Abstract
OBJECTIVE: To measure Hepatitis C Virus (HCV) prevalence, incidence, and initiation of HCV therapy in a representative HIV-infected cohort of the urban poor.
DESIGN: Cohort analysis.
SETTING: The Research and Access to Care for the Homeless (REACH) Cohort is a systematic sample of HIV-infected marginally housed individuals identified from single-room occupancy hotels, homeless shelters, and free lunch programs in San Francisco.
PARTICIPANTS: Two hundred forty-nine participants with 28.9 months (median) of follow-up were studied. Mean age was 44 (range 24 to 75, standard deviation ±8.4) years. Eighty-two percent were male, 43% were African-American, 64% were lifetime injection drug users, and 24% had been on the street or in a shelter in the prior month.
INTERVENTIONS: We measured HCV testing and treatment history with structured interviews; additionally, participants were tested for HCV antibodies (EIA-2) with RNA viral load confirmation.
MAIN RESULTS: At baseline, 172 (69.1%) were HCV-positive and 182 (73.1%) were HCV-positive at follow-up, including 155 (62.2%) with viremia. HCV-positive status was associated with having injected drugs, elevated serum alanine aminotransferase, homelessness in the last 1 year, and more severe depressive symptoms. The incidence of new HCV infection was 4.63% per person-year (ppy; 95% confidence interval, 2.31 to 8.13) in the entire cohort and 16.77% ppy among injection drug users. The prevalence of HCV antibody-negative HCV-viremia was 13.2% (10/76). Nonwhites were less likely to receive HCV testing and subspecialty referral, controlled for drug use and other confounders. Sixty-eight percent (123/182) were aware treatment was available; however, only 3.8% (7/182) or 1.16% ppy received HCV treatment.
CONCLUSIONS: While HCV infection is common, HCV treatment is rare in the HIV-HCV coinfected urban poor. Urban poor, nonwhite individuals are less likely to receive HCV testing and subspecialty referral than their white counterparts. Antibody-negative infection may complicate screening and diagnosis in HIV-infected persons.
Article PDF
Similar content being viewed by others
References
Lauer, G.M. and B.D. Walker, Hepatitis C virus infection. New England Journal of Medicine, 2001. 345(1): p. 41–52.
National Hepatitis C Prevention Strategy: A Comprehensive Strategy for the Prevention and Control of Hepatitis C Virus Infection and its Consequences. 2001, Centers for Disease Control: Atlanta, GA.
Hepatitis C: 170 million infected worldwide and still no vaccine. 1998, World Health Organization: Geneva.
Sulkowski, M.S., et al., Hepatitis C virus infection as an opportunistic disease in persons infected with human immunodeficiency virus. Clin Infect Dis, 2000. 30 Suppl 1: p. S77–84.
Tedaldi, E., Prevalence and characteristics of HCV co-infection in a community based HIV clinical trials group. in 1st IAS Conference on HIV Pathogenesis and Treatment. 2001. Buenos Aires, Argentina.
Sherman, K.E., et al., Hepatitis C Virus prevalence among patients infected with Human Immunodeficiency Virus: a cross-sectional analysis of the US adult AIDS Clinical Trials Group. Clin Infect Dis, 2002. 34(6): p. 831–7.
Nyamathi, A.M., et al., Risk factors for hepatitis C virus infection among homeless adults. J Gen Intern Med, 2002. 17(2): p. 134–43.
Page-Shafer, K.A., et al., Hepatitis C virus infection in young, low-income women: the role of sexually transmitted infection as a potential cofactor for HCV infection. Am J Public Health, 2002. 92(4): p. 670–6.
Cheung, R.C., et al., Viral Hepatitis and Other Infectious Diseases in a Homeless Population. J Clin Gastroenterol, 2002. 34(4): p. 476–480.
Lorvick, J., et al., Prevalence and duration of hepatitis C among injection drug users in San Francisco, Calif. Am J Public Health, 2001. 91(1): p. 46–7.
Rosenblum, A., et al., Hepatitis C and substance use in a sample of homeless people in New York City. J Addict Dis, 2001, 20(4): p. 15–25.
Fleming, C.A., et al., Differences among patients infected with HIV and hepatitis C (HCV) versus those infected with HCV alone in an urban hospital clinic. in 39th Annual Meeting of the Infectious Diseases Society of America. 2001. San Francisco, CA.
Leigh, J.P., et al., Costs of hepatitis C. Arch Intern Med, 2001. 161(18): p. 2231–7.
Kuehne, F.C., et al., Treatment for hepatitis C virus in human immunodeficiency virus-infected patients: clinical benefits and cost-effectiveness. Arch Intern Med, 2002. 162: p. 2545–2556.
