) and effort involved in completing the interview,
and they were reimbursed an additional Au$10 for each net-
work member who they introduced to our outreach workers.
Informed consent was obtained from all research participants,
and the human experimentation guidelines of the authors’ in-
stitutions were followed.
Venous blood samples or blood samples obtained by fin-

Figure 1.
gerprick were collected from 198 IDUs who received full pretest
counseling (1 IDU was interviewed but did not provide a blood
sample). Study participants completed an extensive question-
naire that gathered information about their sociodemographic
characteristics, drug-use and injection histories, social (i.e., in-
jection) networks, and drug-injection and other behaviors prac-
ticed with their network members. Study participants were en-
couraged to bring network members to us to be interviewed,
but they were also asked to provide information about their
network members (including the first 2 letters of the first name,
Social and Molecular Epidemiology of HCV • JID 2004:190 (1 November) • 1589
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(Continued.)
the first 2 letters of the surname, and the physical characteristics
of each network member), to aid in the identification of net-
work members in lieu of a direct introduction. Results of poly-
merase chain reaction (PCR), genotyping, and HCV antibody
testing were provided, in person and with full posttest coun-
seling, on request.
Laboratory analysis. Blood samples underwent screening
for anti-HCV antibody by use of a third-generation EIA (Ab-
bott Laboratories), and anti-HCV–positive specimens were tested
again, by use of Murex anti-HCV antibody (version 4.0; Murex

