– In an unrelenting opioid epidemic, hepatitis C is infecting tens of thousands of mostly young, white injection drug users, with the highest prevalence in the same Appalachian, Midwestern and New England states that are seeing the steepest overdose death rates.

Like the opioid epidemic that is driving it, the rate of new hepatitis C cases has spiked in the last five years. After declining for two decades, new hepatitis C cases shot to an estimated 34,000 in 2015, nearly triple the number in 2010, according to a recent report from the U.S. Centers for Disease Control and Prevention.

With better screening for the bloodborne disease and more treatment using costly but highly effective new drugs, hepatitis C could be eradicated, according to a new study from the National Academies of Sciences, Engineering, and Medicine.

But epidemiologists agree that without quelling the opioid epidemic, or ensuring that nearly all injection drug users have access to sterile needles, hepatitis C will continue to spread. It already affects 3.5 million Americans who, if not treated, could die of liver cirrhosis or cancer.

“We have two public health problems that are related — it’s called a syndemic — and we can’t address one without addressing the other,” said James Galbraith, an emergency room physician at the University of Alabama at Birmingham Hospital.

To reduce new hepatitis C infections, he said, states need to provide clean syringes for injection drug users who otherwise have no other contact with the health care system than emergency departments and jails.

But advocates for syringe exchanges say the prospect of standing up enough clean needle programs in the nation’s hardest hit communities to stem the spread of hepatitis C is daunting.

Unlike the AIDS epidemic of the 1980s and previous drug epidemics, which were spawned and defeated in urban settings, this opioid epidemic is ensnaring people who live in far-flung small cities and rural communities with few public health resources and scant political will to provide sterile needles to illicit drug users.

Compounding the problem is a lack of perceived urgency. Hepatitis C doesn’t kill children or adults in the prime of life. Most people infected with the virus experience no symptoms and the serious liver damage it can cause doesn’t show up for 20 to 40 years after someone is infected.

“HIV is a dreaded disease,” said Brian Strom, who chaired the committee that wrote the National Academies of Sciences study. “Hepatitis isn’t and it should be.”

“It is ignored largely because of a perception that it is tied to drug use and not a threat to the general public,” he said. “The irony is that now that people are starting to worry about drug users because they’re entering the mainstream population, it’s going to help hepatitis get the attention it deserves.”