Awareness of Biologically Confirmed HCV Among a Community
Residing Sample of Drug Users in Baltimore City
Nicole Ennis Whitehead•Lauren E. Hearn•
Michael Marsiske•Maria R. Kahn•
William W. Latimer
Published online: 31 October 2013
? Springer Science+Business Media New York 2013
prevalence and correlates of biologically confirmed Hepa-
titis C (HCV) and (2) the prevalence and correlates of prior
HCV diagnosis and an unmet need for HCV treatment,
among a community residing sample of drug users. The
current study used a subset of HCV tested participants from
the larger NEURO-HIV Epidemiologic Study from Balti-
more, Maryland (Mage= 34.81, SD = 9.25; 46 % female).
All participants were tested for HCV at baseline. Self-
report was used to assess awareness of an HCV diagnosis
and participation in treatment. Of the 782 participants
tested for HCV, 19 % reported having received an HCV
diagnosis in the past while 48 % tested positive for HCV.
Only 6 % reported having received treatment for any form
The present study sought to examine: (1) the
of hepatitis. Of those who tested HCV positive, 63 %
reported never being diagnosed, and only 13 % received
any treatment for HCV. We found that only 35 % of those
who reported a prior HCV diagnosis received any treat-
ment. The findings regarding lack of HCV awareness and
diagnosis were considerable as expected. These deficits
suggest that there are numerous gaps in patients’ knowl-
edge and beliefs regarding HCV that may interfere at
multiple steps along the path from diagnosis to treatment.
This study clearly demonstrates that a critical need exists to
improve public knowledge of HCV risk factors, the need
for testing, and the availability of effective treatment.
treatment ? Drug use
Hepatitis C awareness ? Hepatitis C
Hepatitis C (HCV) is a significant public health issue. In
the US, HCV infection is the most prevalent chronic blood
borne infection and is the leading cause of hepatocellular
carcinoma and liver transplant [1–4]. Current estimates of
the economic impact of the disease are alarming. The
health care costs are estimated at $360 million annually to
treat currently infected patients .
Chronic HCV infection can remain asymptomatic for
years, hence under diagnosis of HCV remains a significant
challenge . Underdiagnosis of HCV is a significant
public health problem which contributes to large propor-
tions of HCV infected people being unaware of their dis-
ease status [1, 7, 8]. Approximately 50–75 % of the
estimated 5.2 million HCV-positive individuals in the
United States are unaware of their diagnosis [9–11]. The
high prevalence of HCV and equally high prevalence of
N. E. Whitehead (&)
Department of Clinical and Health Psychology, College of
Public Health and Health Professions, University of Florida,
1225 Center Drive, Room 3146, Gainesville, FL 32611, USA
L. E. Hearn
Department of Clinical and Health Psychology, University
of Florida, 1225 Center Drive, Room 3180, Gainesville,
FL 32611, USA
Department of Clinical and Health Psychology, University
of Florida, 1225 Center Drive, Room 3146, Gainesville,
FL 32611, USA
M. R. Kahn
Department of Epidemiology, University of Florida, 1225 Center
Drive, Room 3110, Gainesville, FL 32611, USA
W. W. Latimer
Department of Clinical and Health Psychology, University
of Florida, 1225 Center Drive, Room 3151, Gainesville,
FL 32611, USA
J Community Health (2014) 39:487–493
morbidity and mortality that occurs when the disease is
undetected and untreated led the CDC to its recent rec-
ommendation that all adults born between 1945 and 1965
be tested . This recent recommendation complemented
the longstanding recommendation to regularly test high-
risk groups. However, under diagnosis remains a signifi-
cant problem, especially among high risk populations.
Therefore, we need to better understand correlates associ-
ated with under diagnosis of HCV in high risk groups.
Since 1998, the CDC has recommended routine screening
1992 . However, due to patient and system obstacles,
screening levels have fallen short of this recommendation.
of their HCV status and demonstrates the challenges and
shortfalls of our current screening strategies [6, 14, 15].
Though there is strong evidence that HCV infection is under
diagnosed, there is very limited understanding of the factors
influencing under diagnosis among high risk populations. A
greater understanding of factors associated with lack of
awareness of HCV diagnosis would enable us to address dis-
parities in HCV screening and diagnosis.
