Prevalence of human immunodeficiency virus testing in patients with hepatitis B and C infection

HIV testing in patients who are HCV positive: Compliance with CDC guidelines in a large healthcare system

BACKGROUND

There are approximately 300,000 people in the United States who are co-infected with HIV and HCV. Several organizations recommend that individuals who are HCV infected, as well as persons over the age of 13, should be HIV tested. Comorbidities associated with HCV can be reduced with early identification of HIV. Our objective was to determine whether providers routinely followed HIV testing guidelines for patients who tested HCV positive (HCV+).

METHODS

A retrospective chart review was conducted of all patients in primary care at an academic health system from 7/2015-3/2017 who tested HCV+. As part of a primary database, HCV testing data was collected; HIV testing data was abstracted manually. We collected and described the intervals between HCV and HIV tests. To determine associations with HIV testing univariable and multivariable analyses were performed.

RESULTS

We identified 445 patients who tested HCV+: 56.6% were tested for HIV, the mean age was 57 ± 10.9 years, 77% were from the Birth Cohort born 1945-1965 (BC); 61% were male; and 51% were Black/AA. Patients in the BC were more likely to be HIV tested if they were: male (p = 0.019), Black/AA (p<0.001), and had Medicaid (p = 0.005). These differences were not found in the non-BC. Six patients who were tested for both HIV and HCV were found to be newly HIV positive at the time of testing.

CONCLUSION

As demonstrated, providers did not routinely follow CDC recommendations as almost half of the HCV+ patients were not correctly tested for HIV. It is important to emphasize that six persons were tested HIV positive simultaneously with their HCV+ diagnosis. If providers did not follow the CDC guidelines, then these patients may not have been identified. Improvements in EHR clinical decision support tools and provider education can help improve the HIV testing rate among individuals who are HCV+.

The potential impact of routine testing of individuals with HIV indicator diseases in order to prevent late HIV diagnosis

Background

The aim of our work was to evaluate the potential impact of the European policy of testing for HIV all individuals presenting with an indicator disease, to prevent late diagnosis of HIV. We report on a retrospective analysis among individuals diagnosed with HIV to assess whether a history of certain diseases prior to HIV diagnosis was associated with the chance of presenting late for care, and to estimate the proportion of individuals presenting late who could have been diagnosed earlier if tested when the indicator disease was diagnosed.

Methods

We studied a large cohort of individuals newly diagnosed with HIV infection in 13 counselling and testing sites in the Lazio Region, Italy (01/01/2004-30/04/2009). Considered indicator diseases were: viral hepatitis infection (HBV/HCV), sexually transmitted infections, seborrhoeic dermatitis and tuberculosis. Logistic regression analysis was performed to estimate association of occurrence of at least one indicator disease with late HIV diagnosis.

Results

In our analysis, the prevalence of late HIV diagnosis was 51.3% (890/1735). Individuals reporting at least one indicator disease before HIV diagnosis (29% of the study population) had a lower risk of late diagnosis (OR = 0.7; 95%CI: 0.5-0.8) compared to those who did not report a previous indicator disease. 52/890 (5.8%) late presenters were probably already infected at the time the indicator disease was diagnosed, a median of 22.6 months before HIV diagnosis.

Conclusions

Our data suggest that testing for HIV following diagnosis of an indicator disease significantly decreases the probability of late HIV diagnosis. Moreover, for 5.5% of late HIV presenters, diagnosis could have been anticipated if they had been tested when an HIV indicator disease was diagnosed.

However, this strategy for enhancing early HIV diagnosis needs to be complemented by client-centred interventions that aim to increase awareness in people who do not perceive themselves as being at risk for HIV.

Barriers to HIV testing among HIV/AIDS concurrently diagnosed persons in New York City

OBJECTIVES

To assess barriers to human immunodeficiency virus (HIV) testing, health care contacts history, and HIV testing history among patients diagnosed concurrently with HIV and acquired immunodeficiency syndrome (AIDS).

