Abstract
Background
Hepatitis C virus (HCV) infection is highly prevalent in illicit drug user populations, with three in four new HCV infections related to this risk behaviour and a growing HCV disease burden in Canada. Using data from a multi-site cohort study of illicit opioid users in five Canadian cities (OPICAN), this paper explores the prevalence and predictors of HCV status in this high-risk population.
Methods
HCV status of cohort participants was assessed by salivary antibody test. Univariate relationships of HCV status with select variables were examined on the basis of cohort baseline data, and subsequently multivariate models using logistic regression to determine independent predictors of HCV status were generated.
Results
54.6% of the analysis sample (n=482) was HCV positive. Significant differences in terms of HCV prevalence existed across the sites. Significant variables in the final stepwise logistic regression model included age, site (Toronto), unprotected sex, injecting drug use, drug treatment and incarceration in past year, in addition to opioid use in combination with non-opioids.
Discussion
Besides drug injecting, various other socio-behavioural factors were associated with HCV status in our cohort. On this basis, interventions focusing solely on injection risks are overly limited in scope to prevent HCV transmission in the high-risk population of illicit drug users and need to be broadened. Prevention efforts should also target young injectors as a priority.
MeSH terms: Logistic regression, hepatitis C, illicit drug use, infectious disease, marginalization
Résumé
Contexte
Le virus de l’hépatite C (VHC) est extrêmement répandu dans la population de consommateurs de drogues illicites, les trois quarts des nouvelles infections à VHC étant reliées à ce comportement à risque; ainsi donc, le fardeau de cette maladie s’accroît au Canada. Utilisant les données d’une étude de cohorte de consommateurs d’opiacés dans cinq villes canadiennes (OPICAN), notre article porte sur la prévalence et les indicateurs de l’état sérologique relativement au VHC dans cette population à risque.
Méthode
L’infection à VHC chez les participants de la cohorte a été évaluée au moyen d’un test salivaire de détection des anticorps. Les associations univariées entre l’état sérologique relativement au VHC et certaines variables ont été examinées d’après les données de base de la cohorte. Par la suite, des modèles multivariables ont été produits par régression logistique afin de déterminer les indicateurs indépendamment liés à l’état sérologique relativement au VHC.
Résultats
Une proportion de 54,6 % de l’échantillon d’analyse (n = 482) était atteinte du VHC. Il existait des différences significatives, d’une ville à l’autre, en ce qui a trait à la prévalence du VHC. Le modèle final, obtenu par analyse séquentielle de la régression logistique, montre que les facteurs de risque comprennent l’âge, le lieu (Toronto), les relations sexuelles non protégées, l’injection de drogues, les programmes de désintoxication et l’incarcération au cours de l’année antérieure, ainsi que la consommation d’opiacés en combinaison avec des drogues non opioïdes.
Discussion
Plusieurs facteurs socio-comportementaux autres que l’injection de drogues étaient associés à l’infection à VHC dans la cohorte. Par conséquent, les interventions qui visent seulement les risques d’injection sont trop limitées pour prévenir la transmission du VHC dans la population de consommateurs de drogues illicites, et doivent êtres élargies. Les efforts de prévention devraient aussi cibler, de façon prioritaire, les jeunes utilisateurs de drogues injectables.
