RESEARCH AND PRACTICE

Awareness of HCV Infection Among Persons Who Inject Drugs in San Diego, California Melissa G. Collier, MD, MPH, Sandeep K. Bhaurla, MPH, Jazmine Cuevas-Mota, MPH, Richard F. Armenta, PhD, Eyasu H. Teshale, MD, and Richard S. Garfein, PhD

We asked persons who inject drugs questions about HCV, including past testing and diagnosis followed by HCV testing. Of 540 participants, 145 (27%) were anti-HCV positive, but of those who were positive, only 46 (32%) knew about their infection. Asking about previous HCV testing results yielded better results than did asking about prior HCV diagnosis. Factors associated with knowing about HCV infection included older age, HIV testing, and drug treatment. Comprehensive approaches to educating and screening this population for HCV need implementation. (Am J Public Health. 2015; 105:302–303. doi:10.2105/AJPH.2014. 302245)

HCV causes chronic infection in about 75% to 85% of infected persons, potentially leading to cirrhosis and liver cancer.1 Currently in the United States, chronic HCV infection affects an estimated 2.7 million persons.2 Injection drug use is the leading risk factor for infection.3,4 Because self-report of HCV infection might be used to make decisions on who to screen, the limitations of self-report need to be better understood. Past studies on the limitations of self-reported HCV infection have generally described poor agreement between actual and perceived HCV serostatus.5,6 In persons with HCV infection, behavioral counseling can be provided to reduce disease progression (alcohol abstinence) and to reduce HCV transmission (sharing injection equipment).7 We investigated the sensitivity and specificity of perceived compared with actual HCV serostatus and assessed whether

awareness of HCV infection is associated with differences in risk behaviors among HCVpositive persons who inject drugs (PWID).

METHODS We recruited PWID aged 18 to 40 years in San Diego, California, to participate in the Study to Assess Hepatitis C Risk between March 2009 and June 2010. Methods of participant recruitment and data collection were previously published8; briefly, we included anyone who had injected drugs in the previous 6 months. We assessed sociodemographic characteristics, behavioral risk factors including drug use, and access to care using audio computer-assisted self-interviewing technology. We tested all participants for HCV antibodies with Abbott Axsym microparticle enzyme immunoassay (Abbott Laboratories, Chicago, IL).9 We considered repeatedly reactive specimens with a signal-to-cutoff ratio of 10.0 or greater anti-HCV positive; specimens with signalto-cutoff ratios between 1.0 and 10.0 received supplemental testing using recombinant immunoblot assays (Ortho Diagnostics, Raritan, NJ).10 We notified participants of their results and counseled them about HCV. We calculated sensitivity and specificity of self-reported HCV infection compared with anti-HCV test results. We considered selfreported HCV infection status positive if participants answered “yes” to either (1) the question “Has a doctor or health care worker ever told you that you had hepatitis C?” or (2) the question “Have you ever been tested for hepatitis C before today?” and indicated “positive” to the question “What was the result of your last hepatitis C test result?” To determine whether awareness of HCV infection affected risk behavior, we conducted a subanalysis among PWID who tested anti-HCV positive and compared those who reported their infection status as positive with those who reported their infection status as negative. We calculated odds ratios (ORs) and 95% confidence intervals (CIs). We included factors associated with knowledge of infection status at a level of P < .1 during bivariate analysis in a multivariable logistic regression analysis; we retained those significant at P < .05 in the final model. We used SAS version 9.3 (SAS Institute, Cary, NC).

302 | Research and Practice | Peer Reviewed | Collier et al.

RESULTS Of 576 study participants, we tested 540 for HCV. Of these, 145 (27%) were antibody positive. Six persons did not answer the 2 self-report questions, and we excluded them from the analysis. Forty-six (32%) of those testing positive self-reported knowing their HCV infection status. Only 16 (35%) of those who were aware of their HCV infection reported that a provider offered them treatment. Sensitivity and specificity of previous diagnosis from a doctor or health care worker was 35% and 98%, respectively. Sensitivity and specificity of self-reported HCV infection was 55% and 98%, respectively. HCV status awareness among anti-HCV--positive PWID was associated with older age, longer duration of injecting, ever incarcerated, ever tested for HIV, ever in drug treatment, regular alcohol drinking, and binge alcohol drinking (Table 1) on bivariate analysis. We included these variables in a multivariable model; older age (adjusted OR [AOR] = 1.1; 95% CI = 1.03, 1.19), ever tested for HIV (AOR = 14.8; 95% CI = 1.87, 117.01), and ever in drug treatment (AOR = 3.4; 95% CI = 1.26, 9.00) remained independently significant in the final model.

