| |
More Than 27% of LA Homeless Adults Have Hepatitis C, and Nearly Half Don't Know It - new study
|
| |
| |
Download the PDF here
infectioncontroltoday.com
"26.7% of the sample tested HCV-positive and 4.0% tested HIV-positive......We sampled a community-based probability sample of 534 homeless adults from 41 shelters and meal programs in the Skid Row area of downtown Los Angeles, California......nearly half (46.1%) were unaware of their infection........few had ever received any HCV-related treatment......the strongest independent predictor of HCV infection in this sample was lifetime injection drug use......This and previous studies suggest that U.S. urban homeless adults are at high risk for HCV infection. Findings further suggest that as many as half of those infected with HCV may be unaware of their infection. Homeless adults need interventions that include HCV education, counseling, voluntary testing, and treatment services. HCV prevention and treatment programs could be modeled after successful HIV/AIDS interventions developed for shelters, meal programs, health clinics, substance abuse treatment programs, outreach, and other service programs. If resources are limited, findings suggest that interventions prioritize urban homeless subgroups that are at the highest risk for HCV infection; that is, those with a history of injection drug use, time spent in prison, and multiple tattoos."
Recent government studies show that hepatitis C, which can destroy the liver and necessitate a liver transplant, now kills more American adults than AIDS, and new UCLA research shows just how prevalent the disease is among homeless adults in downtown Los Angeles.
In a study published in the July/August issue of Public Health Reports, researchers found that 26.7 percent of homeless adults tested and surveyed in downtown Los Angeles' skid row were infected with the hepatitis C virus (HCV) Ñ more than 10 times the 2 percent rate among the general U.S. population. Of those surveyed, 46.1 percent were unaware that they were infected. Four percent of the sample were HIV-positive.
Few of the infected homeless adults surveyed had ever received any treatment for their HCV, says Dr. Lillian Gelberg, professor of family medicine at the David Geffen School of Medicine at UCLA, who led the study with Dr. Marjorie Robertson of the Public Health Institute's Alcohol Research Group. Less than 3 percent of those who knew they were infected had ever been treated.
"Their hepatitis C can result in high costs to the public and the healthcare system if progression of their disease is not halted through treatment," says Gelberg, who is also a professor of public health at the UCLA Fielding School of Public Health. "The costs of their untreated hepatitis C may start escalating soon, as many are approaching 20 years of infection, which is the point at which we see escalating risk for liver cirrhosis and end-stage liver disease, requiring expensive health services utilization and liver transplantation."
The study surveyed 534 homeless adults from 41 shelters and meal programs in the skid row area between June 2003 and February 2004. Most were males and the majority were African Americans. Each was tested for hepatitis B and C and for HIV. Overall, the researchers found that HCV prevalence was significantly higher among those homeless individuals who had injected drugs or been in prison; who were 40 years of age and older; who had less education; or who were U.S.-born.
Among the other key findings:
· 20.4 percent of those surveyed had injected illicit drugs; of those, 77.6 percent tested positive for HCV. Among those who had injected drugs, HCV infection was associated with older age and a prison history.
· Among those who never used injection drugs, 13.6 percent had HCV. Infection rates were significantly higher among non-injectors if they were older, had less education, used serious non-injection drugs (excluding marijuana), had three or more tattoos, or had been in prison.
· Overall, after controlling for other factors, sexual behaviors were not significantly related to HCV infection.
There are some limitations to this study. For instance, though HCV infection rates were based on blood tests, many of the other measures used were based on self-reporting, which is subject to recall bias and other errors. In addition, the findings may not be applicable beyond the population and geographic area the researchers studied, though the researchers noted that their sample's demographics were similar to those of other urban homeless populations that have been studied, and rates of IV drug use and HCV among injectors were similar to those of a general homeless sample.
"This and previous studies demonstrate that urban homeless adults in the U.S. are at high risk for HCV infection," the researchers concluded. "About half of those infected with HCV were unaware of their infection status. Homeless adults need interventions that include HCV education, counseling, voluntary testing and treatment services. HCV prevention and treatment programs could be modeled after relevant successful interventions developed for U.S. homeless persons with HIV/AIDS."
Other researchers included Lisa Arangua, Ardis Moe, Ronald M. Andersen, Barbara D. Leake, Gerald Sumner and Adeline Nyamathi, all of UCLA, and Hal Morgenstern of the University of Michigan.
------------------------------------
Prevalence, Distribution, and Correlates
of Hepatitis C Virus Infection Among
Homeless Adults in Los Angeles
ABSTRACT
Objective. We documented the prevalence, distribution, and correlates of hepatitis C virus (HCV) infection among urban homeless adults.
Methods. We sampled a community-based probability sample of 534 homeless adults from 41 shelters and meal programs in the Skid Row area of downtown Los Angeles, California. Participants were interviewed and tested for HCV, hepatitis B, and HIV. Outcomes included prevalence, distribution, and correlates of HCV infection; awareness of HCV positivity; and HCV counseling and treatment history.
Results. Overall, 26.7% of the sample tested HCV-positive and 4.0% tested HIV-positive. In logistic regression analysis, independent predictors of HCV infection for the total sample included older age, less education, prison history, and single- and multiple-drug injection. Among lifetime drug injectors, independent predictors of HCV infection included older age, prison history, and no history of intranasal cocaine use. Among reported non-injectors, predictors of HCV infection included older age, less education, use of non-injection drugs, and three or more tattoos. Sexual behaviors and snorting or smoking drugs had no independent relationship with HCV infection. Among HCV-infected adults, nearly half (46.1%) were unaware of their infection.