References
- 1.Wiessing L, Roy K, Sapinho D, Hay G, Taylor A, Goldberg D, et al. Surveillance of hepatitis C infection among injecting drug users in the European Union. In: Jager J, Limburg W, Kretzschmar M, Postma M, Weissing L, et al., editors. EMCDDA Monographs: Hepatitis C and Injection Drug Use: Impact, Costs and Policy Options. Luxembourg: European Monitoring Centre for Drugs and Drug Addiction; 2004. pp. 91–135. [Google Scholar]
- 2.Fischer B, Haydon E, Rehm J, Krajden M, Reimer J. Injection drug use and the hepatitis C virus: Considerations for a targeted treatment approach-The case study of Canada. J Urban Health. 2004;81:428–47. doi: 10.1093/jurban/jth128. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Lauer GM, Walker BD. Hepatitis C virus infection. N Engl J Med. 2001;345:41–52. doi: 10.1056/NEJM200107053450107. [DOI] [PubMed] [Google Scholar]
- 4.Zou S, Tepper M, Giulivi A. Current status of hepatitis C in Canada. Can J Public Health. 2000;91(Suppl.1):S10–S15. doi: 10.1007/BF03405100. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Zou S, Forrester L, Giulivi A. Hepatitis C update. Can J Public Health. 2003;94(2):127–29. doi: 10.1007/BF03404585. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 6.Harder J, Walter E, Riecken B, Ihling C, Bauer TM. Hepatitis C virus infection in intravenous drug users. Clin Microbiol Infect. 2004;10:768–70. doi: 10.1111/j.1469-0691.2004.00934.x. [DOI] [PubMed] [Google Scholar]
- 7.Sulkowski M, Thomas D. Epidemiology and natural history of Hepatitis C virus infection in injection drug users: Implications for treatment. Clin Infect Dis. 2005;40:S263–S269. doi: 10.1086/427440. [DOI] [PubMed] [Google Scholar]
- 8.Thorpe LE, Ouellet LJ, Hershow R, Bailey SL, Williams IT, Williamson J, et al. Risk of hepatitis C virus infection among young adult injection drug users who share injection equipment. Am J Epidemiol. 2002;155:645–53. doi: 10.1093/aje/155.7.645. [DOI] [PubMed] [Google Scholar]
- 9.Edlin BR, Kresina TF, Raymond DB, Carden MR, Gourevitch MN, Rich JD, et al. Overcoming barriers to prevention, care, and treatment of hepatitis C in illicit drug users. Clin Infect Dis. 2005;40(Suppl5):S276–S285. doi: 10.1086/427441. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 10.Hagan H, Thiede H, Weiss NS, Hopkins SG, Duchin JS, Alexander ER. Sharing of drug preparation equipment as a risk factor for hepatitis C. Am J Public Health. 2001;91:42–46. doi: 10.2105/AJPH.91.9.1350. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Diaz T, Des Jarlais D, Vlahov D, Perlis TE, Edwards V, Friedman SR, et al. Factors associated with prevalent hepatitis C: Differences among young adult injection drug users in lower and upper Manhattan, New York City. Am J Public Health. 2001;91:23–30. doi: 10.2105/AJPH.91.1.23. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Backmund M, Meyer K, Wachtler M, Eichenlaub D. Hepatitis C virus infection in injection drug users in Bavaria: Risk factors for seropositivity. Eur J Epidemiol. 2003;18:563–68. doi: 10.1023/A:1024603517136. [DOI] [PubMed] [Google Scholar]
- 13.Garfein RS, Vlahov D, Galai N, Doherty MC, Nelson KE. Viral infections in short-term injection drug users: The prevalence of the hepatitis C, hepatitis B, human immunodeficiency, and human T-lymphotropic viruses. Am J Public Health. 1996;86:655–61. doi: 10.2105/AJPH.86.5.655. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 14.Patrick DM, Tyndall MW, Cornelisse PG, Li K, Sherlock CH, Rekart ML, et al. Incidence of hepatitis C virus infection among injection drug users during an outbreak of HIV infection. CMAJ. 2001;165:889–95. [PMC free article] [PubMed] [Google Scholar]
