Hepatitis B Infection and Vaccination Among High-Risk Noninjection Drug-Using Women: Baseline Data From the UNITY Study

Hepatitis B testing and vaccination among adults with sexually transmitted infections in a large managed care organization

Data on viral hepatitis B (HBV) testing and vaccination in primary care settings among persons at sexual risk for HBV infection have been sparse. We examined rates and factors associated with HBV serologic testing and vaccination rates in adults infected with sexually transmitted infections. We conducted a retrospective cohort study of adults diagnosed with chlamydia, gonorrhea, or syphilis in Kaiser Permanente Southern California in 2008-2011. The vaccine series initiation was examined in subjects who were tested susceptible. The 90-day hepatitis B surface antigen (HBsAg) testing rate was 28.1% in 15 357 adults. Testing rates increased through the study period. Only 8.8% of patients received both HBsAg and hepatitis B surface antibody tests to determine prior exposure and susceptibility to HBV. Among those who were tested susceptible, 116 (10.6%) subjects initiated the vaccine series. In multivariable logistic regression analysis, the odds of receiving testing was inversely associated with female sex, black race, other/unknown race, or having prespecified chronic comorbidities. In survival analysis, adults aged 25-34 years and ≥55 years were more likely to initiate hepatitis B vaccine series compared with those aged 18-24 years. There are missed opportunities in HBV testing and vaccination in primary care. Implementation of provider decision-making support tools in the electronic medical record system may potentially improve hepatitis B testing and vaccination rates.

Can self-prediction overcome barriers to Hepatitis B vaccination? A randomized controlled trial

OBJECTIVE

Hepatitis B virus (HBV) infection remains a serious public health problem, due in part to low vaccination rates among high-risk adults, many of whom decline vaccination because of barriers such as perceived inconvenience or discomfort. This study evaluates the efficacy of a self-prediction intervention to increase HBV vaccination rates among high-risk adults.

METHOD

Randomized controlled trial of 1,175 adults recruited from three sexually transmitted disease clinics in the United States over 28 months. Participants completed an audio-computer-assisted self-interview, which presented information about HBV infection and vaccination, and measured relevant beliefs, behaviors, and demographics. Half of participants were assigned randomly to a "self-prediction" intervention, asking them to predict their future acceptance of HBV vaccination. The main outcome measure was subsequent vaccination behavior. Other measures included perceived barriers to HBV vaccination, measured prior to the intervention.

RESULTS

There was a significant interaction between the intervention and vaccination barriers, indicating the effect of the intervention differed depending on perceived vaccination barriers. Among high-barriers patients, the intervention significantly increased vaccination acceptance. Among low-barriers patients, the intervention did not influence vaccination acceptance.

CONCLUSIONS

The self-prediction intervention significantly increased vaccination acceptance among "high-barriers" patients, who typically have very low vaccination rates. This brief intervention could be a useful tool in increasing vaccine uptake among high-barriers patients.

A randomized trial of enhanced HIV risk-reduction and vaccine trial education interventions among HIV-negative, high-risk women who use noninjection drugs: the UNITY study

BACKGROUND

Limited data are available on interventions to reduce sexual risk behaviors and increase knowledge of HIV vaccine trial concepts in high-risk populations eligible to participate in HIV vaccine efficacy trials.

METHODS

The UNITY Study was a 2-arm randomized trial to determine the efficacy of enhanced HIV risk-reduction and vaccine trial education interventions to reduce the occurrence of unprotected vaginal sex acts and increase HIV vaccine trial knowledge among 311 HIV-negative noninjection drug using women. The enhanced vaccine education intervention using pictures along with application vignettes and enhanced risk-reduction counseling consisting of 3 one-on-one counseling sessions were compared with standard conditions. Follow-up visits at 1 week and 1, 6, and 12 months after randomization included HIV testing and assessment of outcomes.

RESULTS

During follow-up, the percent of women reporting sexual risk behaviors declined significantly but did not differ significantly by study arm. Knowledge of HIV vaccine trial concepts significantly increased but did not significantly differ by study arm. Concepts about HIV vaccine trials not adequately addressed by either condition included those related to testing a vaccine for both efficacy and safety, guarantees about participation in future vaccine trials, assurances of safety, medical care, and assumptions about any protective effect of a test vaccine.

CONCLUSIONS

Further research is needed to boost educational efforts and strengthen risk-reduction counseling among high-risk noninjection drug using women.

Correlates of anal intercourse vary by partner type among substance-using women: baseline data from the UNITY study

Data are limited about anal intercourse among women at risk of HIV infection. HIV-negative non-injection drug using women at sexual risk (N = 404) were recruited. At baseline, 41.7% reported anal intercourse in the prior 3 months; of these, 88.2% reported unprotected anal intercourse (UAI). Factors associated with UAI varied by partner type: UAI with a steady partner was associated with younger age, depressive symptoms, and experience of battering; UAI with casual partners was associated with younger age, cocaine use and negative outcome expectancies for condom use; UAI with exchange partners was associated with cocaine use, negative outcome expectancies for condom use and depressive symptoms. Younger women were more likely to report unprotected anal intercourse if they did not use birth control. Specific counseling messages are needed to identify and address this risk and associated factors, including partner relationships, substance use, birth control, mental health issues and domestic violence.

The potential role of biomarkers in HIV preventive vaccine trials

BACKGROUND

Successful conduct of HIV vaccine efficacy trials entails identification and enrollment of at-risk populations, assessment of appropriate end points as measures of vaccine efficacy for prevention of HIV acquisition, and amelioration of disease course among infected vaccinees, as well as identification of potential confounders or effect modifiers. Although not invariably useful and bringing their own cost in terms of measurement and validation, a variety of biomarkers may aid at each stage of trial conduct.