Salomon, J.A., et al., Cost-effectiveness of treatment for chronic hepatitis C infection in an evolving patient population. Jama, 2003. 290(2): p. 228–37.
Serfaty, L., et al., Impact of early-untreated HIV infection on chronic hepatitis C in intravenous drug users: a case-control study. Aids, 2001. 15(15): p. 2011–6.
Rodriquez, M. and J. Rodriguez, Comparison of the severity of liver disease in HCV-non-HIV-infected patients and HCV-HIV co-infected patients prior to HCV-treatment in an urban area. in Digestive Disease Week. 2001, Atlanta, GA.
Greub, G., et al., Clinical progression, survival, and immune recovery during antiretroviral therapy in patients with HIV-1 and hepatitis C virus coinfection: the Swiss HIV Cohort Study. Lancet, 2000. 356(9244): p. 1800–5.
Louie, J.K., et al., Trends in Causes of Death in Persons with AIDS in the Era of Highly Active Antiretroviral Therapy, San Francisco: 1994–1998. Journal of Infectious Diseases, 2002 (in press).
Monga, H.K., et al., Hepatitis C virus infection-related morbidity and mortality among patients with human immunodeficiency virus infection. Clin Infect Dis, 2001. 33(2): p. 240–7.
Bica, I., et al., Increasing mortality due to end-stage liver disease in patients with human immunodeficiency virus infection. Clin Infect Dis, 2001. 32(3): p. 492–7.
Aceti, A., et al., Hepatotoxicity development during antiretroviral therapy containing protease inhibitors in patients with HIV: the role of hepatitis B and C virus infection. J Acquir Immune Defic Syndr, 2002. 29(1): p. 41–8.
Sulkowski, M.S., et al., Hepatotoxicity associated with nevirapine or efavirenz-containing antiretroviral therapy: role of hepatitis C and B infections. Hepatology, 2002. 35(1): p. 182–9.
Manns, M.P., et al., Peginterferon alfa-2b plus ribavirin compared with interferon alfa-2b plus ribavirin for initial treatment of chronic hepatitis C: a randomised trial. Lancet, 2001. 358(9286): p. 958–65.
Chung, R., A Randomized, Controlled Trial of Pegylated Interferon alfa-2a with Ribavirin vs Interferon alfa-2a with Ribavirin for the Treatment of Chronic HCV in HIV Co-Infection: ACTG A5071. in 9th Conference on Retroviruses and Opportunistic Infections. 2002. Seattle, WA.
Kushel, M.B., E. Vittinghoff, and J.S. Haas, Factors associated with the health care utilization of homeless persons. Jama, 2001. 285(2): p. 200–6.
Hibbs, J.R., et al., Mortality in a cohort of homeless adults in Philadelphia. N Engl J Med, 1994. 331(5): p. 304–9.
Freudenberg, N., Health promotion in the city: a review of current practice and future prospects in the United States. Annu Rev Public Health, 2000. 21: p. 473–503.
Moore, R.D., et al., Racial differences in the use of drug therapy for HIV disease in an urban community. N Engl J Med, 1994. 330(11): p. 763–8.
Johnson, P.A., et al., Effect of race on the presentation and management of patients with acute chest pain. Ann Intern Med, 1993. 118(8): p. 593–601.
Maynard, C., et al., Blacks in the coronary artery surgery study (CASS): race and clinical decision making. Am J Public Health, 1986. 76(12): p. 1446–8.
Todd, K.H., N. Samaroo, and J.R. Hoffman, Ethnicity as a risk factor for inadequate emergency department analgesia. Jama, 1993. 269(12): p. 1537–9.
Moore, R.D., et al., Prevalence, detection, and treatment of alcoholism in hospitalized patients. Jama, 1989. 261(3): p. 403–7.
Powe, N.R., et al., Access to recombinant erythropoietin by Medicare-entitled dialysis patients in the first year after FDA approval. Jama, 1992. 268(11): p. 1434–40.
Diehr, P., et al., Treatment modality and quality differences for black and white breast- cancer patients treated in community hospitals. Med Care, 1989. 27(10): p. 942–58.
Robertson, M., et al., HIV seroprevalence and risk factors in a representative sample of homeless and marginally housed adults in San Francisco. AJPH, 2003. in press.
Koegel, P., M.A. Burnam, and R.K. Farr, The prevalence of specific psychiatric disorders among homeless individuals in the inner city of Los Angeles. Arch Gen Psychiatry, 1988. 45(12): p. 1085–92.
Zolopa, A.R., et al., HIV and tuberculosis infection in San Francisco’s homeless adults. Prevalence and risk factors in a representative sample. Jama, 1994. 272(6): p. 455–61.
Beck, A.T., R.A. Steer and G.K. Brown, Beck Depression Inventory (BDI-II) Manual. 1996, The Psychological Corporation: San Antonio, Texas, U.S.A.
