Hepatitis C Awareness and Risky
Injection Behaviors among Injection
Drug Users in Treatment
PT Korthuis1, D Feaster2, Z Gomez2, M Das-Douglas3, S Tross4, K
Wiest5, A Douaihy6, RN Mandler7, JL Sorensen3, G Colfax8, PE Penn9, D
Lape5, L Metsch2.
1Oregon
Health and Science University; 2University of Miami Miller
School of Medicine; 3University of California, San Francisco;
4Columbia University; 5CODA; 6University of Pittsburgh School of
Medicine; 7National Institute on Drug Abuse; 8San Francisco
Department of Public Health; 9La Frontera;
Acknowledgements
• No Conflicts of Interest
•
•
•
•
Funding by NIDA Clinical Trials Network
PI Lisa Metsch
Co-authors
Participants
Background
• Injection drug use (IDU) remains a leading
cause of HIV and Hepatitis C (HCV)
transmission worldwide
• Among IDU, predictors for HCV seroconversion
include sharing needles, syringes, & cotton.
• Across multiple U.S. studies, 35-65% of
current IDU report needle sharing, but access
to clean needles has improved.
Awareness of Infectious Status and
Risk Behaviors
• HIV: Those aware of HIV infection decrease
risky sexual behavior 68%1 but not IDU risk2
• HCV:
– Survey of 197 IDU’s in Denver : HCV-aware
engaged in fewer HCV risk behaviors3
– Survey of 213 Swedish IDU: knowledge of HCV not
associated with change in risky behaviors4
– Survey of 337 IDU in Seattle: HCV-aware more
likely to “sero-sort” needle sharing5
1Marks
G, JAIDS 2005;39:446
SK, JSAT 200;19:15
3Kwiatkowski CF Addiction 2002;97:1289
4Norden, Scan J Infect Dis 2009;41: 727
5Burt RD, Drug & Alc Dep 2009;105: 215
2Avants
Research Question & Hypothesis
• What are current injection behaviors among
IDU’s in treatment?
– Hypothesis: Needle sharing lower than historically
high rates.
• Is Awareness of Self-reported HCV status
associated with less risky injection behaviors?
– Hypothesis: IDU aware of HCV status will report
less sharing of needles/works
Study Setting and Participants
• NIDA CTN0032: A randomized trial of 3 HIV
testing & counseling strategies for persons
presenting for addiction treatment
• Sites: 12 community-based U.S. addiction
treatment programs
• Eligibility: Age >18, English-speaking, HIVnegative
• Analytic Sample: Those reporting recent IDU
(= use in last 6 mo)
Measures
• Independent Variable: Self-reported
awareness of HCV status (“Are you positive for
Hepatitis C?”)—Yes, No
• Dependent Variable: Self-reported sharing of
needles or works in past 6 months
• Covariates: age, gender, race, education,
source of needles, & specific substances used
Analysis
• Descriptive statistics for frequency of drug
use, injection behaviors, and needle sharing
• Multivariate logistic regression to estimate
associations between HCV status and sharing
needles/works
– Covariates included in Multivariate analysis if
p<.20 in bivariate analysis or a priori significance
Results:
Injection Drug Use in Past 6 Months
• 245/1281 (19%) of
CTN0032 participants
reported recent IDU
Participant Characteristics,
by HCV Self Report (n=245)
Mean Age (SD)
Male Gender (%)
Race/Ethnicity (%)
White
Hispanic
Black
Other
Employed (%)
Education (%)
< High School
High School
≥ Some College
Court Mandated
Treatment (%)
Jailed last 6 mo (%)
HCV Positive
(n = 92)
45.3 (8.80)
44 47.8%
55
17
9
10
21
59.8%
11.1%
9.8%
10.9%
23.1%
HCV Negative
(n = 153)
35.6 (10.6)
105 68.6%
106
18
17
13
30
69.3%
19.6%
11.1%
8.5%
19.6%
Total
(n = 245)
39.3 (11.0)
149 60.8
161
35
26
23
51
65.7%
14.3%
10.6%
9.4%
20.9%
p-value
<.001
.001
.251
.519
.927
28 30.4%
32 34.8%
32 34.8%
43 28.1%
55 35.9%
55 35.9%
71 29.0%
87 35.5%
87 35.5%
17 18.5%
32 20.9%
49 20.0%
.644
20 21.7%
55 35.9%
75 30.6%
.019
Non-Injection Use in Past 6 Months,
by HCV Self Report (n=245)
HCV Positive
HCV Negative
Total
p-value
Ecstasy
4 4.3%
22 14.4%
26 10.6%
.014
Opioid
61 66.3%
101 66.0%
162 66.1%
.963
Powder Cocaine
19 20.7%
55 35.9%
74 30.2%
.012
Crack
43 46.7%
67 43.8%
110 44.9%
.653
Pot
38 41.3%
81 52.9%
119 48.6%
.078
Tranquilizer
30 32.6%
57 37.3%
87 35.5%
.462
Painkillers
31 33.7%
75 49.0%
106 43.3%
.019
Speed
17 18.5%
37 24.2%
