Viral hepatitis and injection drug use in Appalachian Kentucky: a survey of rural health department clients

Promoting Safe Injection Practices, Substance Use Reduction, Hepatitis C Testing, and Overdose Prevention Among Syringe Service Program Clients Using a Computer-Tailored Intervention: Pilot Randomized Controlled Trial

BACKGROUND

Syringe service programs (SSPs) are safe, highly effective programs for promoting health among people who inject drugs. However, resource limitations prevent the delivery of a full package of prevention services to many clients in need. Computer-tailored interventions may represent a promising approach for providing prevention information to people who inject drugs in resource-constrained settings.

OBJECTIVE

The aim of this paper is to assess the effect of a computer-tailored behavioral intervention, called Hep-Net, on safe injection practices, substance use reduction, overdose prevention, and hepatitis C virus (HCV) testing among SSP clients.

METHODS

Using a social network-based recruitment strategy, we recruited clients of an established SSP in Wisconsin and peers from their social networks. Participants completed a computerized baseline survey and were then randomly assigned to receive the Hep-Net intervention. Components of the intervention included an overall risk synthesis, participants' selection of a behavioral goal, and an individualized risk reduction exercise. Individuals were followed up 3 months later to assess their behavior change. The effect of Hep-Net on receiving an HCV screening test, undergoing Narcan training, reducing the frequency of drug use, and sharing drug equipment was assessed. The individual's readiness to change each behavior was also examined.

RESULTS

From 2014 to 2015, a total of 235 people who injected drugs enrolled into the Hep-Net study. Of these, 64.3% (151/235) completed the follow-up survey 3-6 months postenrollment. Compared with the control group, individuals who received the Hep-Net intervention were more likely to undergo HCV testing (odds ratio [OR] 2.23, 95% CI 1.05-4.74; P=.04) and receive Narcan training (OR 2.25, 95% CI 0.83-6.06; P=.11), and they shared drug equipment less frequently (OR 0.06, 95% CI 0.55-0.65; P<.001). Similarly, individuals who received the intervention were more likely to advance in their stage of readiness to change these 3 behaviors. However, intervention participants did not appear to reduce the frequency of drug use or increase their readiness to reduce drug use more than control participants, despite the fact that the majority of the intervention participants selected this as the primary goal to focus on after participation in the baseline survey.

CONCLUSIONS

Implementing computer-based risk reduction interventions in SSPs may reduce harms associated with the sharing of injection equipment and prevent overdose deaths; however, brief computerized interventions may not be robust enough to overcome the challenges associated with reducing and ceasing drug use when implemented in settings centered on the delivery of prevention services.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02474043; https://clinicaltrials.gov/ct2/show/NCT02474043.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

RR1-10.2196/resprot.4830.

Hepatitis A Outbreaks Associated With the Opioid Epidemic in Kentucky Counties, 2017-2018

Objectives. To describe county-level socioeconomic profiles associated with Kentucky's 2017-2018 hepatitis A outbreak that predominately affected communities affected by the opioid epidemic.Methods. We linked county-level characteristics on socioeconomic and housing variables to counties' hepatitis A rates. Principal component analysis identified county profiles of poverty, education, disability, income inequality, grandparent responsibility, residential instability, and marital status. We used Poisson regression to estimate adjusted relative risks (RRs) and 95% confidence intervals (CIs).Results. Counties with scores reflecting an extremely disadvantaged profile (RR = 1.21; 95% CI = 0.99, 1.48) and greater percentage of nonmarried men, residential instability, and income inequality (RR = 1.15; 95% CI = 0.94, 1.41) had higher hepatitis A rates. Counties with scores reflecting more married adults, residential stability, and lower income inequality despite disability, poverty, and low education (RR = 0.77; 95% CI = 0.59, 1.00) had lower hepatitis A rates. Counties with a higher percentage of workers in the manufacturing industry had slightly lower rates (RR = 0.97; 95% CI = 0.94, 1.00).Conclusions. As expected, impoverished counties had higher hepatitis A rates. Evaluation across the socioeconomic patterns highlighted community-level factors (e.g., residential instability, income inequality, and social structures) that can be collected to augment hepatitis A data surveillance and used to identify higher-risk communities for targeted immunizations.