Figure 2. A, Hepatitis C virus (HCV) core gene tree for genotype 3a. B, HCV nonstructural 5a protein region gene tree for genotype 3a.
Biotech), for confirmation of the results. Irrespective of anti-
HCV antibody status, all samples were tested for the presence
of HCV RNA by use of the Cobas Amplicor HCV test (Roche).
Fingerprick blood spots were obtained, in lieu of venous spec-
imens, from 15 subjects who had badly damaged veins. The blood
spots were eluted using Qiagen lysis buffer (QIAamp Viral RNA
Mini Kit; Qiagen), and they were extracted using the semiau-
tomated MagNA Pure LC instrument and dedicated Total NA
Isolation Kit (Roche). Eluted material was diluted in the Roche
1590 • JID 2004:190 (1 November) • Aitken et al.
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Cobas Amplicor HCV test specimen diluent and was subjected
to amplification as performed for the other blood samples.
PCR-positive blood samples were genotyped using a reverse-
phase hybridization line-probe assay (LiPA [Versant HCV ge-
notype assay; Bayer]), as described elsewhere [17]. For molec-
ular studies, PCR amplification was performed using a nested
in-house PCR with primers specific to the core region [18],
and sequencing was performed on the PCR products by use
of the ABI Prism Dye Terminator Cycle Sequencing Ready Re-
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(Continued.)
Figure 2.
action Kit (PE Applied Biosystems). Sequences were compared
with sequences in the National Center for Biotechnology In-
formation nucleotide sequence database, and the genotype ob-
tained was compared with the LiPA result for each sample. Core
sequences (307–328 bp, depending on genotype) were grouped
according to genotype, and phylogenetic analysis was performed
using the PHYLIP package [19]. For analysis of genotypes 2, 6,
and 7, the core sequences were supplemented with genotype-
specific control sequences sourced from the HCV sequence da-
tabase of the Victorian Infectious Diseases Reference Laboratory
(VIDRL; North Melbourne, Australia). For each pair of virus
samples of the same genotype, genetic distances were calculated
using the DNADIST program, for comparison with the network
data and for the creation of HCV core gene trees by use of the
Kimura 2-parameter method and the tree construction pro-
gram NEIGHBOR. The PHYLIP program SEQBOOT was used
to bootstrap (⫻1000) each set of genotype-specific sequence
data, to estimate the significance of the clusters. HCV infections
were identified as being significantly related if their bootstrap
value was ⭓70% [20].
Additional sequencing in the nonstructural protein 5a (NS5a)
region (a more variable region) was performed on significant
clusters for samples genotyped as genotype 1 and 3, for which
specific primers were available [21]. Phylogenetic analysis of these
NS5a sequences and of 20 genotype-specific control sequences
from the VIDRL HCV sequence database (219 bp for genotype
1a sequences and 227 bp for genotype 3a sequences) was per-
formed [9, 21], and the clusters that were identified were com-
pared with those from the core sequence analysis.
Statistical analysis. Data obtained from interviews and
blood tests were entered into a relational FileMaker Pro 5 da-
tabase (Claris), which enabled simultaneous manipulation of re-
lated files that contained information about interviewees and
their network members, and the data were exported to SPSS for
analysis. The principal network measure used in this analysis is
social distance—that is, the number of links that separate 2 IDUs,
where a “link” denotes the naming of 1 IDU as an injection
partner by another IDU, and/or the reverse. A pair of IDUs
separated by 1 link (i.e., a social distance of 1) is known as a
“dyad.” Social network measurements were generated by ex-
porting data on links to UCINET [22] and by merging the re-
sulting matrices into SPSS data files. Relationships between the
social and genetic distances that separated the study participants
were investigated using regression analysis.
RESULTS
Network characteristics. Of the 199 IDUs interviewed, 197
were members of 1 large, connected network component that
included 577 dyadic relationships (therefore, a path that con-
sisted of a finite number of injection-associated links could be
1592 • JID 2004:190 (1 November) • Aitken et al.
drawn between any 2 IDUs). Connections between initially
distinct network subcomponents surfaced as recruitment for
the study progressed, despite the deliberate recruitment of seed
cases from a broad spectrum of IDU groups identified during
our initial fieldwork. The remaining 2 IDUs were “isolates”—
that is, they did not nominate any other interviewed IDUs as
network members, and they were nominated by none of the
other interviewed IDUs. IDUs nominated a mean of 4.6 net-
work members each (range, 1–10), and a mean of 3.3 network
members (range, 1–10) were interviewed. IDUs were linked to
a mean of 6.2 network members (range, 1–23).
HCV test data. Of 198 blood samples, anti-HCV antibody
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was detected in 172 (86.9%) of the samples, and HCV RNA
was detected in 138 (69.7%) of the samples. Twenty-one blood
samples were negative both for anti-HCV antibody and for
HCV RNA. One blood sample was found to be anti-HCV an-
tibody negative and HCV RNA positive, indicative of early
infection. Two blood samples had indeterminate results of test-
ing for anti-HCV antibody and were HCV RNA negative, and
2 blood samples obtained by fingerprick were antibody negative
and unsuitable for PCR.
Genotype distribution among the 138 HCV RNA–positive
IDUs (table 1) was similar to that reported for the Australian
HCV-infected community, with HCV genotypes 1, 1a, and 1b
(52.2% of 138 IDUs) and genotype 3a (36.2% of 138 IDUs)
found to be the predominant types [17]. The genotype deter-
mined by the LiPA was compared with the genotype deter-
mined by core sequencing. The genotypes matched for all but
6 IDUs. For the blood samples of 4 IDUs, the genotype was
correctly identified, by core sequence analysis, as HCV geno-
type 7a (this genotype had been mistyped as genotype 1b by
LiPA) [18]. The blood sample of 1 IDU was found to have a
mixture of genotypes 1a and 3a, according to LiPA, core, and
NS5a region sequencing. For the blood sample of the other
IDU, the genotype identified by LiPA was genotype 3a, but the