Bangsberg, D.R., et al., Adherence to protease inhibitors, HIV-1 viral load, and development of drug resistance in an indigent population. Aids, 2000. 14(4): p. 357–66.
Hahn, J.A., et al., Hepatitis C virus infection and needle exchange use among young injection drug users in San Francisco. Hepatology, 2001. 34(1): p. 180–7.
Thorpe, L.E., et al., Risk of hepatitis C virus infection among young adult injection drug users who share injection equipment. Am J Epidemiol, 2002. 155(7): p. 645–53.
Garfein, R.S., et al., Prevalence and incidence of hepatitis C virus infection among young adult injection drug users. J Acquir Immune Defic Syndr Hum Retrovirol, 1998. 18(Suppl 1): p. S11–9.
Villano, S.A., et al., Incidence and risk factors for hepatitis C among injection drug users in Baltimore, Maryland. J Clin Microbiol, 1997. 35(12): p. 3274–7.
Fleming, C.A., et al., Experience of an urban hospital referral clinic for evaluation of patients co-infected with HIV and hepatitis C virus (HCV). in 39th Annual Meeting of the Infectious Diseases Society of America. 2001, San Francisco, CA.
Cawthorne, C.H., et al., Limited success of HCV antiviral therapy in United States veterans. Am J Gastroenterol, 2002. 97(1): p. 149–55.
Wong, J.B., et al., Pretreatment evaluation of chronic hepatitis C: risks, benefits, and costs. Jama, 1998. 280(24): p. 2088–93.
Alter, M.J., The epidemiology of hepatitis C. in NIH Consensus Development Conference: Management of Hepatitis C. 1997. Bethesda, MD.
Hyams, K.C., et al., Viral hepatitis in the U.S. military: a study of hospitalization records from 1974 to 1999. Mil Med, 2001. 166(10): p. 862–5.
Strathdee, S.A., et al., Barriers to use of free antiretroviral therapy in injection drug users [see comments]. Jama, 1998. 280(6): p. 547–9.
Celentano, D.D., et al., Self-reported antiretroviral therapy in injection drug users. Jama, 1998. 280(6): p. 544–6.
Hare, C.B., et al., Viral Hepatitis, Liver Damage, and Antiretroviral Prescribing Patterns in an HIV Community Network. in 9th Conference on Retroviruses and Opportunistic Infections. 2002. Seattle, WA.
Pratt, C.C., et al., Hepatitis C screening and management practices: a survey of drug treatment and syringe exchange programs in New York City. Am J Public Health, 2002. 92(8): p. 1254–6.
Fraser, M. and J. Buffington, Survey of local health department capacity for hepatitis C and HIV/AIDS prevention and control programs. in 128th Annual Meeting of the APHA. 2000. Boston, MA.
Aragon, T., Hepatitis C Infection: Epidemiology. 2000, San Francisco Department of Public Health: San Francisco, CA.
Teshale, E.H., et al., Adherence to Guidelines among HIV/HCV Co-Infected Persons and Providers. in 9th Conference on Retroviruses and Opportunistic Infections. 2002. Seattle, WA.
Fultz, S.L., et al., Testing, referral, and treatment patterns for hepatitis C virus coinfection in a cohort of veterans with human immunodeficiency virus infection. Clin Infect Dis, 2003. 36(8): p. 1039–46.
National Institutes of Health Consensus Development Conference Panel Statement: management of hepatitis C, 2002. 2002.
National Institutes of Health Consensus Development Conference Panel Statement: management of hepatitis C. Hepatology, 1997. 26(3 Suppl 1): p. 2S–10S.
Alexander, G.C. and A.R. Sehgal, Barriers to cadaveric renal transplantation among blacks, women, and the poor. JAMA, 1998. 280(13): p. 1148–52.
Schulman, K.A., et al., The effect of race and sex on physicians’ recommendations for cardiac catheterization. New England Journal of Medicine, 1999. 340(8): p. 618–26.
Edlin, B.R., et al., Is it justifiable to withhold treatment for hepatitis C from illicit-drug users? N Engl J Med, 2001. 345(3): p. 211–5.
Backmund, M., et al., Treatment of hepatitis C infection in injection drug users. Hepatology, 2001. 34(1): p. 188–93.
Sylvestre, D., Sustained virologic response in methadone patients treated for HCV. in 52nd Annual Meeting and Postgraduate Course of the American Association for the Study of Liver Diseases (AASLD). 2001. Dallas, TX.
Gross, R., et al., Effect of adherence to newly initiated antiretroviral therapy on plasma viral load. Aids, 2001. 15(16): p. 2109–17.
Liu, H., et al., A comparison study of multiple measures of adherence to HIV protease inhibitors. Ann Intern Med, 2001. 134(10): p. 968–77.