METHODS

We surveyed patients concurrently diagnosed with HIV/AIDS who had participated in the partner notification program of the New York City Department of Health and Mental Hygiene, between January 2008 and December 2008.

RESULTS

The most common reason interviewees volunteered for delaying testing (64%) was that they did not believe they were at risk for HIV. When read a list of potential barriers, 69% of interviewees replied affirmatively that they did not test for HIV because they did not believe they were at risk, and 52% replied affirmatively that they did not test because they thought their behaviors kept them safe from getting HIV. Half of all interviewees reported having insurance during part or all of the year before they were diagnosed with HIV/AIDS, and 70% had at least 1 health care visit in the year before they were diagnosed with HIV/AIDS.

CONCLUSIONS

A lack of perception of risk was the most common reason for not testing for HIV sooner among these concurrently diagnosed patients. The majority of these patients were accessing medical care, indicating that this population could have benefited from routine HIV testing.

High HIV prevalence in male patients with acute hepatitis A in the Rome metropolitan area, Italy 2002-2008

BACKGROUND & AIMS

Several outbreaks of hepatitis A affecting homosexual men have been reported in Europe. However, the prevalence of HIV infection in patients affected by hepatitis A has not been extensively studied and hepatitis A is not considered as an indicator disease for routine HIV testing.

METHODS

We retrospectively analyzed all adult cases of acute hepatitis A, reported by the National Institute of Infectious Disease "L. Spallanzani", Rome-Italy, in 2002-2008. Data on HIV infection were obtained by chart review and cross-linkage with laboratory. Information on exposure to risk factors were collected from the standard questionnaire of the Local Health Unit.

RESULTS

We analyzed a total of 473 cases of hepatitis A, 368 (77.2%) males that accounted for 75% of all reported cases in Rome, aged 25-64 years (same gender distribution). During the study period, we diagnosed a high proportion of cases among male individuals (78%). Among the male patients, HIV serology was available for 203/368 (55.2%). The overall HIV prevalence was 15.2% (56/368); it was significantly associated with same gender sex and was significantly higher than that observed among patients with hepatitis B (4.0%).

CONCLUSIONS

We found a high HIV prevalence, associated with same gender sex, among adult male patients diagnosed with hepatitis A in the period 2002-2008, except for 2006. Our data suggest that in a low incidence area for hepatitis A, with a constant high proportion of cases among male individuals, all individuals with acute hepatitis A should be routinely offered an HIV test.

HIV quality performance measures in a large integrated health care system

HIV quality performance measurements are critical to evaluating a care program's success in areas of testing, access to and retention in care, care processes and outcomes. Kaiser Permanente (KP) provides care to over 8 million Americans and over 19,000 HIV-infected adults. We undertook a quality performance measurement program to assess the care and outcomes for our HIV-positive patient population. We also examined HIV testing practices among our HIV-uninfected patients presenting with a sexually transmitted infection. Our metrics were extracted electronically (encompassing two time periods: July 1, 2005 through June 30, 2006 and the entire calendar year 2007) and did not require any manual data extraction, which was a primary objective of our strategy. For most individual care measures, improvement over time was noted, with 85% or more performance seen on some measures (accessing care and initiating antiretroviral therapy). Opportunities for improvement were identified on other measures, such as diagnosing HIV at an earlier stage of infection, and more consistent Pneumocystis jiroveci pneumonia prophylaxis. Over 90% of our patients on antiretroviral therapy had maximal viral control, along with high median antiretroviral medication adherence. Our results compare favorably to those of other organizations, with a KP HIV mortality rate less than 50% of the overall U.S. rate. These results have implications for improving our care process going forward, as well as for the new U.S. domestic HIV/AIDS Strategy.