dominant sequence produced by core sequencing was genotype
7a. The underlying genotype 3a sequence was apparent, and
the presence of genotype 3a was confirmed by sequence analysis
of the NS5a region, by use of type-specific primers. Type-spe-
cific primers for genotype 7a were not available for sequence
analysis of the NS5a region.
Phylogenetically related infections. Phylogenetic analysis
of 138 core region sequences from 6 genotypes identified 18
clusters of related infections (12 pairs, 2 triplets, 2 quadruplets,
1 sextuplet, and 1 septuplet) that involved 51 individual IDUs
(table 2). Thus, of the 138 HCV RNA–positive IDUs, nearly
40% had an HCV infection that was genetically related to that
of at least 1 other IDU in our cohort. Figures 1 and 2 show
the core and NS5a region gene trees, respectively, with boot-
strap values indicating the degree of relatedness for genotypes
Figure 3. Four clusters of related infections involving multiple injection drug users, according to genotype. Solid arrows, dyadic relationships (social
distance, 1); broken arrows, finite paths of ⭓2 links (social distance, 11).
1a and 3a, which are the 2 most common genotypes. For ge-
notype 1a, all 5 significant clusters in the core region were
confirmed in the NS5a region. For genotype 3a, the 7 significant
clusters in the core region had identical groupings in the NS5a
region; however, 2 of the 7 clusters deemed to be significant
on the basis of core region sequences did not reach the 70%
bootstrap value (the threshold for significance) when NS5a
region sequences were analyzed.
To examine the social links between the related infections,
the 18 clusters of related infections were split into their 66
constituent pairs (i.e., 12 + [2*3!/2!1!] + [2*4!/2!2!] + [1*6!/4!2!]
+ [1*7!/5!2!]). In social network terms, only 12 (18.2%) of the
66 pairs with genetically related infections were dyads; there-
fore, only 12 (3.8%) of the 313 HCV RNA–positive social dyads
in the network had related infections. Social distance was in-
finite for 9 related infection pairs that included 1 of the isolates
described earlier; distances of 2–3 links (mean distance, 5.6
links) separated IDUs who comprised the remaining 45 (i.e.,
66 ⫺ 12 ⫺ 9) pairs. Figure 3 depicts 4 clusters of related infec-
tions and the social relationships of the IDUs involved.
In the first triplet (genotype 3a), there is 1 dyadic relation-
ship, but the shortest distance between either member of that
pair and the third IDU is 6 links; in the second triplet (genotype
7a), there is 1 dyadic relationship, and the third IDU is 2 links
distant from both members of that dyad. In the first quadru-
plet (genotype 1b), 2 IDUs are directly linked to a third IDU
but not to each other, and all IDUs are at a distance of 2–5
links from the fourth IDU; the second quadruplet (genotype
1a) consists of a “3-clique” (i.e., 3 IDUs with all 3 possible
links present) and an isolate. In the sextuplet (genotype 3a)
and septuplet (genotype 1b), among 15 and 21 discrete pairs
of IDUs with related infections, there were only 2 and 1 dyads,
respectively. The sole dyad in the sextuplet included the only
IDU with seroconversion in the present study (with serocon-
version determined by a positive PCR result and a negative
anti-HCV antibody test result), who reported (1) injecting with
his dyadic partner 2–3 times/day over a period of 1 month and
(2) injecting with the partner’s used needle 5 times, thereby
strongly implicating that IDU as the source of infection.
Genetic distance and social distance. To examine the cor-
respondence between virus relatedness and social distance, the
Social and Molecular Epidemiology of HCV • JID 2004:190 (1 November) • 1593
social distances between all pairs of IDUs with known genotypes
were compared with the genetic relatedness of their viral se-
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quences, within each genotype group, by use of regression analy-
sis. (Social distances for each genotype group were normally
distributed, but genetic distances were not; log-normal and
other transformations were evaluated, but none improved on
the linear model). The 2 isolates (who neither named nor were
named by other cohort members as injection partners) were
removed from the analyses, because they were at an infinite
social distance from all other IDUs in the data set, and no
regression was performed for genotype 2b, because only 3 IDUs
with that genotype were recruited for the study. IDUs with a
genotype that could not be definitively identified as genotype
1a or 1b were included in both analyses, as were the 2 IDUs
with mixed-genotype infections. Results of regression analysis
are presented in table 3. Regressions for 4 of 5 genotypes pro-
duced statistically significant associations, all of which had low
r2 values; 2 associations are inverted, predicting decreasing so-
cial distance with increasing genetic distance. Confidence in-
tervals are tight around the regression constants, which vary from
3.78 to 7.39 for the 4 statistically significant associations; there-
fore, for genetic distances of zero (which denote identical or
nearly identical viral sequences), the regression constants accu-
rately represent estimated social distances, thereby confirming
the weakness of the associations. If correspondence between so-
cial and molecular distance had been very high, the regression
constants would be close to 1, so that a genetic distance of zero
would produce an estimate of social distance approaching 1 (de-
noting a dyadic relationship).
Genetic distance and duration of injection drug use history.
We expected that related infections would be more often de-
tected among IDUs in the early stages of their injection drug
use history, because their social networks are more likely to
include the source of their HCV infections, and because pairs
of infections are more likely to remain phylogenetically simi-
lar. To test this idea, we compared the mean duration of the
injection drug use history of IDUs who were (n p 51 ) or were
not (n p 87) members of related infection pairs. The mean du-
rations of injection drug use histories for these groups were
virtually identical (10.65 years [for IDUs who were members of
 Table 3. Associations between genetic and social distances, according to genotype, as determined by regression
analysis.

