Abstract
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.
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 HCV-positive 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 signal-to-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 self-reported 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).
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.
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 | Not Aware of HCV Infection (n = 93), No. (%) or Median (IQR) | Aware of HCV Infection (n = 46), No. (%) or Median (IQR) | OR (95% CI) | P |
| Age, y | 30 (26–33) | 33 (28–38) | 1.09 (1.02, 1.17) | .008 |
| Years injecting | 9 (5–12) | 12 (6–16) | 1.07 (1.01, 1.13) | .017 |
| Male gender | 69 (74) | 35 (76) | 1.12 (0.49, 2.52) | .809 |
| Race/ethnicity | .101 | |||
| Non-Hispanic White | 51 (55) | 18 (39) | 1.00 (Ref) | |
| Non-Hispanic Black | 2 (2) | 0 (0) | . . . | |
| Hispanic | 28 (30) | 14 (30) | 1.42 (0.61, 3.27) | |
| Non-Hispanic other | 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) | .164 |
| Ever received drug treatment | 51 (55) | 39 (85) | 4.48 (1.82, 11.05) | .001 |
| Ever used a syringe exchange program | 54 (59) | 27 (59) | 1.00 (0.49, 2.05) | ≥ .99 |
| Shares syringes | 52 (58) | 27 (60) | 1.10 (0.53, 2.27) | .805 |
| 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 |
Note. CI = confidence interval; IQR = interquartile range; OR = odds ratio; STI = sexually transmitted infection. Ellipses indicate unable to calculate.
DISCUSSION
In this analysis, only 32% of all HCV-infected 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 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.
Acknowledgments
This study was funded by the Centers for Disease Control and Prevention (grant 200 2007 21016).
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.
Human Participant Protection
The University of California San Diego institutional review board approved the study protocol.
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