A comparison of risk factors for HCV-mono-infection, HIV-mono-infection, and HCV/HIV-co-infection in a community setting

The prevalence of HIV infection in HCV patients is much lower than the prevalence of HCV infection in HIV patients. Whereas the higher prevalence of HCV infection in HIV is clearly related to drug abuse, the reasons for the lower prevalence of HIV infection in HCV patients has not been reported. The prevalence of non-sexual and sexual risk factors associated with acquisition of hepatitis C and HIV were studied in HIV-mono-infected, HCV-mono-infected, and HCV/HIV-co-infected individuals. None of the 114 HCV-mono-infected patients tested positive for HIV and this finding was associated with a significantly lower number of men who have sex with men (MSM) among the HCV-mono-infected subjects than among either the HIV-mono-infected or HCV/HIV-co-infected individuals. Unprotected anal intercourse and sex for money or drugs were reported less often by HCV-mono-infected individuals than by HIV-mono-infected and HCV/HIV-co-infected subjects. Having sex with an intravenous-drug user (IVDU) was reported more frequently by both HCV-mono-infected and HCV/HIV-co-infected individuals than by HIV-mono-infected individuals. Sub-analysis of the group of MSM revealed that IVDU differentiated between HIV-mono-infected and HCV/HIV-co-infected subjects. These results reveal that the lower prevalence of HIV in HCV patients is related to a lower number of MSM in this group and that sex with an IVDU is a surrogate marker for drug abuse related to acquiring HCV but not HIV. The guidelines should include strategies for testing for HCV and HIV in patients with these infections.

A qualitative study among injection drug using women in Rhode Island: attitudes toward testing, treatment, and vaccination for hepatitis and HIV

HIV and hepatitis C virus infection are serious and prevalent health conditions among many women who inject drugs. Qualitative interviews with 20 injection drug using women at a short term drug treatment center in Rhode Island revealed six primary barriers and facilitators for testing and receiving results and treatment for hepatitis and HIV, as well as for hepatitis vaccination. The primary barriers were prioritization of drug use; low level of disease-specific knowledge; stigmatization; accessibility of testing, results and treatment; and psychological factors. The primary facilitator was interest in promoting one's health. Our findings indicate that injection drug using women experience multiple barriers to HIV and hepatitis testing, results, treatment and vaccination. Methods for improving the motivators for health, facilitating infectious disease prevention, and decreasing unnecessary disease complications of injection drug using women need to be utilized. These methods should include strategies that minimize stigma and facilitate accessibility of health care.

National multicenter study of HIV testing and HIV seropositivity in patients with chronic hepatitis C virus infection

BACKGROUND

Although HIV testing is recommended for persons with hepatitis C virus (HCV) infection who are at risk for HIV, little is known about HIV testing in this population.

METHODS

Data were prospectively collected in 4364 HCV-infected patients at 24 Veterans Affairs medical centers across the United States, including demographics, risk factors for HIV infection, and self-reported information on HIV testing.

RESULTS

Overall, 76.8% had been tested for HIV at least once, 14.8% were never tested, 6.6% did not know if they were tested, and 1.8% declined to answer. Multivariable analysis identified injection drug use, needlestick injury, sex with a same-sex partner, a greater number of lifetime sexual partners, and sex with an injection drug user as factors that were independently associated with HIV testing. At least one risk factor for HIV infection was present in 84.5% of the 646 patients who were never HIV tested. Among the 3350 subjects who were tested for HIV, 8.4% were positive, 88.3% were negative, 2.4% did not know the results of their test, and 0.9% declined to answer. Multivariable analysis identified African American and Hispanic race/ethnicity, income < or = 10,000 dollars, sex with a same-sex partner, and sex with an injection drug user as the only variables that were independently associated with HIV seropositivity.

CONCLUSIONS

Although a substantial proportion of HCV-infected patients have been tested for HIV, missed opportunities for early diagnosis of HIV infection exist. Public health strategies to improve HIV testing among patients with chronic HCV infection are needed.

