Back HCV Epidemiology More than a Quarter of Homeless People in Los Angeles May Have Hepatitis C

More than a Quarter of Homeless People in Los Angeles May Have Hepatitis C

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As many as 1 in 4 homeless adults in the Skid Row area of downtown Los Angeles may be infected with hepatitis C virus (HCV), researchers reported in the July-August 2012 issue of Public Health Reports.

The most recent national hepatitis C prevalence estimate, based on the 1999-2002 National Health and Nutrition Examination Survey, indicated that 1.6% of the general population, or 4.1 million people, have HCV. But experts believe the true number is likely to be larger because some uncounted populations -- including prisoners, military personnel, and homeless people -- have higher rates.

Lillian Gelbergfrom the University of California at Los Angeles and colleagues analyzed the prevalence, distribution, and risk factors associated with HCV infection ina community-based probability sample of 534 homeless people at 41 Skid Row shelters and meal programs.

Between June 2003 and February 2004 the researchers recruited English-speaking adults who were homeless the previous night -- that is, they reported sleeping in a shelter or on the streets. Most (74%) were men, 80% were black, 90% were born in the U.S., and the average age was 46 years. About 70% reported chronic homelessness; approximately one-third reported depression, alcohol dependence, and/or drug dependence. More than a quarter (28%) reported ever being in prison and 19% had spent time in a psychiatric hospital.

Participants were interviewed and tested for HCV, hepatitis B virus (HBV), and HIV. They were paid $30 for their time and were given an appointment to receive their results 1 week later; they could also get results from a toll-free phone line. Those testing positive were referred for follow-up medical care.

Results

  • Overall, 27% of study participants tested positive for HCV.
  • 5% of this group had ALT levels at least twice the upper limit of normal, suggesting active liver disease.
  • 4% tested HIV positive.
  • 0.7% were coinfected with both HCV and HIV; 18% of people with HIV also had HCV, while 3% with hepatitis C also had HIV.
  • Among people who tested positive for HCV, nearly half (46%) were previously unaware of their status.
  • Looking at HCV risk factors, 20% of the study sample reported ever injecting drugs, 11% had 3 or more tattoos, and less than 10% reported receiving a blood transfusion before screening was instituted in 1990.
  • 60% of people testing positive for HCV reported ever injecting drugs, and 78% of injectors had HCV (compared with 14% of non-injectors), making this the strongest predictor of infection.
  • In a multivariate analysis, independent predictors of HCV infection included older age, less education, prison history, and injection drug use.
  • Among the subgroup of people with a history of drug injection, other independent predictors included older age, prison history, and lack of intranasal cocaine use.
  • Among the non-injecting subgroup, independent predictors included older age, less education, use of non-injection drugs, and having 3 or more tattoos.
  • Sexual behavior and snorting or smoking drugs were not independently associated with higher likelihood of HCV infection.

"Despite the high prevalence of HCV infection, nearly half of the cases were hidden and few had ever received any HCV-related treatment," the study authors concluded. "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."

"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," they elaborated in their discussion. "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."

"These findings demonstrate a clear unmet need for prevention, screening, and treatment interventions among this high-risk population," they recommended. "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."

6/19/12

Reference

L Gelberg, M Robertson, L Arangua, et al. Prevalence, Distribution, and Correlates of Hepatitis C Virus Infection among Homeless Adults in Los Angeles. Public Health Reports127:407-421. July-August 2012.