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High Rates of HCV, HIV/HCV Coinfection, and Alcohol Abuse in NYC Veterans
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"Prevalence of Hepatitis C and Coinfection With HIV Among United States Veterans in the New York City Metropolitan Area"
The general study message was released in the Fall but here are added details from the publication that are interesting.
The aims of this study were to determine the prevalence of hepatitis C virus (HCV) infection and its risk factors, as well as the prevalence of coinfection with HIV and its risk factors, among patients with confirmed HCV
infection. In a 1-day cross-sectional HCV survey at six Veterans Affairs Medical Centers in the New York City metropolitan area, all 1943 patients undergoing phlebotomy for any reason were asked to be tested for HCV antibody by
enzyme immumoassay (EIA). A total of 1098 patients (57%) agreed to HCV testing, 1016 of whom also completed a questionnaire on demographics and HCV risk factors. All HCV EIA (+) samples were confirmed by HCV RNA and
HCV recombinant immunoblot assay (RIBA) antibody testing and were also tested for HCV viral load, HCV genotype, and antibodies to HIV in a blinded fashion. The prevalence of confirmed HCV infection was 10.6% (95% CI = 8.7-12.4%), and the prevalence of HCV viremia was 8.2% (95% CI = 6.6 -9.8%). The rate of HCV viremia among anti-HCV(+) patients was 77.6%, and HCV
genotype 1 was present in 87.5% of viremic patients. Independent risk factors for HCV infection were injection drug use (OR =35.6, 95% CI =16.9 -75.2), blood exposure during combat (OR =2.6, 95% CI = 1.2-5.7), alcohol abuse (OR = 2.4; 95% CI =1.2- 4.8), and service in the Vietnam era (OR =2.1; 95% CI = 1.0 -4.5). Coinfection with HIV was present in 24.8% of anti-HCV(+) patients.
The only independent risk factor for coinfection was age <50 yr (OR = 3.7, 95% CI =1.1-12.1).
The authors concluded, U.S. veterans who are receiving medical care at VA medical centers in the New York City metropolitan area have a much higher rate of chronic hepatitis C than the general population, with a high frequency of genotype 1. Coinfection with HIV is very common in patients with confirmed HCV infection, and these patients should routinely be offered HIV testing. (Am J Gastroenterol 2002; 97:2071-2078.)
Interestingly, of the 138 individuals who were antibody positive (EIA-3) 65% had chronic HCV (HCV-RNA+), the authors characterized 18.8% as HCV resolved (not chronic, HCV-RNA negative and RIBA+), and a relatively high rate (15.9%) of false positive EIA (HCV-RNA negative and RIBA-). Of the all confirmed 116 anti-HCV+ individuals, 77.6% had chroniv HCV (HCV-RNA+). Coinfectiion rates were higher at urban VAMCs than at suburban VAMCs (28.6% vs 8.7%): 35% in Brooklyn, 33% in the Bronx, 21.9% in New York, 11% in NJ, 7.7% in Northport LI, and 6.7% in Hudson Valley.
The present study found an HCV EIA(+) rate of 12.6% among U.S. veterans in the New York City area, the highest among all VA regions. The true prevalence of HCV infection (i.e., confirmed positivity for anti-HCV), was 10.6%. This is substantially higher than the rate of 1.8% found in the general U.S. population.
The majority of anti-HCV(+) patients (56%) were unaware of their diagnosis. Chronic HCV viremia was present in 8.2% of patients, indicating that a large number of VA patients in the New York City metropolitan area are at risk for progressive liver disease from hepatitis C.
The 1-day cross-sectional method of identifying patients for this survey is not without potential bias, because patients who undergo phlebotomy for diagnostic tests may have a higher morbidity (including from HCV and HIV infection) than patients with infrequent or no blood drawing. However,
in this study only a small proportion of patients were referred from gastroenterology, infectious diseases, and substance abuse clinics (9.9% total), where higher rates of hepatitis C are expected. The rates of HCV infection were obtained from U.S. veterans who received health care at a VAMC in the New York City region and who agreed to be tested. The authors added that these data cannot be extrapolated to other veterans networks, to all U.S. veterans receiving care at VA facilities, or to U.S. veterans in general.
Service in the Vietnam era may be a marker for undisclosed injection
drug use as well. Vietnam veterans commonly engaged in substance abuse, including injection drug use, especially those who experience chronic posttraumatic stress disorder. By contrast, U.S. veterans with posttraumatic stress disorder from other combat theaters (World War II, Korea) commonly developed alcoholism but rarely other substance abuse. Exposure to blood during combat may have served as a direct mode of transmission, as HCV viremia was found in U.S. servicemen as early as 1948-1954 (25). Recently, the U.S. Department of Veterans Affairs has added "Vietnam-era veteran" to the risk factors that should prompt VA clinicians to test patients for anti-HCV.
Among veterans with chronic hepatitis C in this study, alcohol abuse was very common (53.4%), placing the ma-jority of these patients at high risk for progressive liver disease.
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