Management of chronic hepatitis C

Hepatitis C virus (HCV) infection is transmitted primarily through percutaneous exposure to blood, and most infections are associated with injection drug use. Progression to chronic HCV occurs in 55% to 86% of infected people, and persistent infection is a major cause of cirrhosis, end stage liver disease, and hepatocellular carcinoma. The detection of HCV antibodies should be performed initially to screen at risk populations. In those who are seropositive, HCV viraemia should be assessed to determine if chronic HCV is present. The HCV genotype should also be determined, as this is the strongest predictor of response to available treatment. A liver biopsy is very often helpful because it can estimate degree of hepatic fibrosis, identify concurrent diseases that might contribute to hepatic injury, and aid in selection of patients for treatment. The decision to start antiviral therapy should take into account potential contraindications to therapy, patient motivation, severity of disease, age, and HCV genotype. Combination therapy with weekly subcutaneous pegylated interferon and daily oral ribavirin is the standard of care for treating patients with chronic HCV.

Impact of chronic viral hepatitis on health-related quality of life in HIV: results from a nationally representative sample

BACKGROUND

Little is known about the health burden of chronic viral hepatitis in HIV-infected patients. We compared health-related quality of life (HRQOL) of patients with HIV and hepatitis C virus (HCV) or HIV and hepatitis B virus (HBV) coinfection to those with HIV monoinfection.

METHODS

Using a nationally representative sample of 1,874 adults with HIV who completed a baseline and two follow-up interviews, we identified those with HIV monoinfection (n = 1,493), HIV-HCV coinfection (n = 279), and HIV-HBV coinfection (n = 122). We measured baseline and change over time scores for physical and mental health (PHS, MHS), overall quality of life (QOL), overall health, and disability days. To identify the independent effect of coinfection, we adjusted for demographic and clinical predictors of HRQOL using multivariable regression.

RESULTS

Despite significant differences in socio-demographic characteristics between groups, there were no differences in the baseline scores for PHS, MHS, overall QOL, overall health, or disability days between groups. The HRQOL did not decline significantly over time for the HIV patients with or without HCV or HBV coinfection. All groups reported similar longitudinal changes in the HRQOL scores for all measures.

CONCLUSIONS

We found no significant differences in disease burden as assessed by a generic HRQOL instrument between patients with HIV monoinfection and HIV-HCV or HIV-HBV coinfection. These data are relevant in counseling coinfected patients regarding the impact of coinfection on HRQOL, and are important in designing clinical trials and conducting cost-effectiveness analyses including this vulnerable cohort.

Peginterferon Alpha/Ribavirin Combination Therapy for the Treatment of Hepatitis C Infection

Chronic infection with the hepatitis C virus is widespread in the United States. This disease is associated with a progression of fibrosis of the liver leading to liver cirrhosis in as many as 20% of cases. The current standard of care for the treatment of chronic hepatitis C infection is combination therapy with pegylated interferon alpha plus ribavirin. In more than 50% of patients, this regimen has been shown to induce a sustained viral response, defined as undetectable hepatitis C viral ribonucleic acid (RNA) for 6 months after the end of treatment. Typically, patients are treated for 24 or 48 weeks. A number of possible adverse events are associated with combination therapy, and patient empowerment through supportive nursing care is critical to facilitating patient adherence to treatment. This article provides an update on information concerning the diagnosis and treatment of chronic hepatitis C infection. This information can be tailored to provide patient-focused assessment, education, and treatment.

Update on Hepatitis B and C Coinfection in HIV

Coinfection with hepatitis B virus (HBV) or hepatitis C virus (HCV) is common in patients with HIV infection. HIV infection and immunosuppression alter the natural history of chronic viral hepatitis, and some patients experience accelerated progression to clinically significant liver disease. Therapies used in the treatment of HBV or HCV monoinfection have been applied to the treatment of HIV-coinfected patients. However, development of viral resistance and lack of virologic response remain significant areas of concern. Timely diagnosis and clinical staging of chronic hepatitis infection are critical in the management of HIV-coinfected patients.