54 22.0%
.297
2 2.2%
18 11.8%
20 8.2%
.008
53 57.6%
120 78.4%
173 70.6%
.001
Hallucinogens
Alcohol to
Intoxication
Injection Drug Use in Past 6 Months,
by HCV Self Report (n=245)
HCV Negative
43 28.1%
11 7.2%
Total
65 26.5%
20 8.2%
p-value
.472
.473
10 10.9%
18 11.8%
28 11.4%
.831
5 5.4%
3 2.0%
8 3.3%
.138
Cocaine
48 31.4%
27 29.3%
75 30.6%
.739
Heroin & Speed
Speed
Dilaudid
8 8.7%
12 13.0%
6 6.5%
11 7.2%
19 12.4%
13 8.5%
19 7.8%
31 12.7%
19 7.8%
.670
.887
.576
Heroin
63 68.5%
84 54.9%
147 60.0%
.036
6 6.5%
2 2.2%
23 15.0%
9 5.9%
29 11.8%
11 4.5%
.046
.175
69 75.0%
106 69.3%
175 71.4%
.337
1 1.1%
2 1.3%
3 1.2%
.879
1 1.1%
3 2.0%
4 1.6%
.601
69 75.8%
128 83.7%
197 80.7%
.133
Powder Cocaine
Crack
Heroin & Powder Cocaine
Heroin & Crack
Painkillers
Methadone
Opioids
Barbiturates
Tranquilizers &
Barbiturates
Injected Multiple Drugs at
a Time
HCV Positive
22 23.9%
9 9.8%
Injection Frequency and Needle
Source in Past 6 Months,
by HCV Self Report
Positive (n = 91) Negative (n = 152) Total (n = 244)
Frequency of injection
Less than once a month
1-3 times a month
About once a week
> Once a week, but not
every day
Every day
Where Needles Obtained
Diabetic
Street
MS/Hepatitis
Drug store
Shooting gallery
Needle exchange program
Other
20 21.7%
16 17.4%
11 12.0%
35 23.2%
21 13.9%
7 4.6%
55 22.6%
37 15.2%
18 7.4%
25 27.2%
44 29.1%
69 28.4%
20 21.7%
44 29.1%
64 26.3%
17
13
3
42
5
33
16
34
25
2
84
5
28
23
18.5%
14.1%
3.3%
45.7%
5.4%
35.9%
17.4%
22.4%
16.3%
1.3%
54.9%
3.3%
18.3%
15.0%
51
38
5
126
10
61
39
20.8%
15.5%
2.0%
51.4%
4.1%
24.9%
15.9%
p-value
.206
.485
.644
.295
.161
.407
.002
.625
Needle Cleaning in Past 6 Months, By
HCV Self Report
Positive
Needle Cleaning Habits (n=244)
Always use new needles
Always clean before shooting
up
Always clean after shooting up
Sometimes clean needle
Never clean needle
Needle Cleaning Method (n=125)
Clean with bleach
Clean with soap and water
Clean with alcohol
Clean with boiling water
Did not clean needles
Negative
Total
36 39.6%
77 51.3%
113 46.9%
16 17.6%
19 12.7%
35 14.5%
22 24.4%
14 15.4%
3 3.3%
37 24.7%
14 9.3%
3 2.0%
59 24.5%
28 11.6%
6 2.5%
37
18
4
6
0
34
31
18
13
1
71
49
22
19
1
69.8%
34.0%
7.5%
11.3%
.0%
46.6%
42.5%
24.7%
17.8%
1.4%
56.3%
38.9%
17.5%
15.1%
.8%
p-value
.310
.009
.334
.013
.315
.392
Needle Sharing in Last 6 Months
• 94/244 (38.5%) current IDU reported Needle
Sharing in Past 6 Months
– 88% Both Receptive and Distributive sharing
– 8% Distributive Sharing only
– 3% Receptive Sharing only
Multivariate Associations with Needle Sharing
Participant
Characteristics
% Needle
Sharing
(n = 244)
OR
95%
Confidence
Interval
Age
n/a
0.95 (0.92, 0.99)
Male
31.8%
0.52 (0.28, 0.96)
Race/Ethnicity
White
42.9%
Hispanic
36.0%
2.11 (0.82, 5.43)
Black
36.6%
2.04 (0.65, 6.41)
Other
47.8%
2.06 (0.75, 5.66)
Ref
Education (%)
< High School
51.4%
High School
34.5%
0.50 (0.24, 1.05)
≥ Some College
32.2%
0.47 (0.22, 0.99)
Hepatitis C Positive
44.6%
2.37 (1.15, 4.88)
Used Street Needles
57.9%
2.66 (1.18, 5.97)
Any Opioid
46.3%
4.43 (1.44, 13.7)
Any Pot
47.9%
2.10 (1.09, 4.03)
IDU Crack
65.0%
3.19 (1.07, 9.49)
Ref
Limitations
• Self-reported HCV status
– But predictive value of self-reported positive 94%1
– Belief about status more important behavioral
determinant than biologic HCV status
• Cross-sectional Design limits causal inference
– Greater HCV prevalence among those who share
needles.
1Hagan
HJ, Pub Health Rep 2006;121:710
Conclusions
• Needle sharing remains common among IDU in
community based treatment settings.
• Majority of IDUs obtained needles from drug
stores and exchange programs
• HCV-aware IDU more frequently exhibited harm
reduction behaviors:
– Used needle exchange programs
– Cleaned needles with bleach
– Avoided drinking alcohol to intoxication
• BUT… were more likely to share needles/works
Implications
• Hepatitis C screening in treatment programs
may identify clients in need of targeted harm
reduction interventions.
• Interventions that decrease risky injection
behaviors among IDU presenting for addiction
treatment may reduce HCV transmission