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75% HCV/HIV Coinfection Rates in SF Homeless- few treated
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"S.F.'s homeless with HIV plagued by hepatitis C virus -- few treated"
Carl T. Hall,
San Francisco Chronicle
April 2, 2004
About 3 out of 4 HIV-positive homeless or "marginally housed" people in San Francisco also harbor the virus that causes chronic hepatitis C disease, and nearly none of them is being treated for it, a new study has found.
The study, by doctors at UCSF and San Francisco General Hospital, is among the first to document how widespread hepatitis C infections have become among the HIV-positive urban poor. Results suggest that the indigent are a cauldron of co-infections, by all accounts a widely ignored problem that promises to significantly complicate the fight against AIDS among San Francisco's down and out.
Hepatitis C tends to make the AIDS virus even more dangerous and difficult to treat. One reason: HCV, as the hepatitis C microbe is known, can seriously impair liver function, increasing the risk of toxic side effects from AIDS medications.
In the study, doctors tested and interviewed 249 HIV-positive people recruited from shelters, soup kitchens and single-room-occupancy hotels. The tests showed that 69 percent were positive for the hepatitis C virus. After nearly three years of follow-up, the figure had risen to 74 percent. Yet only about 4 percent of those infected were being treated.
The results appear today in the Journal of General Internal Medicine.
Dr. Christopher Hall, a fellow in infectious diseases at UCSF and lead author of the new study, said the situation is undoubtedly worse in other big cities that lack San Francisco's public-health system and that may be paying even less heed to what has been called a hidden epidemic.
Public health implications reach far beyond San Francisco's homeless shelters and single-room-occupancy hotels.
"It's a reservoir. It's there,'' Hall said. "Theoretically at least, there's more of a potential for the spread of infection than you would have if you were more aggressive about treating this population."
The new study did not set out to identify how many of those infected with the hepatitis C virus actually needed treatment, although the study's authors said the number was surely much higher than what was found.
Because of their HIV status, all the study participants qualified for free care through San Francisco's well-regarded public-health system. But Hall said the system has yet to focus seriously on the growing problem of HIV- hepatitis C co-infections.
"There is a profound lack of treatment," he said. "That's the big surprise. Had we looked at a population that was out of the health care loop, that lack of treatment would be more intuitive."
Hepatitis C, the leading cause of liver transplants, is a blood-borne virus estimated to infect 4 million people in the United States -- about four times as many as are infected with HIV. It is almost always contracted through blood contact, such as from sharing needles and other drug paraphernalia.
About 15 percent of those exposed manage to clear the virus with their own immune systems. Most of the remainder suffer no serious symptoms for years or even decades. Chronic, sometimes life-threatening liver disease occurs in about 70 percent of chronic infections, according to the U.S. Centers for Disease Control and Prevention.
Treatment has been shown to work about half the time, somewhat less for those co-infected with HIV. But treatment is expensive, and because of the unpredictable side effects, patients must be closely monitored. Standard recommended treatment includes weekly injections of interferon drugs for up to 18 months, along with a regimen of anti-viral pills.
The study's senior author, Dr. David Bangsberg, an associate professor at UCSF and director of San Francisco General's Epidemiology and Prevention Interventions Center, said the results document longtime indifference to chronic liver disease in the poorest of the urban poor.
A new effort has begun at S.F. General to address this problem, he noted, but it's too soon for results to become evident on the streets. "One of the broader issues here is that this city has done a great job making sure everyone, regardless of housing status and income, is getting high-quality care for HIV. The city has not done the same in making sure there's access to treatment for HCV," Bangsberg said.
Even when HIV patients are found to carry antibodies to the hepatitis virus, which indicates exposure, problems arise during follow-up.
First, patients must find their way to a primary care provider. If hepatitis C is found, they need referral to a subspecialist for evaluation, followed by a liver biopsy to stage the disease and make a decision as to what treatment is needed. Then it's a wait for test results, followed by the weekly injections for those prescribed medications.
"For each of these steps," Bangsberg said, "you lose people along the way. "
Meanwhile, the hepatitis C virus has ample opportunity to spread.
The San Francisco researchers found that 64 percent of those in the study had used intravenous drugs at some point. About 21 percent had injected within the previous month.
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