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. 2013 Jun;103(6):1028–1030. doi: 10.2105/AJPH.2012.301129

Missed Opportunities for Hepatitis C Testing in Opioid Treatment Programs

Jemima A Frimpong 1,✉
PMCID: PMC3670662  PMID: 23597374

Abstract

HCV has surpassed HIV as a cause of death in the United States and is particularly prevalent among injection drug users. I examined the availability of on-site HCV testing in a nationally representative sample of opioid treatment programs. Nearly 68% of these programs had the staff required for HCV testing, but only 34% offered on-site testing. Availability of on-site testing increased only slightly with the proportion of injection drug users among clients. The limited HCV testing services in opioid treatment programs is a key challenge to reducing HCV in the US population.

HCV recently surpassed HIV as a cause of death in the United States.1,2 Approximately 3.2 million people nationwide are living with chronic hepatitis, but most are unaware of their status because of limited opportunities for testing.3–6 Persons who inject drugs are particularly at risk for HCV infection as a result of sharing and reusing of needles.4,7 The estimated prevalence of antibodies to HCV (anti-HCV) among injection drug users ranges from 35% to 65%.8 The Centers for Disease Control and Prevention (CDC) thus recommends routine HCV testing for all current or former injection drug users.1,9 Offering HCV testing services in drug abuse treatment programs could help increase HCV case finding and reduce transmission.10,11 It could also help foster the adoption of preventive behaviors: knowledge of one’s anti-HCV status may indeed lead to safer injection practices (or other protective behaviors).12,13

I examined the availability of on-site HCV testing services in opioid treatment programs (i.e., physical facilities with resources dedicated specifically to treating opiate dependence with methadone, buprenorphine, or both).14,15 Opioid treatment programs treat both persons who inject drugs and people who have opiate addiction but do not inject drugs. The current recommended HCV testing protocol requires the collection of venous blood, performed by qualified staff (i.e., phlebotomists).16 However, the availability of (1) human resources required to offer HCV testing services and (2) on-site HCV testing services at opioid treatment programs nationwide is not known. I examined relations among the availability of on-site HCV testing services, human resources for HCV testing, and the proportion of injection drug users among opioid treatment program clients.

METHODS

I analyzed data from the 2011 National Drug Abuse Treatment System Survey (NDATSS).14,17,18 In total, a nationally representative sample of 200 opioid treatment programs completed the survey. Twenty-two opioid treatment programs refused to participate, and 90 initially screened were unable to complete interviews. A response rate of 87% was calculated with the Council of American Survey Research Organization method.19 I found no significant differences between responders and nonresponders.

I used 3 data elements from the 2011 NDATSS: (1) the proportion of injection drug users among clients of an opioid treatment program, (2) the presence of staff who perform blood collection, and (3) the availability of HCV testing services on site. I calculated the proportion of opioid treatment programs with human resources capacity and on-site HCV testing. I categorized opioid treatment programs by the prevalence of injection drug users among their clients (0%–24%, 25%–49%, 50%–74%, or 75%–100%). I used logistic regression with controls for opioid treatment program size (i.e., total number of clients in past year) to examine the association between human resources capacity and on-site HCV testing and the proportion of injection drug users among clients. I report predicted probabilities from these regressions. I used the simple Wald test to determine whether the proportion of opioid treatment programs with human resources capacity or on-site HCV testing differed between levels of the injection drug users variable. Among opioid treatment programs that did not offer on-site HCV testing, I examined the proportion of facilities that referred clients to off-site HCV testing services.

RESULTS

The results showed that 68.0% (95% confidence interval [CI] = 61.1, 74.4) of opioid treatment programs nationwide had staff capacity for HCV testing, but only 33.7% (95% CI = 27.1, 40.7) actually offered on-site HCV testing (Figure 1). The availability of HCV testing on site increased with the proportion of injection drug users among clients; however, only 32.3% (95% CI = 17.4, 47.3) of the opioid treatment programs with the most injection drug users among their clients (≥ 75%) offered on-site HCV testing. Human resources capacity increased significantly in proportion to higher prevalence of injection drug users among the clients of opioid treatment programs. However, more than half (58.5%) of the opioid treatment programs with staff capacity to provide on-site HCV testing did not offer such services. Among opioid treatment programs that did not offer on-site HCV testing, 84.1% referred their clients to off-site testing facilities. This proportion did not vary with the proportion of injection drug users among the clients of opioid treatment programs.

FIGURE 1—

FIGURE 1—

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Human resource (HR) capacity to test and availability of on-site HCV testing services in opioid treatment programs (OTPs): 2011 National Drug Abuse Treatment System Survey.

DISCUSSION

I found large gaps in the availability of on-site HCV testing services and the human resources capacity of opioid treatment programs to provide testing, especially to high-risk populations (e.g., injection drug users). Even in opioid treatment programs with staff capacity, more than half did not offer on-site testing, thus creating large missed opportunities for HCV case finding and early treatment. Several factors may account for these findings, including policy and organizational factors (i.e., affiliation, ownership) and client characteristics (e.g., race, sex). Opioid treatment programs that do not offer on-site HCV testing appear to have referral agreements in place for their clients to undergo HCV testing off site. However, findings from other studies suggest that uptake of off-site HCV testing is likely to be much lower.20,21

My findings had several limitations. First, the sample was limited to programs that treat opiate dependence with methadone or buprenorphine. Second, I did not measure the uptake of HCV testing among clients of opioid treatment programs where on-site HCV testing was offered. Third, opioid treatment programs must have the required human resources to provide on-site HCV testing, but this is far from the only requirement: other factors, including state-level requirements, certification to test, availability of funding, and changes in payment systems, may limit the capacity of opioid treatment programs to offer on-site HCV testing to their clients.

Notwithstanding these limitations, results from this study have important implications for strategies to curb the HCV epidemic in the United States. These results indicated that increasing human resources capacity (i.e., hiring or training phlebotomists) alone is not sufficient to increase the availability of HCV testing services in opioid treatment programs. However, promoting the use of rapid HCV tests, which do not necessarily require phlebotomists, could help rapidly increase the availability of HCV testing services in opioid treatment programs. State-level requirements for certification may influence the use and availability of rapid testing.22 In addition, on-site HCV testing could serve as an important complementary service to prevention initiatives.

Overall, HCV prevention and testing services must become an integral component of services delivered by opioid treatment programs,23 particularly those with injection drug users. Additionally, client preferences for mode of testing, which may influence uptake of testing, should be considered in any initiative to promote HCV testing.24,25 Policies and investments similar to those adopted for HIV testing and counseling (e.g., opt-out testing) may be required to avert increasing mortality linked to HCV.

Acknowledgments

This publication was supported by the National Center for Advancing Translational Sciences, National Institutes of Health (grant KL2 TR000081), formerly, the National Center for Research Resources (grant KL2 RR024157), and the National Institute of Drug Abuse (grant R01 DA030459 02S1).

The author thanks Thomas D’Aunno for his valuable feedback.

Note. The content is solely the responsibility of the author and does not represent the official views of National Institute on Drug Abuse or the National Institutes of Health.

Human Participant Protection

The institutional review board at the Columbia University Medical Center approved all aspects of this study.

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