DISCUSSION In this analysis, only 32% of all HCVinfected PWID reported prior knowledge of their infection, which is similar to other results in the literature.5,6 Asking for previous anti-HCV testing results is more sensitive than is asking about a previous diagnosis from a health care provider; questions to address HCV self-reported serostatus should be about previous HCV testing and results. Anti-HCV---positive PWID who knew their status were older and had been injecting longer. Only 35% of anti-HCV---positive PWID who knew of their infection reported being offered treatment by a provider. Although any alcohol consumption can contribute to liver fibrosis in persons who are chronically HCV infected,11,12 anti-HCV---positive PWID who knew their status were no less likely to regularly consume alcohol or binge drink alcohol and were more likely to have been in drug treatment than were those who thought they

American Journal of Public Health | February 2015, Vol 105, No. 2

RESEARCH AND PRACTICE

Note. The findings and conclusions in this study are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention.

TABLE 1—Bivariate Analysis of Sociodemographic Characteristics and Reported Risk Behaviors of Anti-HCV–Positive Participants by Self-Reported Awareness of HCV Infection Status: San Diego, CA, March 2009–June 2010

Characteristic Age, y Years injecting

Human Participant Protection The University of California San Diego institutional review board approved the study protocol.

Not Aware of HCV Infection (n = 93), No. (%) or Median (IQR)

Aware of HCV Infection (n = 46), No. (%) or Median (IQR)

OR (95% CI)

30 (26–33)

33 (28–38)

9 (5–12)

P

References

1.09 (1.02, 1.17)

.008

1. Guidelines for the Screening, Care and Treatment of Persons With Hepatitis C Infection. Geneva, Switzerland: World Health Organization; 2014.

12 (6–16)

1.07 (1.01, 1.13)

.017

69 (74)

35 (76)

1.12 (0.49, 2.52)

.809

Non-Hispanic White Non-Hispanic Black

51 (55) 2 (2)

18 (39) 0 (0)

1.00 (Ref) ...

Hispanic

28 (30)

14 (30)

1.42 (0.61, 3.27)

Non-Hispanic other

Male gender Race/ethnicity

.101

12 (13)

14 (30)

3.31 (1.29, 8.46)

Spanish speaking

23 (25)

12 (26)

1.07 (0.48, 2.41)

.862

Ever incarcerated

73 (78)

43 (93)

3.93 (1.10, 13.99)

.035

Ever tested for HIV

64 (70)

43 (98)

18.81 (2.47, 143.49)

.005

Ever treated for STI

12 (13)

10 (23)

1.94 (0.76, 4.91)

Ever received drug treatment Ever used a syringe exchange program

51 (55) 54 (59)

39 (85) 27 (59)

4.48 (1.82, 11.05) 1.00 (0.49, 2.05)

.164

Shares syringes

52 (58)

27 (60)

1.10 (0.53, 2.27)

Shares works

73 (79)

33 (73)

0.72 (0.31, 1.64)

.431

Regular alcohol consumption (> 1 drink/d)

48 (52)

32 (70)

2.10 (0.99, 4.43)

.053

Alcohol binge drinking (> 5 drink/d)

35 (50)

27 (71)

2.46 (1.06, 5.70)

.037

.001 ‡ .99 .805

Note. CI = confidence interval; IQR = interquartile range; OR = odds ratio; STI = sexually transmitted infection. Ellipses indicate unable to calculate.

were negative or were unaware of their status. Additionally, we observed no difference in drug equipment---sharing behaviors. These findings suggest that HCV counseling should place greater emphasis on abstaining from alcohol use and reducing drug equipment sharing. Ever being in drug treatment was significantly associated with knowing one’s HCV-positive status, suggesting that some drug treatment programs might be screening participants for HCV and sharing their results with the participants. Previous HIV testing was also significantly associated with HCV infection awareness, suggesting that HCV screening might be occurring with HIV screening. Our study was limited by small numbers; some CIs were wide and should be interpreted with caution. Behavior counseling for HCV transmission prevention and alcohol avoidance in this population is important,7 and the most effective outreach, testing, and counseling techniques available should be used.13,14 Comprehensive

approaches to HCV testing and counseling with follow-up for PWID should be considered. j