The opioid and related drug epidemics in rural Appalachia: A systematic review of populations affected, risk factors, and infectious diseases

Background/aims: To examine trends in rural Appalachian opioid and related drug epidemics during the past 10 years, including at-risk populations, substance use shifts and correlates, and associated infections. Methods: We conducted this review in accordance with the Preferred Reporting Items for Systematic Reviews (PRISMA) guidelines. Seven databases were searched for quantitative studies, published between January 2006 and December 2017, of drug use, drug-related mortality, or associated infections in rural Appalachia. Results: Drug-related deaths increased in study states, and a high incidence of polydrug toxicity was noted. Rural substance use was most common among young, white males, with low education levels. A history of depression/anxiety was common among study populations. Prescription opioids were most commonly used, often in conjunction with sedatives. Women emerged as a distinct user subpopulation, with different routes of drug use initiation and drug sources. Injection drug use was accompanied by risky injection behaviors and was associated with hepatitis C. Conclusions: This review can help to inform substance use intervention development and implementation in rural Appalachian populations. Those at highest risk are young, white males who often engage in polysubstance use and have a history of mental health issues. Differences in risk factors among other groups and characteristics of drug use in rural Appalachian populations that are conducive to human immunodeficiency virus (HIV) spread also warrant consideration.

Rural risk environments for hepatitis c among young adults in appalachian kentucky

BACKGROUND

Rural Kentucky is an epicenter of hepatitis C(HCV), especially among young adults who inject drugs. While the Risk Environment Framework (REF) has been used widely to study and address socio-ecological determinants of infectious disease among people who inject drugs (PWID), it has been almost exclusively applied to urban environments. Applying REF to rural environments can enhance our understanding of the drivers of HCV epidemics in these hard-hit areas, and inform the creation and implementation of harm reduction interventions in this local context.

METHODS

Participants were recruited between March and August 2017 via community-based outreach methods (e.g., cookouts, flyers) and peer referral. Individuals who met eligibility criteria (aged 18-35, recently used prescription opioids and/or heroin to get high, lived in one of the 5 target counties) participated indepth, semi-structured interviews. The interview guide was informed by the REF, and covered HCV-related risk behaviors and environmental features that shaped vulnerability to engaging in these behaviors. Interviews were transcribed and analyzed using constructivist grounded-theory methods.

RESULTS

Participants (N=19) described multiple intersecting risk environment features that shaped vulnerability to HCV transmission. Economic decline generated intergenerational poverty, dwindling employment prospects, and diminished social enrichment opportunities that collectively contributed to substance misuse and risky injection practices. Geographic isolation, lack of collective knowledge about HCV transmission risks, scarce harm reduction services, familial poverty, and fear of law enforcement interacted to increase the odds of people injecting in "trap houses" (akin to shooting galleries) or secluded areas, spaces in which they rushed to inject and shared injection equipment. Pervasive stigma was a structural barrier to adopting, expanding, and using harm reduction services.

CONCLUSION

This exploratory study identified features of rural risk environments that may contribute to significant HCV burdens in Appalachian Kentucky. Findings signal the importance of expanding proven harm reduction strategies and anti-stigma interventions tailored to rural contexts.

Hepatitis C Testing Increased Among Baby Boomers Following The 2012 Change To CDC Testing Recommendations

In 2012 the Centers for Disease Control and Prevention recommended routine testing for hepatitis C for people born in the period 1945-65. Until now, the recommendation's impact on hepatitis C screening rates in the United States has not been fully understood. We used an interrupted time series with comparison group design to analyze hepatitis C screening rates in the period 2010-14 among 2.8 million commercially insured adults in the MarketScan database. Hepatitis C screening rates increased yearly between 2010 and 2014, from 1.65 to 2.59 per 100 person-years. A 49 percent increase in screening rates among people born during 1945-65 followed the release of the recommendation, but no such increase was observed among adults born after 1965. The effect among the target population was sustained, and by twenty-four months after the recommendation's release, screening rates had increased 106 percent. We conclude that the hepatitis C testing policy change resulted in significantly increased testing among the target population and may have decreased the magnitude of the hepatitis C epidemic.