Conclusions. Despite the high prevalence of HCV infection, nearly half of the cases were hidden and few had ever received any HCV-related treatment. While injection drug use was the strongest independent predictor, patterns of injection drug use, non-injection drug use, prison stays, and multiple tattoos were also independent predictors of HCV. Findings suggest that urgent interventions are needed to screen, counsel, and treat urban homeless adults for HCV infection.
The hepatitis C virus (HCV) is the most common chronic blood-borne viral infection in the United States. Beginning in 1988-1994,1 the National Health and Nutrition Examination Survey (NHANES), a survey of U.S. households, began estimating prevalence rates for hepatitis C infection in the U.S. general population for those aged 6 years and older. The most recent national prevalence estimate (based on the 1999-2002 NHANES) was 1.6%, or about 4.1 million people.2 The primary identified means of transmission was through injection drug use. Unfortunately, the NHANES excluded large groups at high risk for HCV infection. A recent article suggested that if high-risk groups that were missed or underrepresented in NHANES (i.e., homeless or incarcerated people, Veterans, health-care workers, and those on long-term dialysis)3 had been included, a conservative estimate of HCV in the U.S. would have been somewhat higher, at 2.0% or about 5.2 million people.4,5 These understudied populations that constitute a significant reservoir of HCV infection can provide additional insight into the extent and correlates of HCV infection.
Recent studies suggest that homeless adults in urban areas are at particularly high risk for hepatitis C infection (19%-69%) due to high rates of risky injection drug use.6-13 Unfortunately, these studies have usually been based on convenience, clinical, or subgroup samples, and findings may not generalize beyond the groups studied.14
We documented the prevalence, distribution, and risk factors for HCV infection based on a probability sample of homeless adults. This study fills an important gap in the literature by using a large representative sample of inner-city homeless adults to generate a more accurate estimate of HCV infection in an urban homeless adult population. Further, we documented the high prevalence of "hidden" (i.e., participants were unaware of their infection status) HCV infection in this group and the current unmet need for HCV screening and HCV-specific health services. Findings will inform future intervention and treatment programs aimed at preventing exposure to and transmission of HCV among homeless people and the general population.
HCV prevalence among homeless people in Skid Row
In this representative community-based sample of homeless adults in the Skid Row area of LA, lifetime prevalence of HCV infection was 26.7%. This rate is comparable with lower estimates reported for U.S. homeless adults based on clinical or convenience samples (19%-69%).5,7-9,11- 13,36 However, it contrasts starkly with the 1.6%-2.0% HCV prevalence estimated for the U.S. general population (in part, the high contrast is exaggerated by the younger age range of the NHANES comparison group [those aged 6 years and older], which includes very low-risk young people).2-5
Injection drug use. Consistent with the literature on HCV among general1,37,38 and homeless6 populations,8,10 the strongest independent predictor of HCV infection in this sample was lifetime injection drug use. Similar to the general population,1 other independent predictors of HCV among injectors included older age and prison history. Injectors had a much higher HCV prevalence (77.6%) compared with reported non-injectors in this sample (13.6%), and compared with injectors of similar age in the U.S. general population (58%).2 The rates of injection drug use and HCV among injectors in the sample were similar to those for a general homeless sample.11 However, the rate of injection drug use in this study was lower compared with previous studies of high-risk homeless subsamples.6-10,12,13
"Hidden" hepatitis C and unmet need for treatment
This study documented a high rate of hidden HCV infection among homeless adults. That is, nearly half of homeless adults with HCV infection were unaware of their HCV status. Only half of those with HCV infection had ever been tested for HCV.
The lack of awareness of HCV infection can have serious consequences. First, if individuals do not know their HCV infected status, they can inadvertently infect others. Furthermore, most people exposed to HCV in the U.S. general population develop chronic HCV (85%-95%) and never clear the virus from their systems.49 If unaware of their infections, they will not seek out primary or specialty health care to monitor and treat their HCV, which can lead to long-term risk for serious medical problems (e.g., cirrhosis, end-stage liver disease, liver transplantation, or hepatocellular carcinoma) and even death.5 Because most HCV-infected injectors in this study first used injection drugs 20 or more years ago, the majority may soon need costly medical care.14 Studies are needed to identify barriers to testing and treatment of homeless people and to determine the degree to which early screening and appropriate treatment of HCV infection might reduce serious long-term health problems and costs associated with chronic HCV infection.
Only one-quarter of the sample had ever received any counseling or education about the prevention, consequences, and transmission of HCV. Even among those who correctly knew that they were infected, few had received any HCV-related medical care. These findings demonstrate a clear unmet need for prevention, screening, and treatment interventions among this high-risk population.50,51
Our findings reinforce the recommendation that clinicians screen (i.e., test) homeless adults for HCV, particularly those reporting a history of injection drug use, a prison stay, unspecified hepatitis, or HIV.2 Using the CDC-recommended method for HCV screening,27 only 13% of homeless adults who tested HCV-positive on initial screening with ELISA required the more costly RIBA test for confirmation. Thus, voluntary testing for all homeless adults, especially those at high risk for HCV, should be feasible, even with fiscal constraints.
CONCLUSIONS
This and previous studies suggest that U.S. urban homeless adults are at high risk for HCV infection. Findings further suggest that as many as half of those infected with HCV may be unaware of their infection. Homeless adults need interventions that include HCV education, counseling, voluntary testing, and treatment services. HCV prevention and treatment programs could be modeled after successful HIV/AIDS interventions developed for shelters, meal programs, health clinics, substance abuse treatment programs, outreach, and other service programs. If resources are limited, findings suggest that interventions prioritize urban homeless subgroups that are at the highest risk for HCV infection; that is, those with a history of injection drug use, time spent in prison, and multiple tattoos.
|
|
| |
| |
|
|
|