- 15.Archibald CP, Ofner M, Strathdee SA, Patrick DM, Sutherland D, Rekart ML, et al. Factors associated with frequent needle exchange program attendance in injection drug users in Vancouver, Canada. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;17:160–66. doi: 10.1097/00042560-199802010-00010. [DOI] [PubMed] [Google Scholar]
- 16.Tortu S, McMahon J, Pouget E, Hamid R. Sharing of noninjection drug-use implements as a risk factor for hepatitis C. Subst Use Misuse. 2004;39:211–24. doi: 10.1081/JA-120028488. [DOI] [PubMed] [Google Scholar]
- 17.Roy E, Haley N, Leclerc P, Boivin JF, Cedras L, Vincelette J. Risk factors for hepatitis C virus infection among street youths. CMAJ. 2001;165:557–60. [PMC free article] [PubMed] [Google Scholar]
- 18.Weinstock HS, Bolan G, Reingold AL, Polish LB. Hepatitis C virus infection among patients attending a clinic for sexually transmitted diseases. JAMA. 1993;269:392–94. doi: 10.1001/jama.1993.03500030090039. [DOI] [PubMed] [Google Scholar]
- 19.Sulkowski MS, Mast EE, Seeff LB, Thomas DL. Hepatitis C virus infection as an opportunistic disease in persons infected with human immunodeficiency virus. Clin Infect Dis. 2000;30:S77–S84. doi: 10.1086/313842. [DOI] [PubMed] [Google Scholar]
- 20.Stein JA, Nyamathi A. Correlates of hepatitis C virus infection in homeless men: A latent variable approach. Drug Alcohol Depend. 2004;75:89–95. doi: 10.1016/j.drugalcdep.2004.02.002. [DOI] [PubMed] [Google Scholar]
- 21.Cheung RC, Hanson AK, Maganti K, Keeffe EB, Matsui SM. Viral hepatitis and other infectious diseases in a homeless population. J Clin Gastroenterol. 2002;34:476–80. doi: 10.1097/00004836-200204000-00021. [DOI] [PubMed] [Google Scholar]
- 22.Fox RK, Currie SL, Evans J, Wright TL, Tobler L, Phelps B, et al. Hepatitis C virus infection among prisoners in the California state correctional system. Clin Infect Dis. 2005;41:177–86. doi: 10.1086/430913. [DOI] [PubMed] [Google Scholar]
- 23.Guimaraes T, Granato CF, Varella D, Ferraz ML, Castelo A, Kallas EG. High prevalence of hepatitis C infection in a Brazilian prison: Identification of risk factors for infection. Braz J Infect Dis. 2001;5:111–18. doi: 10.1590/S1413-86702001000300002. [DOI] [PubMed] [Google Scholar]
- 24.Hahn JA, Page-Shafer K, Lum PJ, Bourgois P, Stein E, Evans JL, et al. Hepatitis C virus seroconversion among young injection drug users: Relationships and risks. J Infect Dis. 2002;186:1558–64. doi: 10.1086/345554. [DOI] [PubMed] [Google Scholar]
- 25.Hallinan R, Byrne A, Amin J, Dore GJ. Hepatitis C virus incidence among injecting drug users on opioid replacement therapy. Aust N Z J Public Health. 2004;28:576–78. doi: 10.1111/j.1467-842X.2004.tb00050.x. [DOI] [PubMed] [Google Scholar]
- 26.National Institutes of Health. Final Statement. Washington: National Institutes of Health; 2002. Management of hepatitis C: 2002. [Google Scholar]
- 27.Pollack H, Heimer R. The impact and cost-effectiveness of methadone maintenance treatment in preventing HIV and Hepatitis C. In: Jager J, Limburg W, Kretzschmar M, Postma M, Weissing L, editors. EMCDDA Monographs: Hepatitis C and injecting drug use: impact, costs and policy options. Luxembourg: EMCDDA; 2004. pp. 345–67. [Google Scholar]
- 28.Fischer B, Rehm J, Brissette S, Brochu S, Bruneau J, el-Guebaly N, et al. Illicit opioid use in Canada: Comparing social, health and drug use characteristics of untreated users in five cities (OPICAN study) J Urban Health. 2005;82:250–66. doi: 10.1093/jurban/jti049. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 29.SPSS for Windows [Version] 12, 2005.