METHODS

A review of selected articles, chosen based on quality, relevance of the biomarker to HIV vaccine trials, and availability of the publication, was conducted. The authors also drew experience from current trials and other planned or ongoing trials.

CONCLUSIONS

Biomarkers are available to assess HIV incidence in potential study populations, but care is needed in interpreting results of these assays. During trial conduct, sexually transmitted infections such as herpes simplex virus type 2 may act as effect modifiers on primary and secondary end points, including HIV incidence and set point viral load. The utility of sexually transmitted infection biomarkers will likely depend heavily on local epidemiology at clinical trial sites. Analyses from recent large HIV vaccine efficacy trials point to the complexities in interpreting trial results and underscore the potential utility of biomarkers in evaluating confounding and effect modification.

Chronic hepatitis B in Asian women of childbearing age

Hepatitis B virus (HBV) infection is a serious clinical problem affecting approximately 2 billion people worldwide. An estimated 350 million live with chronic hepatitis B (CHB) infection and are at an increased risk for serious liver sequelae and death from acute or chronic consequences of CHB infection. Individuals with CHB have a 20-30% risk of early death from complications, including liver cirrhosis and hepatocellular carcinoma. In the Asia-Pacific region, half of the CHB burden results from vertical or mother-to-child transmission, with early childhood horizontal transmission accounting for the remaining half. Screening and vaccination are key factors in the successful prevention and control of HBV infection. Over the last 20 years, the implementation of screening programs and universal HBV vaccination for all individuals born in endemic areas have reduced the prevalence of HBV infection and HBV-related liver diseases among individuals younger than 30 years. Women of childbearing age are key stakeholders in preventing HBV infection and, as such, play a critical role in reducing the vertical and horizontal transmission of HBV. Further efforts are needed to implement screening and educational programs for women of childbearing age, particularly those with CHB, to prevent the transmission of HBV to newborns, spouses, other household members, and sexual partners. In addition, healthcare workers need to learn how to avoid iatrogenic transmission in the healthcare setting. This article reviews these issues and highlights areas in which their engagement with public health efforts serves to improve quality of life and society as a whole.

Prevalence of hepatitis B virus and risk factors in Brazilian non-injecting drug users

Non-injecting drug users are at high-risk for acquiring hepatitis B virus (HBV), although the factors contributing to this increased risk are not known. In the present study, the overall and occult HBV infection prevalence rates were determined in a large population of non-injecting drug users in the Central-West region of Brazil. HBV genotypes and predictors of infection were also identified. A total of 852 individuals in 34 drug treatment centers were interviewed, and their serum samples were tested for the presence of HBV markers by ELISA. HBsAg and anti-HBc-positive samples were tested for HBV DNA by PCR. Samples with HBV DNA were genotyped by restriction fragment length polymorphism (RFLP). The overall prevalence of HBV infection was 14% (95% CI: 11.7-16.5). A multivariate analysis of risk factors showed that age >30 years, non-white race/ethnicity, duration of drug use >10 years, lifetime number of sexual partners >10, non-use of condoms, and HCV and HIV status were associated significantly with HBV infection. Of the 9 (1%) HBsAg-reactive samples, HBV DNA was present in 2/2 of HBeAg-positive and in 5/7 anti-HBe-positive samples. An occult HBV infection rate of 2.7% (3/110) was found among anti-HBc-positive individuals. All HBV DNA-positive samples were genotyped: seven were genotype A, two were genotype D, and one was genotype F. Finally, few individuals (8%) had serological evidence of a previous HBV vaccination. These findings indicate that preventive interventions are needed for both sexual and drug-related high-risk behavior. Additionally, non-injecting drug users should be targeted for HBV vaccination.

Positive impact of a shelter-based hepatitis B vaccine program in homeless Baltimore children and adolescents

Homeless youth are at increased risk for hepatitis B virus (HBV) infection and HBV vaccine coverage is poor in this group. The purpose of our study was to determine if a shelter-based HBV vaccine program in children and adolescents 2-18 years of age with a randomized controlled trial using a culturally appropriate HBV video could increase HBV vaccine coverage rates. Subjects were randomized to an 8 min HBV video or a control, smoking prevention video. Before exposure to the videos, HBV knowledge, and demographics were assessed in caregivers and adolescents. HBV vaccine no. 1 was offered to all subjects who did not produce a vaccine record; subsequently, an accurate HBV vaccine history was obtained from medical providers. Subjects were asked to return 1 and 3 months after visit 1, HBV vaccine was offered to all with incomplete coverage, and HBV knowledge was reassessed. There were 328 children and adolescents cared for by 170 caregivers enrolled in the study. One hundred and four had incomplete HBV vaccine coverage. Data are reported for all family units with at least one subject needing vaccine. There were 53 children and adolescents randomized to the HBV video vs. 51 to the smoking video. HBV knowledge scores of caregivers improved at Visit no. 2 vs. no. 1 in the HBV video group (p = 0.01) but not in the smoking group (p = 0.82). Similar results were observed for adolescents in the HBV video group (p = 0.05) but not in the smoking group (p = 0.40). Exposure to the HBV video vs the smoking video had a significant effect on return rates for vaccine at Visit no. 2 (59 vs. 31%; p = 0.05) but not at Visit no. 3 (47 vs. 18%, p = 0.06). The shelter-based vaccine program was very effective in increasing HBV coverage rates in the entire group of 328 children and adolescents enrolled in the study, from 68% coverage at baseline to 85% at the conclusion of the study. We conclude that shelter-based HBV vaccine programs can be highly effective in increasing vaccine coverage rates in older children and adolescents. A brief exposure to a culturally appropriate HBV video improves HBV knowledge and may improve return rates for vaccine.