No. of IDU pair Regression constant

a
Genotype No. of IDUs combinations b (95% CI) (95% CI) r2 P
1a 60 1770 ⫺23.40 (⫺34.16 to ⫺12.64) 7.39 (7.09 to 7.69) 0.0102 .000
1b 30 435 9.10 (2.52 to 15.68) 6.20 (5.81 to 6.58) 0.0169 .007
3a 51 1275 25.02 (12.11 to 37.93) 5.34 (4.90 to 5.78) 0.0112 .000
6a 7 21 ⫺86.57 (⫺142.70 to ⫺30.45) 3.78 (2.69 to 4.86) 0.3540 .004
7a 5 10 9.09 (⫺10.60 to 28.78) 1.49 (0.67 to 2.31) 0.1239 .318

NOTE. Regression results were calculated as follows: social distance p bootstrap value ⫻ (genetic distance + regresssion constant).
CI, confidence interval; IDUs, injection drug users.
a
Regression slope.

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related infection pairs] vs. 10.63 years [for IDUs who were not
members of such pairs]; P p .988), refuting our hypothesis.
DISCUSSION
The present study is the first application of combined social
network and molecular phylogenetic techniques to the epide-
miology of HCV. The results of the study confirm that molecular
epidemiological and social network methods can overlap in their
descriptions of pathways of HCV transmission. Variability in the
core region proved adequate for the identification of significant
clusters of related infections. Further analysis in the more variable
NS5a region confirmed the presence of clusters of infections of
genotypes 1a and 3a, the major genotypes present in the cohort.
Of IDUs who had detectable HCV RNA levels, nearly 40% had
an HCV infection that was phylogenetically related to that of at
least 1 other IDU in the cohort. More than 18% of the IDU
pairs with related HCV infections were identified in the social
network data as injection partners (i.e., as dyads). Of interest,
all but 2 of the IDUs interviewed were members of 1 large
network of IDUs, a scenario that has obvious implications for
transmission of disease and that has not been observed in pre-
vious studies of IDU networks [23–25].
The low level of correlation between social network and
phylogenetic data may be ascribed to a variety of reasons. Our
ability to track patterns of HCV infection through the social
networks of IDUs was diminished by the practical constraints
of finding and interviewing specific IDUs in a busy and rapidly
shifting street-drug scene. As other authors have noted [15],
the situation is one of incomplete capture of a complex picture.
In addition, the epidemic nature of HCV in a high-risk pop-
ulation, such as IDUs, hinders reconstruction of infection pat-
terns. There is a high prevalence of exposure to HCV among
Australian IDUs (64% of participants in the 2001 national Nee-
dle and Syringe Program Survey tested positive for anti-HCV
antibody), and exposure frequently occurs early in the injection
drug use history of IDUs [26]. The IDUs investigated in the
present study had been injecting drugs for just 110 years, on
average (and 70% had been injecting drugs for ⭓5 years), and
the prevalence of anti-HCV antibody was already 185%; thus,
for the majority of IDUs, their first exposure to HCV is likely
to have occurred years before the interview was conducted,
which is well beyond any reasonable period for recall of com-
plex social network information. Meanwhile, we were un-
avoidably reliant on a much more recent period in the injection
drug use history of our study participants, to have a good
chance of recruiting their network members. The fact that a
substantial minority of participants were living in transient ac-
commodation when they were interviewed, having recently ar-
rived from other parts of Victoria or Australia, further reduced
our ability to make social network connections and to identify
related infections. In contrast, molecular studies were able to
definitively identify related HCV infections in clusters of IDUs,
some of which had corresponding social connections.
Two blood samples were identified as showing evidence of
mixed-genotype infection after comparison of the genotype re-
sults of LiPA with those of sequencing. It is apparent from these
results that not all genotype mixtures may be detected using
standard assays in which only the dominant genotype is de-
tected [27, 28]—a phenomenon with obvious implications for
the provision of treatment for HCV infection to current or
former IDUs. This phenomenon may also be at least part of
the explanation for the absence, in the present study, of any
difference between the mean durations of injection drug use
history of IDUs with or without related infections.
Investigation of the injection drug use histories of the 21
individuals who showed no clinical evidence of HCV infection
revealed instances of needle-sharing with known HCV-positive
individuals on multiple occasions. The absence of infection
could be due to several factors, including innate immunity of
the host [29]. Further study of this phenomenon may shed
light on the mechanisms leading to initial development of in-
fection, chronicity, and clearance.
In conclusion, the present study involved the collection and
analysis of data regarding a single large social network of IDUs.
The low correlation between social network data and phylo-
genetic data highlights the practical difficulties involved in map-

1594 • JID 2004:190 (1 November) • Aitken et al.

ping networks of (frequently) highly mobile IDUs in whom
HCV infection typically occurs very early in their injection drug
use history and among whom HCV infection is invariably
highly prevalent. Another possible confounder is that infections
with multiple HCV genotypes are not always identified using
the LiPA. Although our data show that the risk networks of
IDUs therefore are not a reliable guide to actual patterns of
HCV infection, the identification of a subgroup of anti-HCV–
negative IDUs with high-risk injection behavior warrants fur-
ther investigation. Molecular epidemiology was shown to be a
powerful tool with which to identify related infections in IDUs.
It can provide insights into the spread of HCV infection in a
limited population of IDUs; however, because of the rapid evo-
lution of the virus and because of the difficulties associated
with studying this population, the use of molecular epidemi-
ological methods is probably best restricted to the tracking of
recent infections.
Acknowledgment
We thank Dr. Graham Byrnes (Department of Mathematics and Statis-
tics, University of Melbourne, Parkville, Victoria, Australia) for his advice
on the interpretation of the phylogenetic data in the present study.
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