- 30.Hagan H. Hepatitis C virus transmission dynamics in injection drug users. Subst Use Misuse. 1998;33:1197–212. doi: 10.3109/10826089809062214. [DOI] [PubMed] [Google Scholar]
- 31.Garfein R, Doherty MC, Monterroso ER, Thomas DL, Nelson K, Vlahov D. Prevalence and incidence of hepatitis C virus infection among young adult injection drug users. J Acquir Immune Defic Syndr Hum Retrovirol. 1998;18:S11–S19. doi: 10.1097/00042560-199802001-00004. [DOI] [PubMed] [Google Scholar]
- 32.Bourgois P, Bruneau J. Needle exchange, HIV infection, and the politics of science: Confronting Canada’s cocaine injection epidemic with participant observation. Med Anthropol. 2000;18:325–50. doi: 10.1080/01459740.2000.9966161. [DOI] [Google Scholar]
- 33.Booth R, Watters J, Chitwood D. HIV risk-related sex behaviors among injection drug users, crack smokers, and injection drug users who smoke crack. Am J Public Health. 1993;83:1144–48. doi: 10.2105/AJPH.83.8.1144. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 34.Gates J, Post J, Kaldor J, Pan Y, Haber P, Lloyd A, et al. Risk factors for hepatitis C infection and perception of antibody status among male prison inmates in the Hepatitis C Incidence and Transmission in Prisons Study Cohort, Australia. J Urban Health. 2004;81:448–52. doi: 10.1093/jurban/jth129. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Sylvestre DL. virus infection in active substance users. Clin Infect Dis. 2005;40(Suppl5):S321–S324. doi: 10.1086/427447. [DOI] [PubMed] [Google Scholar]
- 36.Backmund M, Reimer J, Meyer K, Gerlach JT, Reinhart Z. Hepatitis C virus infection and injection drug users: Prevention, risk factors, and treatment. Clin Infect Dis. 2005;40(Suppl5):S330–S335. doi: 10.1086/427475. [DOI] [PubMed] [Google Scholar]
- 37.Kresina T, Khalsa J, Cesari H, Francis H. Hepatitis C virus infection and substance abuse: Medical management and developing models of integrated care-An introduction. Clin Infect Dis. 2005;40:S259–S262. doi: 10.1086/427438. [DOI] [PubMed] [Google Scholar]
- 38.Mehta S, Cox A, Hoover D, Wang X-H, Mao Q, Ray S, et al. Protection against persistence of hepatitis C. Lancet. 2002;359:1478–83. doi: 10.1016/S0140-6736(02)08435-0. [DOI] [PubMed] [Google Scholar]
- 39.Freeman AJ, Dore GJ, Law MG, Thorpe M, Von OJ, Lloyd AR, et al. Estimating progression to cirrhosis in chronic hepatitis C virus infection. Hepatology. 2001;34:809–16. doi: 10.1053/jhep.2001.27831. [DOI] [PubMed] [Google Scholar]
- 40.Darke S. Self-report among injecting drug users: A review. Drug Alcohol Depend. 1998;51:253–62. doi: 10.1016/S0376-8716(98)00028-3. [DOI] [PubMed] [Google Scholar]
- 41.Hosmer D, Lemeshow S. Applied Logistic Regression. New York, NY: John Wiley and Sons; 1989. [Google Scholar]
- 42.Thorpe LE, Ouellet LJ, Levy JR, Williams IT, Monterroso ER. Hepatitis C virus infection: Prevalence, risk factors, and prevention opportunities among young injection drug users in Chicago, 1997–1999. J Infect Dis. 2000;182:1588–94. doi: 10.1086/317607. [DOI] [PubMed] [Google Scholar]
- 43.Fischer B, Kalousek K, Rehm J, Powis J, Krajden M, Reimer J. Hepatitis C, illicit drug use and public health: Does Canada really have a viable plan? Can J Public Health. 2006;97(6):485–88. doi: 10.1007/BF03405233. [DOI] [PMC free article] [PubMed] [Google Scholar]