Injection drug use, HIV/HCV, and related services in nonurban areas of the United States: A systematic review

BACKGROUND

Injection drug use (IDU) in nonurban areas of the United States is a growing public health concern, but there has been no comprehensive assessment of existing research on injection-related HIV and hepatitis C (HCV) in nonurban communities. We conducted a systematic review to assess the current literature and identify knowledge gaps.

METHODS

We systematically searched six databases for relevant articles published between January 1990 and June 2016 and screened, extracted, and analyzed the resulting data. Studies were included if they reported original findings from the nonurban U.S. related to 1) IDU and its role in HIV/HCV transmission, and/or 2) HIV/HCV services for people who inject drugs (PWID).

RESULTS

Of 2330 studies, 34 from 24 unique research projects in 17 states met inclusion criteria. Despite increasing HCV and high vulnerability to injection-related HIV outbreaks in nonurban areas, only three studies since 2010 recruited and tested PWID for HIV/HCV. Twelve reported on sharing injection equipment but used varying definitions of sharing, and only eight examined correlates of injection risk. Nine studies on syringe access suggest limited access through syringe exchange programs and pharmacies. Only two studies addressed HCV testing, none addressed HIV testing, and three examined behavioral or other interventions.

CONCLUSIONS

Despite growing concern regarding nonurban IDU there are few studies of HIV/HCV and related services for PWID, and the existing literature covers a very limited geographical area. Current research provides minimal insights into any unique factors that influence injection risk and HIV/HCV service provision and utilization among nonurban PWID.

Increases in Acute Hepatitis B Virus Infections - Kentucky, Tennessee, and West Virginia, 2006-2013

As many as 2.2 million persons in the United States are chronically infected with hepatitis B virus (HBV) (1), and approximately 15%-25% of persons with chronic HBV infection will die prematurely from cirrhosis or liver cancer (2). Since 2006, the overall U.S. incidence of acute HBV infection has remained stable; the rate in 2013 was 1.0 case per 100,000 persons (3). Hepatitis B vaccination is highly effective in preventing HBV infection and is recommended for all infants (beginning at birth), all adolescents, and adults at risk for HBV infection (e.g., persons who inject drugs, men who have sexual contact with men, persons infected with human immunodeficiency virus [HIV], and others). Hepatitis B vaccination coverage is low among adults: 2013 National Health Interview Survey data indicated that coverage with ≥3 doses of hepatitis B vaccine was 32.6% for adults aged 19-49 years (4). Injection drug use is a risk factor for both hepatitis C virus (HCV) and HBV. Among young adults in some rural U.S. communities, an increased incidence of HCV infection has been associated with a concurrent increase of injection drug use (5); and recent data indicate an increase of acute HCV infection in the Appalachian region associated with injection drug use (6). Using data from the National Notifiable Diseases Surveillance System (NNDSS) during 2006-2013, CDC assessed the incidence of acute HBV infection in three of the four Appalachian states (Kentucky, Tennessee, and West Virginia) included in the HCV infection study (6). Similar to the increase of HCV infections recently reported, an increase in incident cases of acute HBV infection in these three states has occurred among non-Hispanic whites (whites) aged 30-39 years who reported injection drug use as a common risk factor. Since 2009, cases of acute HBV infection have been reported from more non-urban than urban regions. Evidence-based services to prevent HBV infection are needed.

Epidemiology of Acute Hepatitis B in the United States From Population-Based Surveillance, 2006-2011

BACKGROUND

An estimated 20 000 new hepatitis B virus (HBV) infections occur each year in the United States. We describe the results of enhanced surveillance for acute hepatitis B at 7 federally funded sites over a 6-year period.

METHODS

Health departments in Colorado, Connecticut, Minnesota, Oregon, Tennessee, 34 counties in New York state, and New York City were supported to conduct enhanced, population-based surveillance for acute HBV from 2006 through 2011. Demographic and risk factor data were collected on symptomatic cases using a standardized form. Serum samples from a subset of cases were also obtained for molecular analysis.