About the Authors Melissa G. Collier and Eyasu H. Teshale are with the Division of Viral Hepatitis, National Center for HIV, Hepatitis, STD, and TB Prevention, Centers for Disease Control and Prevention, Atlanta, GA. Sandeep K. Bhaurla, Jazmine Cuevas-Mota, Richard F. Armenta, and Richard S. Garfein are with the Division of Global Public Health, School of Medicine, University of California, San Diego. Correspondence should be sent to Melissa G. Collier, Division of Viral Hepatitis, Centers for Disease Control and Prevention, 1600 Clifton Rd NE, MS G-37, Atlanta, GA 30329 (e-mail: [email protected]). Reprints can be ordered at http://www.ajph.org by clicking the “Reprints” link. This brief was accepted August 12, 2014.

2. Denniston MM Jr, Drobeniuc J, Klevens RM, Ward JW, McQuillan GM, Holmberg SD. Chronic hepatitis C virus infection in the United States, National Health and Nutrition Examination Survey 2003 to 2010. Ann Intern Med. 2014;160(5):293---300. 3. Amon JJ, Garfein RS, Ahdieh-Grant L, et al. Prevalence of hepatitis C virus infection among injection drug users in the United States, 1994---2004. Clin Infect Dis. 2008;46(12):1852---1858. 4. Armstrong GL, Wasley A, Simard EP, McQuillan GM, Kuhnert WL, Alter MJ. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med. 2006;144(10):705---714. 5. Kwiatkowski CF, Fortuin Corsi K, Booth RE. The association between knowledge of hepatitis C virus status and risk behaviors in injection drug users. Addiction. 2002;97(10):1289---1294. 6. Hagan H, Campbell J, Thiede H, et al. Self-reported hepatitis C virus antibody status and risk behavior in young injectors. Public Health Rep. 2006;121(6):710---719. 7. Centers for Disease Control and Prevention. Integrated prevention services for HIV infection, viral hepatitis, sexually transmitted diseases, and tuberculosis for persons who use drugs illicitly: summary guidance from CDC and the US Department of Health and Human Services. MMWR Recomm Rep. 2012;61(RR-5):1---40. 8. Garfein RS, Rondinelli A, Barnes RF, et al. HCV infection prevalence lower than expected among 18---40year-old injection drug users in San Diego, CA. J Urban Health. 2013;90(3):516---528. 9. Morota K, Fujinami R, Kinukawa H, et al. A new sensitive and automated chemiluminescent microparticle immunoassay for quantitative determination of hepatitis C virus core antigen. J Virol Methods. 2009;157(1):8---14. 10. Pawlotsky JM, Fleury A, Choukroun V, et al. Significance of highly positive c22-3 “indeterminate” second-generation hepatitis C virus (HCV) recombinant immunoblot assay (RIBA) and resolution by third-generation HCV RIBA. J Clin Microbiol. 1994;32(5):1357---1359. 11. Monto A, Patel K, Bostrom A, et al. Risks of a range of alcohol intake on hepatitis C-related fibrosis. Hepatology. 2004;39(3):826---834.

Contributors

12. Szabo G. Moderate drinking, inflammation, and liver disease. Ann Epidemiol. 2007;17(5):S49---S54.

All authors made substantial contributions to the article conceptualization or design, helped in drafting or critically revising it for important intellectual content, had final approval of publication, and agreed to be accountable for all aspects.

13. Latka MH, Hagan H, Kapadia F, et al. A randomized intervention trial to reduce the lending of used injection equipment among injection drug users infected with hepatitis C. Am J Public Health. 2008;98(5):853---861.

Acknowledgments This study was funded by the Centers for Disease Control and Prevention (grant 200 2007 21016).

February 2015, Vol 105, No. 2 | American Journal of Public Health

14. Bruneau J, Zang G, Abrahamowicz M, Jutras-Aswad D, Daniel M, Roy E. Sustained drug use changes after hepatitis C screening and counseling among recently infected persons who inject drugs: a longitudinal study. Clin Infect Dis. 2014;58(6):755---761.

Collier et al. | Peer Reviewed | Research and Practice | 303

Awareness of HCV infection among persons who inject drugs in San Diego, California.

We asked persons who inject drugs questions about HCV, including past testing and diagnosis followed by HCV testing. Of 540 participants, 145 (27%) we...
451KB Sizes 0 Downloads 6 Views