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Hepatitis C testing and treatment uptake among young people who use opioids in New York City: A cross-sectional study
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03 November 2020
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we found a high HCV antibody prevalence among PWID and substantial gaps in the HCV testing and treatment cascade that have persisted despite the development of highly effective and well-tolerated direct-acting antiviral treatment. New York State, like other jurisdictions, has committed to ending the HCV epidemic by reducing incidence and treating prevalent disease.26 Our findings underscore some of the challenges that public health programmes will need to overcome to achieve this goal.
All 539 participants received rapid HCV antibody testing in the study. A total of 105 participants (19.5%) had a positive HCV antibody test and all of these were PWID. Hence, the prevalence among the 353 PWID was 29.7%. When adjusted for RDS sampling, the estimated prevalence of HCV antibody positivity was 17.7% for the overall sample and 25.3% among PWID.
Participants who had never been tested reported their perceived barriers to HCV testing (69 PWID and 100 non-PWID). The most frequently identified barrier was “Don't think you are at risk” (39% of PWID, 65% of non-PWID). 19% of PWID were “Afraid of finding out you have HCV,” but only 3% of non-PWID were worried about this. Other common barriers were participants feeling they “didn't have time” (14% of PWID, 16% of non-PWID) and who were “afraid of losing their job, housing or insurance if they tested positive” (9% of PWID, 12% of non-PWID).
The association of US-born status with receipt of testing was an unexpected finding of this analysis. Of the non-US-born individuals, the majority had emigrated from former Soviet Union countries in Eastern Europe. Previous research from New York City has shown high levels of stigma, limited engagement with health services and a low perception of risk related to HCV or HIV among young people who use opioids in the Russian-speaking immigrant community.50, 51 Because of low numbers, we were not able to determine associations for different regions of origin. The uptake of HCV testing may be different across immigrant communities, because there is significant variation in the injection risk behaviours of these communities in the United States..52
A critical strategy for preventing new HCV infections is reducing community prevalence by treating current PWID or “treatment as prevention”.45 The care continuum reported in this study shows a higher proportion of individuals who started HCV treatment than other studies of young PWID, but still shows significant gaps in linkage to care and in treatment initiation.46, 47 The current study reflects data from early in the direct-acting antiviral era; more individuals may have engaged in care since that time due to increasing availability of treatment. Early restrictions by Medicaid programmes (including New York) may also have restricted access by limiting reimbursement for people who currently used drugs, but these restrictions have been lifted over time.48 Despite that, the structural factors that inhibit this age group from seeking care are likely to be persistent in the US healthcare system. Low-threshold models that offer care in a destigmatized environment and reduce financial and logistical steps may promote treatment uptake. Our team is studying one such model in a clinical trial recruiting young HCV-infected PWID in New York City that is currently ongoing.49
In conclusion, we show that gaps in HCV testing remain among young people who use drugs in New York City, though PWID have higher rates of testing than people who do not inject. We also show that longer duration of injection experience and substance use treatment engagement are associated with testing, suggesting a need to improve our capacity to test those who have recently transitioned to injection and PWID who are not yet engaged with programmes. Finally, similar to other cohorts, we show gaps in treatment linkage and uptake, suggesting that interventions to promote HCV treatment among this population may enhance HCV elimination efforts.
Abstract
Young people who use drugs have a rising hepatitis C (HCV) incidence in the United States, but they may face barriers to testing and treatment adoption due to stigma.
We conducted a cross-sectional study of New York City residents aged 18-29 years who reported non-medical prescription opioid and/or heroin use in the past 30 days.
Participants were recruited from the community between 2014-2016 via respondent-driven sampling. Participants completed an in-person structured survey that included questions about HCV testing and treatment and received HCV antibody testing.
There were 539 respondents: 353 people who inject drugs (PWID) and 186 non-PWID.
For PWID, median age was 25 years, 65% were male and 73% non-Hispanic White. For non-PWID, median age was 23 years, 73% were male and 39% non-Hispanic White.
20% of PWID and 54% of non-PWID had never been tested for HCV (P < .001). Years since first injection (aOR 1.16, CI: 1.02-1.32, P = .02) and history of substance use treatment (aOR 3.17, CI: 1.53-6.61, P = .02) were associated with prior testing among PWID.
The seroprevalence of HCV among PWID was 25%, adjusted for sampling weights.
Of the 75 who were aware of their HCV-positive status, 53% had received HCV-related medical care, and 28% had initiated treatment.
HCV prevalence among young PWID is high, and many have never been tested.
Injection experience and treatment engagement is associated with testing. Interventions to increase testing earlier in injection careers, and to improve linkage to HCV treatment, will be critical for young PWID.
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many barriers to HCV testing and treatment remain. People who use drugs face immense stigma within the healthcare system, and because of this, may not access care or disclose drug use behaviours.12 Due to the same stigma, providers may not ask about drug use, or they may be reluctant to offer treatment to this population.13, 14 Young people may not perceive HCV as being severe. Knowledge about HCV and its complications is limited among young PWID.15 Various studies have described the infection as being normalized among PWID, seen as inevitable, and even as a part of identity for people who inject.16, 17 Medical providers, who know that the health effects of HCV are often decades away, may also diminish the urgency of testing or treatment, especially when HCV co-exists with more immediate risks such as HIV or overdose.16, 17 Some insurance plans may restrict reimbursement for treatment if patients are currently using drugs, further limiting access.18
Given the factors described above, young people's trajectory of HCV care may be changing. There are few studies in the current era of HCV treatment which focus on the critical population of young people who use opioids. The goal of this research is to describe the patterns of HCV testing and treatment among young people who use opioids in New York City.