Arnsten, J.H., et al., Antiretroviral therapy adherence and viral suppression in HIV-infected drug users: comparison of self-report and electronic monitoring. Clin Infect Dis, 2001. 33(8): p. 1417–23.
Paterson, D.L., et al., Adherence to protease inhibitor therapy and outcomes in patients with HIV infection. Ann Intern Med, 2000. 133(1): p. 21–30.
McNabb, J., et al., Adherence to highly active antiretroviral therapy predicts virologic outcome at an inner-city human immunodeficiency virus clinic. Clin Infect Dis, 2001. 33(5): p. 700–5.
Bangsberg, D.R., et al., Provider assessment of adherence to HIV antiretroviral therapy. J Acquir Immune Defic Syndr, 2001. 26(5): p. 435–42.
Bangsberg, D.R. and A. Moss, When should we delay highly active antiretroviral therapy? J Gen Intern Med, 1999. 14(7): p. 446–8.
Forton, D.M., et al., Hepatitis C and cognitive impairment in a cohort of patients with mild liver disease. Hepatology, 2002. 35(2): p. 433–9.
Renault, P.F., et al., Psychiatric complications of long-term interferon alfa therapy. Arch Intern Med, 1987. 147(9): p. 1577–80.
Ademmer, K., et al., Suicidal ideation with IFN-alpha and ribavirin in a patient with hepatitis C. Psychosomatics, 2001. 42(4): p. 365–7.
Bonkovsky, H.L. and J.M. Woolley, Reduction of health-related quality of life in chronic hepatitis C and improvement with interferon therapy. The Consensus Interferon Study Group. Hepatology, 1999. 29(1): p. 264–70.
Bernstein, D., et al., Relationship of health-related quality of life to treatment adherence and sustained response in chronic hepatitis C patients. Hepatology, 2002. 35(3): p. 704–8.
Katz, M.H., et al., Depression and use of mental health services among HIV-infected men. AIDS Care, 1996, 8(4): p. 433–42.
Sambamoorthi, U, et al., Antidepressant treatment and health services utilization among HIV-infected medicaid patients diagnosed with depression. J Gen Intern Med, 2000. 15(5): p. 311–20.
Stein, M.D., J. Maksad, and J. Clarke, Hepatitis C disease among injection drug users: knowledge, perceived risk and willingness to receive treatment. Drug Alcohol Depend, 2001. 61(3); p. 211–5.
Cotler, S.J., et al., Patients’ values for health states associated with hepatitis C and physicians’ estimates of those values. Am J Gastroenterol, 2001. 96(9): p. 2730–6.
Thio, C.L., et al., Screening for hepatitis C virus in human immunodeficiency virus-infected individuals. J Clin Microbiol, 2000. 38(2): p. 575–7.
Bonacini, M., H.J. Lin, and F.B. Hollinger, Effect of coexisting HIV-1 infection on the diagnosis and evaluation of hepatitis C virus. J Acquir Immune Defic Syndr, 2001. 26(4): p. 340–4.
Bangsberg, D., et al., Protease inhibitors in the homeless. Jama, 1997. 278(1): p. 63–5.
Des Jarlais, D.C. and A. Schuchat, Hepatitis C among drug users: deja vu all over again? Am J Public Health, 2001. 91(1): p. 21–2.
Bamberger, J.D., et al., Helping the urban poor stay with antiretroviral HIV drug therapy. Am J Public Health, 2000. 90(5): p. 699–701.
Author information
Authors and Affiliations
Corresponding author
Additional information
Drs. Tomás Aragón, Brian Edlin, Elise Riley, and Kimberly Page-Shafer provided important critique of the analysis and presentation. In addition, sincere appreciation goes to Richard Clark, Nelia de la Cruz, David Guzman, Tarek Elbeik, Paula Zenti, Sandra Monk, John Day, James McDonald, Gina Hobson, Kelly Winslow, William Benjamin, and Johanna Crane who were responsible for data collection.
Supported by the Centers for Disease Control and Prevention Post-doctoral Fellowship Training Program in Infectious Diseases, National Institute of Mental Health, The Doris Duke Charitable Foundation, and an unrestricted grant from Agouron Pharmaceuticals, Inc. Agouron representatives did not participate in data collection, analysis, drafting of manuscript or decision to submit the manuscript for publication.
Rights and permissions
About this article
Cite this article
Hall, C.S., Charlebois, E.D., Hahn, J.A. et al. Hepatitis C virus infection in san francisco’s HIV-infected urban poor. J GEN INTERN MED 19, 357–365 (2004). https://doi.org/10.1111/j.1525-1497.2004.30613.x
Issue Date:
DOI: https://doi.org/10.1111/j.1525-1497.2004.30613.x