| |
Women and HCV
|
| |
| |
This study (American Journal of Epidemiology, 155 (7), 645-53, April 1, 2002)
demonstrates women in urban areas tend to have higher rates of HCV and engage
in certain risky behaviors. The likelihood of having HCV tended to increase
for women who use IV drugs and have sex for money/drugs. The study found
women with HSV-2 (suggesting this could also be true for syphillis & other
STDs) may have higher risk for getting HCV. Women with low income appear to
be more likely to engage in these risky behaviors. This study found that
African-Americans were more likely to engage in these baviors and to have
HCV. An HCV prevention program should be launched to target these women.
The study authors (Kimberly Page-Shafer, University of California-SF)
evaluated risk for hepatitis C virus (HCV) infection in women residing in
low-income neighborhoods of northern California. A sample of 1707 women, aged
18 to 29, were surveyed and screened for sexually transmitted infections and
HCV. Women infected with HCV (2.5%) were more likely to have a history of
injection and noninjection drug use, to exchange sex for money or drugs, and
to have sexually transmitted infections. 1.8% of the US general population
are HCV-infected. And its unofficially estimated that the rate for women is
<1%. HCV was independently associated with history of injection drug use,
herpes simplex virus type 2 (HSV-2) infection, and heroin and cocaine use.
Injection drug use is the highest risk exposure for HCV, but HSV-2 and
noninjection drug use contribute significantly to increased risk. HCV
prevention programs in impoverished areas should integrate drug treatment and
sexually transmitted infection control.
Sexual Transmission
High rates of sexually transmitted infections and HCV coinfection among IDUs
suggest that ulcerative or nonulcerative urogenital infections may be
cofactors for HCV transmission. However, investigation of sexually
transmitted infections as potential cofactors for sexual transmission of HCV
is hampered by the confounding effects of concomitant high-risk sexual
behavior and injection practices.18 Lack of data on the determinants of
sexual transmission of HCV has limited the development of guidelines for
sexual partners who may be at risk for transmitting or acquiring HCV.
The current study examined HCV in the Young Women's Survey, a
population-based sample of young women recruited in low income, multiethnic
neighborhoods of northern California. Analysis focused on sexual behavior and
sexually transmitted infections as risk factors for HCV and their associated
population attributable fractions. The Young Women's Survey was a
single-stage, cluster-sample, population-based, door-to-door, cross-sectional
survey designed to measure the prevalence of HIV, sexually transmitted
diseases, and related risk behavior in young, low-income women in northern
California.
RESULTS
The population-based estimate of HCV prevalence among women aged 18 to 29
years in low-income neighborhoods of the 4-county target area was 2.5%. More
than a third (39.2%) of the subjects were African American, 31.9% were
Latina, 15.4% were White, 6.7% were Asian or Pacific Islander, and 6.7%
indicated other or mixed race/ethnicity. Most women (70.5%) were born in the
United States; 16.9% were born in Mexico, and 12.5% were born in other
countries. The median age was 23.9 years.
The prevalence of HCV varied significantly by county of residence, income
level, and race/ethnicity. HCV prevalence was highest in the 2 most urban
counties: San Francisco (4.3%) and Alameda (3.8%). HCV prevalence increased
with decreasing income, reaching 5.1% among women in the lowest income
category (< $500 per month). By race/ethnicity, HCV prevalence was highest
among African Americans (4.0%).
Prevalence of HCV was significantly higher among women with serologic markers
for infection with syphilis (18.3%), HSV-2 (4.2%), HBV (8.3%), and HIV
(63.5%). Prevalence of HCV increased with increasing number of lifetime male
sexual partners, from 0.4% among women with 1 partner to 3.9% among women
with 5 or more partners.
Other sexual risk behaviors associated with increased HCV prevalence were sex
with an IDU (12.6%), exchange sex (trading sex for money, drugs, or other
needs) (13.6%), and ever having anal sex.
Having had sex while high on alcohol increased likelihood of women having HCV
by 2.6 times. HCV prevalence was significantly higher among women reporting
use of amphetamine, cocaine, or heroin compared with women not using these
drugs. For each of these drugs, HCV prevalence was higher among those
reporting injecting compared with those not injecting.
The strongest independent associations with HCV infection were history of
injection drug use (OR = 4.9), serological evidence of HSV-2 infection (OR =
3.7), any use of heroin (OR = 5.6), any use of cocaine (OR = 3.40, and very
low income (for income < $500 per month OR= 4.2). Sexual risk behavior did
not reach statistical significance in the model. African American women were
most likely to have HSV-2 infection, to have lower income, and to report a
history of trading sex for drugs or money and thus were at highest risk for
HCV infection. The adjusted odds ratio for HCV infection associated with HIV
infection was 7.5.
Discussion by Authors
The 2.5% prevalence of HCV infection in this population-based survey of
young, lowincome women was higher than that reported in a national sample of
women, in which prevalence was of 1.2% overall1 and 0.6% among women aged 20
to 29 years (M. Alter, PhD, personal communication, 2000). HCV infection was
most highly associated with a history of injection drug use, although
noninjection use of heroin and cocaine persisted as independent risk factors.
HCV transmission has been hypothesized to occur through sharing of straws or
other devices that deliver the virus to hyperemic and traumatized nasal
mucosa. Very low income was the strongest socioeconomic correlate of HCV
infection. Of particular note, HSV-2 infection was independently associated
with HCV infection.
The independent association of anti-HCV with HSV-2 infection suggests a
possible cofactor for sexual transmission or acquisition of HCV. As has been
hypothesized with HIV, HSV-2 infection may serve to increase the efficiency
of sexual acquisition of HCV infection through enhanced viral reproduction or
by providing a portal of entry through ulceration or inflammation. The
cross-sectional design of this study, however, precludes confirmation of this
hypothesis and limits causal inference.
A similar association between HCV and HSV-2 was shown in a study of
heterosexual couples who were HCV serodiscordant.24 Alter et al.1 found that
HCV infection was associated with HSV-2 infection in the National Health and
Nutrition Examination Survey III study in analyses controlling for age but
not for drug use and high-risk sexual behaviors. Similarly, in a recent study
among drug users in treatment, Hwang et al.25 found no association between
HCV and HSV-2 after controlling for the confounding effects of injection
history and sexual risk.
Despite study limitations, our data provide rare population-based estimates
of HCV prevalence and related risk factors among young, low-income women.
Understanding the epidemiology of HCV infection among women in low-income
neighborhoods is a critical first step in designing primary and secondary
interventions to mitigate the morbidity and mortality of this emerging
infection. The growing evidence linking HSV-2 to HIV and HBV1517,29 points
to a potential role for HSV-2 as a cofactor in sexual transmission of HCV as
well. Strong empirical evidence supports the efficacy of sexually transmitted
infection control as a means of reducing HIV risk through clinical and
behavioral intervention.15 Prevention of sexual transmission of HCV should be
considered from a similar public health perspective. Although the per-contact
likelihood of HCV transmission may be lower than through syringe sharing, a
large and growing pool of carriers may generate significant numbers of new
infections through sexual intercourse. Because many of the risk factors
responsible for HCV infection are also related to risk of other adverse
health outcomes, public health efforts aimed at reducing drug use and sexual
risk vulnerability in very-low-income women should have multiple positive
results.
| |
| |
| |
|
|
|