A consequence of inadequate screening and detection of
HCV infection is that most infected with HCV do not
receive needed care such as education, counseling or
medical monitoring . In addition, although effective
treatments are available, lack of awareness leaves those
most in need of treatment with an unmet need for treatment
. Although extant literature has documented that many
of those diagnosed do not receive needed treatment, few
prior studies have measured the unmet need for treatment
among those diagnosed.
The current study sought to address these gaps in our
understanding of diagnosis and treatment of HCV in a
community residing sample of drug users in Baltimore
City, a population at high risk of HCV infection. Therefore,
the present study sought to examine (1) the prevalence and
correlates of biologically confirmed Hepatitis C (HCV) and
(2) the prevalence and correlates of prior HCV diagnosis
and unmet need for HCV treatment, among those with
of the NEURO-HIV Epidemiologic Study. This study was
approved by the University of Florida’s Institutional Review
Board and has received annual renewals. The baseline
assessment was designed to examine neuropsychological and
social-behavioral risk factors ofHIV, hepatitis A,hepatitis B,
and hepatitis C among both injection and non-injection drug
users. In order to be eligible for participation in the parent
study, participants had to be 18 and older and report use of
non-injection and/or injection drugs in the past 6 months.
Recruitment strategies for participation included advertise-
ments in local newspapers, street outreach, and referrals from
local service agencies. Participants were paid $45 for the
baseline assessment. Participants provided written informed
consent and completed a face to face HIV Risk Behavior
Interview. Blood and urine samples were also collected atthe
baseline assessment. Blood was drawn by a phlebotomist and
tested for HIV, hepatitis A, B, and C. Urine samples were
tested for the presence of drugs. Participants were subse-
quently notified of their HIV and/or viral hepatitis status and
were referred to drug treatment and social services for coun-
seling with respect to their blood and urine analysis results.
Biologically Confirmed HCV
at baseline and HCV antibody testing was performed. HCV
antibodies are assessed by enzyme immunoassays (either
EISA 2.0, Abbot or ELISA 3.0, Ortho Diagnostic Systems,
Inc Raritan, NJ. Reactive sera were then re-tested by RIBA
3.0 strip immunoblot assay (Chiron) in order to confirm
Blood samples were taken
Biologically Confirmed HIV
baseline and HIV antibody testing was performed standard
ELISA screening and confirmatory Western Blots.
Blood samples were taken at
ipants immediately following informed consent. Urine was
analyzed for the presence of drugs including opiates,
cocaine, cannabinoids, amphetamines, methamphetamines,
methadone, PCP, barbiturates, benzodiazepines, MDMA,
Urine samples were collected from all partic-
HIV Risk Behavior Interview
collected using the HIV Risk Behavior Interview a detailed
behavioral assessment of drug use and sexual practices.
This assessment was adapted from a similar interview used
in the REACH and ALIVE studies [18, 19]. Questions
addressed demographic, educational, medical and neuro
developmental variables along with a detailed assessment
of lifetime and recent drug use and sexual practices.
Self-report measures were
488 J Community Health (2014) 39:487–493
Self-report HCV Status
you ever been told by a Health Professional that you had
Hepatitis?’’ ‘‘What type of Hepatitis were you told you have
(response choices: Hepatitis A, Hepatitis B, Hepatitis C,
Unknown Hepatitis)?’’ Those who responded yes to both
as 1; those responded negatively to both or were diagnosed
with a different type of hepatitis were coded as 0.
Participants were asked ‘‘Have
been told you have Hepatitis C’’ were then asked ‘‘Was
treatment given?’’; Those who responded yes were coded
as a 1 and those who responded no were coded as 0.
Participants who responded yes to ‘‘ever
questions regarding gender, race, education, marital status,
source of income, and stability of housing resources.
Study demographic questionnaire include
Injection Drug Risk Behaviors
‘‘Have you ever used a needle that you know someone else
used?’’; ‘‘Have you ever backloaded?’’; ‘‘Have you ever
shared a cooker?’’; ‘‘Have you ever shared cotton?’’; and
who did not endorse any of those behaviors were coded as 0.
Participants were asked:
To meet study aims, descriptive statistics were used to cal-
of interest. The sample was divided into two groups: those
who tested positive for HCV and those who tested negative.
Chi square (v2) and t test analyses compared the two groups
on demographic and predictor variables of interest. We then
examined the subset of HCV-positive participants. Fre-
quencies, means, and percentages for each variable of
interest were calculated in order to examine differences
between those who reported being given a positive HCV
diagnosis. Logistic regression analyses were then conducted
to assess the influence of demographic and relevant behav-
ioral variables in relation to self- reported HCV diagnosis.