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In this cohort of young people who use opioids, we found a high HCV antibody prevalence among PWID and substantial gaps in the HCV testing and treatment cascade that have persisted despite the development of highly effective and well-tolerated direct-acting antiviral treatment. New York State, like other jurisdictions, has committed to ending the HCV epidemic by reducing incidence and treating prevalent disease.26 Our findings underscore some of the challenges that public health programmes will need to overcome to achieve this goal. The prevalence of HCV antibody estimated from our high-risk sample is higher than the overall prevalence of chronic hepatitis C in New York City (estimated at 1.4% in 2018), and within the range of past reports of seroprevalence in young PWID nationally, where estimates vary from 10% to 53% depending on the cohort.7, 27-29
We show that young PWID are more likely to be tested than people who have used opioids but never injected. This expected finding is in line with medical society recommendations about HCV testing at the time of the study, which prioritized testing for PWID. The Centers for Disease Control and Prevention's 2012 guidelines state that people who use drugs by snorting or sniffing may be at increased risk, whereas the Association for the Study of Liver Disease and Infectious Diseases Society of America's joint guidelines recommend at least one-time testing for people who use drugs intranasally.30, 31 One practical consideration is that individuals may not disclose injection practices in healthcare settings as a means to avoid stigma, preventing clinicians from accurately differentiating these risk groups.12 Additionally, people who misuse prescription opioids are also at increased risk of subsequently injecting drugs.32-34 Data from the current study show that individuals who report injecting drugs reported initiating injection an average of 4 years after starting non-injection opioid misuse.19 While the diagnostic value of screening may be lower in people who have never injected when compared to PWID, this is a critical population to keep engaged in prevention efforts, because of the risk of future transition to injection drug use. Routine screening, informing patients of their HCV status and normalizing conversations about HCV risk reduction may play an important part in prevention education—similar to approaches taken to prevent HIV.35, 36
Among PWID, while most individuals had been tested within the past year, gaps in testing continue to exist. Factors associated with increased likelihood of being tested include greater injection experience and engagement with substance use treatment programmes. HCV testing was also associated with syringe service programme use, but this association was not significant after adjustment. These associations are not surprising, as increased time and engagement with programmes would lead to additional opportunities to be offered testing. Despite relatively high availability of these services in New York City, individuals who have only recently begun injecting may not yet be connected to testing.37 Previously published data from the same population showed an average of 3 years from initiating drug use to entering a substance use treatment programme, during which time they are at risk for acquiring HCV and may inadvertently transmit HCV to others.19 Additionally, not all treatment or harm reduction programmes offer testing. In 2018, only 10% of New York City syringe service programme clients were screened onsite for viral hepatitis, and national data suggest that fewer than half of substance use treatment programmes offer HCV testing.38, 39 The reasons for low-uptake of HCV testing at these programmes are myriad, but potential barriers may include lack of funding, inability to conduct phlebotomy, and the need to train staff.40, 41 The low availability of testing in these settings is a missed opportunity for diagnosis of HCV in high-risk populations.
In addition to making testing more available, other approaches can engage individuals who are not yet connected to substance use-related services. The United States Preventive Services task force recently recommended one-time testing in all adults regardless of birth cohort or risk.42 This approach might encourage testing during routine clinical encounters, even when drug use behaviours are not disclosed. The social networks in which people inject can be leveraged to increase the reach of service delivery. PWID who are engaged with services often help educate and connect their peers—these individuals can be empowered to encourage HCV testing.43, 44 Public health agencies can extend their reach by implementing contact tracing, in which injection partners of newly infected individuals are offered testing, but these services need to be implemented without fear of criminalization or stigma.9 Educational initiatives may also be effective, but to maximize impact, these would need to successfully reach individuals not currently engaged with programmes.
A critical strategy for preventing new HCV infections is reducing community prevalence by treating current PWID or “treatment as prevention”.45 The care continuum reported in this study shows a higher proportion of individuals who started HCV treatment than other studies of young PWID, but still shows significant gaps in linkage to care and in treatment initiation.46, 47 The current study reflects data from early in the direct-acting antiviral era; more individuals may have engaged in care since that time due to increasing availability of treatment. Early restrictions by Medicaid programmes (including New York) may also have restricted access by limiting reimbursement for people who currently used drugs, but these restrictions have been lifted over time.48 Despite that, the structural factors that inhibit this age group from seeking care are likely to be persistent in the US healthcare system. Low-threshold models that offer care in a destigmatized environment and reduce financial and logistical steps may promote treatment uptake. Our team is studying one such model in a clinical trial recruiting young HCV-infected PWID in New York City that is currently ongoing.49
The association of US-born status with receipt of testing was an unexpected finding of this analysis. Of the non-US-born individuals, the majority had emigrated from former Soviet Union countries in Eastern Europe. Previous research from New York City has shown high levels of stigma, limited engagement with health services and a low perception of risk related to HCV or HIV among young people who use opioids in the Russian-speaking immigrant community.50, 51 Because of low numbers, we were not able to determine associations for different regions of origin. The uptake of HCV testing may be different across immigrant communities, because there is significant variation in the injection risk behaviours of these communities in the United States..52
In conclusion, we show that gaps in HCV testing remain among young people who use drugs in New York City, though PWID have higher rates of testing than people who do not inject. We also show that longer duration of injection experience and substance use treatment engagement are associated with testing, suggesting a need to improve our capacity to test those who have recently transitioned to injection and PWID who are not yet engaged with programmes. Finally, similar to other cohorts, we show gaps in treatment linkage and uptake, suggesting that interventions to promote HCV treatment among this population may enhance HCV elimination efforts.
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