RESULTS

In the 6-year period, 2220 acute hepatitis B cases were reported from the 7 sites. For all sites combined, the incidence rate of HBV infection declined by 19%, but in Tennessee incidence increased by 90%, mainly among persons of white race/ethnicity and those aged 40-49 years. Of all reported cases, 66.1% were male, 57.1% were white, 58.4% were aged 30-49 years, and 60.1% were born in the United States. The most common risk factor identified was any drug use, notably in Tennessee; healthcare exposure was also frequently reported. The most common genotype for all reported cases was HBV genotype A (82%).

CONCLUSIONS

Despite an overall decline in HBV infection, attributable to successful vaccination programs, a rise in incident HBV infection related to drug use is an increasing concern in some localities.

Hepatitis C vaccine clinical trials among people who use drugs: potential for participation and involvement in recruitment

Candidate prophylactic HCV vaccines are approaching phase III clinical trial readiness, yet little is known about the potential for participation among target groups or innovative ways to promote enrollment within 'hard-to-reach' populations. This study describes HCV vaccine trial participation willingness among a high-risk sample of people who use drugs and their willingness to assist researchers by promoting the trial among peers. Willingness to participate in and encourage peers' participation in an HCV vaccine trial was assessed among injection and non-injection drug users enrolled in a cohort study in Kentucky using interviewer-administered questionnaires (n=165 and 415, respectively, with willingness to participate assessed among HCV-seronegative participants only). Generalized linear mixed models were used to determine correlates to being "very likely" to participate or encourage participation in a trial. Most reported being likely to participate or encourage participation in a vaccine trial (63% and 87%, respectively). Men were significantly less likely to report willingness to encourage others' participation, while willingness to encourage was higher among lower income, HCV-seropositive, heroin-using, and methamphetamine-using participants. Unemployment, lesser education, receipt of financial support from more peers, and nonmedical prescription drug use were positively associated with willingness to participate. Differential enrollment in HCV vaccine clinical trials by socioeconomic status may occur, underscoring ethical considerations and need for avoiding coercion. Notably, the data suggest that a peer-driven approach to promoting trial participation among people who use drugs could be feasible in this population and that HCV-seropositive individuals and women could be especially instrumental in these efforts.

Association of opioid agonist therapy with lower incidence of hepatitis C virus infection in young adult injection drug users

IMPORTANCE

Injection drug use is the primary mode of transmission for hepatitis C virus (HCV) infection. Prior studies suggest opioid agonist therapy may reduce the incidence of HCV infection among injection drug users; however, little is known about the effects of this therapy in younger users.

OBJECTIVE

To evaluate whether opioid agonist therapy was associated with a lower incidence of HCV infection in a cohort of young adult injection drug users.

DESIGN, SETTING, AND PARTICIPANTS

Observational cohort study conducted from January 3, 2000, through August 21, 2013, with quarterly interviews and blood sampling. We recruited young adult (younger than 30 years) injection drug users who were negative for anti-HCV antibody and/or HCV RNA.

EXPOSURES

Substance use treatment within the past 3 months, including non-opioid agonist forms of treatment, opioid agonist (methadone hydrochloride or buprenorphine hydrochloride) detoxification or maintenance therapy, or no treatment.

MAIN OUTCOMES AND MEASURES

Incident HCV infection documented with a new positive result for HCV RNA and/or HCV antibodies. Cumulative incidence rates (95% CI) of HCV infection were calculated assuming a Poisson distribution. Cox proportional hazards regression models were fit adjusting for age, sex, race, years of injection drug use, homelessness, and incarceration.

RESULTS

Baseline characteristics of the sample (n = 552) included median age of 23 (interquartile range, 20-26) years; 31.9% female; 73.1% white; 39.7% who did not graduate from high school; and 69.2% who were homeless. During the observation period of 680 person-years, 171 incident cases of HCV infection occurred (incidence rate, 25.1 [95% CI, 21.6-29.2] per 100 person-years). The rate ratio was significantly lower for participants who reported recent maintenance opioid agonist therapy (0.31 [95% CI, 0.14-0.65]; P = .001) but not for those who reported recent non-opioid agonist forms of treatment (0.63 [95% CI, 0.37-1.08]; P = .09) or opioid agonist detoxification (1.45 [95% CI, 0.80-2.69]; P = .23). After adjustment for other covariates, maintenance opioid agonist therapy was associated with lower relative hazards for acquiring HCV infection over time (adjusted hazard ratio, 0.39 [95% CI, 0.18-0.87]; P = .02).

CONCLUSIONS AND RELEVANCE

In this cohort of young adult injection drug users, recent maintenance opioid agonist therapy was associated with a lower incidence of HCV infection. Maintenance treatment with methadone or buprenorphine for opioid use disorders may be an important strategy to prevent the spread of HCV infection among young injection drug users.

Higher risk of incident hepatitis C virus among young women who inject drugs compared with young men in association with sexual relationships: a prospective analysis from the UFO Study cohort

BACKGROUND

Female injection drug users (IDUs) may report differences in injection behaviours that put them at greater risk for hepatitis C virus (HCV). Few studies have examined these in association with HCV incidence.

METHODS

Longitudinal data from a cohort of 417 HCV-uninfected IDU aged 30 or younger were analysed. Cox proportional hazards was used to model female sex as a predictor of new HCV infection. General estimating equation (GEE) analysis was used to model female sex as a predictor of HCV-associated risk behaviour prospectively.

RESULTS

Women were significantly more likely than men to become infected with HCV during study follow-up (HR 1.4, p<0.05), and were also more likely than men to report high-risk injecting behaviours, especially in the context of sexual and injecting relationships. Sex differences in injecting behaviours appeared to explain the relationship between sex and HCV infection.

CONCLUSIONS

Young women's riskier injection practices lead to their higher rates of HCV infection. Further study on the impact of intimate partnership on women's risk behaviour is warranted.

Epidemiology of hepatitis C virus in Pennsylvania state prisons, 2004-2012: limitations of 1945-1965 birth cohort screening in correctional settings

OBJECTIVES

We described hepatitis C virus antibody (anti-HCV) prevalence in a state prison system and retrospectively evaluated the case-finding performance of targeted testing of the 1945 to 1965 birth cohort in this population.

METHODS

We used observational data from universal testing of Pennsylvania state prison entrants (June 2004-December 2012) to determine anti-HCV prevalence by birth cohort. We compared anti-HCV prevalence and the burden of anti-HCV in the 1945 to 1965 birth cohort with that in all other birth years.

RESULTS

Anti-HCV prevalence among 101,727 adults entering prison was 18.1%. Prevalence was highest among those born from 1945 to 1965, but most anti-HCV cases were in people born after 1965. Targeted testing of the 1945 to 1965 birth cohort would have identified a decreasing proportion of cases with time.

CONCLUSIONS

HCV is endemic in correctional populations. Targeted testing of the 1945 to 1965 birth cohort would produce a high yield of positive test results but would identify only a minority of cases. We recommend universal anti-HCV screening in correctional settings to allow for maximum case identification, secondary prevention, and treatment of affected prisoners.

Injection drug use and hepatitis C virus infection in young adult injectors: using evidence to inform comprehensive prevention

The hepatitis C virus (HCV) virus epidemic is ongoing in the United States and globally. Incidence rates remain high, especially in young adult injection drug users. New outbreaks of HCV in the United States among young adults, in predominantly suburban and rural areas, have emerged and may be fueling an increase in HCV. This paper discusses some key HCV prevention strategies that to date have not been widely researched or implemented, and wherein future HCV prevention efforts may be focused: (1) reducing sharing of drug preparation equipment; (2) HCV screening, and testing and counseling; (3) risk reduction within injecting relationships; (4) injection cessation and "breaks"; (5) scaled-up needle/syringe distribution, HCV treatment, and vaccines, according to suggestions from mathematical models; and (6) "combination prevention." With ongoing and expanding transmission of HCV, there is little doubt that there is a need for implementing what is in the prevention "toolbox" as well as adding to it. Strong advocacy and resources are needed to overcome challenges to providing the multiple and comprehensive programs that could reduce HCV transmission and associated burden of disease worldwide in people who inject drugs.