Descriptive data analyses and regression analysis were per-
formed using IBM SPSS Statistics 21 (2013).
The current study includes a subset of the larger study con-
sistingofmenandwomenwhowereHCVtested(n = 782).Of
excluded cases the only significant demographic differences
was that sixty-six percent of those missing an HCV test were
female. Table 1 shows a complete summary of participant
demographics for the current sample. The study sample was
36 %whiteand60 %Black/AfricanAmerican,and4 %other.
Fifty-four percent of the sample was male, with 40 % having
completed high school or equivalent. The majority of the
sample,67 %,wassingle-nevermarried.Inthepast6 months,
19 % of the sample reported being homeless, 51 % reported
receiving public assistance and 40 % reported having money
a mean of 34.81 and a standard deviation of 9.25 years. Fifty-
four percent reported having seen a mental health professional
for an emotional or behavioral problem at some point in their
life and 65 % reported seeking treatment for a physical or
medical illness in their life. Eighty-five percent of the sample
urine tested positive for illicit drug use at baseline. Of the 782
participants tested for HCV 19 % reported having received an
Only 6 % reported having received treatment for any form of
Five participants who tested HCV negative reported having
received an HCV diagnosis and of those four reported having
Demographics Stratified by HCV Status
Frequency distributions for demographic and study variables
HCV status (Table 1). Those who tested positive for HCV
were slightly older (M = 35.65, SD = 9.30) than those who
tested negative (M = 34.03, SD = 9.14) t(780) = -2.45,
p = 0.014).MalesweremorelikelytobeHCVpositive(v2(1,
n = 782) = 3.79, p = 0.051) than females. African Ameri-
cans were more likely to be HCV negative (v2(2,
n = 778) = 43.20,p\0.001)thanwhites.Inaddition,those
who had an education of 11th grade or less (v2(2,
n = 781) = 36.84, p = 0.001) and had not received money
fromaregularjob(v2(1,n = 780) = 28.57,p\0.001)inthe
past 6 months were more likely to be HCV positive. Both
groups differed as expected on drug risk taking (v2(1,
n = 780) = 156.04, p\0.001), with more HCV-positive
with more HCV-positive individuals being HIV-positive.
public assistance, homelessness, biologically confirmed drug
help for a physical/medical illness.
Prevalence and Correlates of HCV Diagnosis, Among
Those Infected with HCV
diagnosed (Fig. 1). We then examined the characteristics of
J Community Health (2014) 39:487–493489
HCV diagnosis versus those who reported not receiving any
diagnosis (Table 2). Using logistic regression analyses we
examined the association between demographic and drug
risk behavior variables as predictors of self-reported HCV
diagnosis. We found that age, gender, education, marital
status,homelessness, public assistance, and HIV status were
not significantly associated with self-reported HCV diag-
nosis. African Americans were less (AOR = .525, 95 %
CI = .279–.985, p = .04) likely to self-report an HCV
diagnosis than whites; those who self-reported seeking help
likely to self-report (AOR = 2.11, 95 % CI = 1.29–3.74,
p = .003) an HCV diagnosis than those who did not seek
care; and those who engaged in drug risk behaviors were
almost 5 times (AOR = 4.90, 95 % CI = 2.71–8.86,
Table 1 Demographic comparisons by (N = 782)
Variable Entire sample HCV negative HCV positive Test statistics
M or N S.D. or %M or N S.D. or %M or N S.D. or %
v2or t testp value
Age 34.819.2534.03 9.14 35.659.3
Male 42154 20551 216 57
Female36146201 49 160 43
White281 3610726 174 46
African American468 6028770 181 48
High school or GED
33243 133 3319953
316 40181 4513536
Some college133 17912242 11
Single never married 52667 27869 24866
Married/common law 80 10 4812328
Divorced/widowed/separated 17222 77199525
Money from a regular job (yes)311 40198 51113 3028.57
0.23 Public assistance (yes)400 51206 51201 541.55
Health problems (life)511 65260 64251 670.64 0.45
Emotional behavioral problems (life) 42054 21353 20755 0.470.51
Homeless in last 6 months (yes)15119691782 22 2.90.1
Biologically confirmed drug use662 8534685 31684 0.011
Drug risk behaviors-life36146101 2526069156.04
Self-reported HCV Dx 145 1951 14037 166.6
Self reported Hep Tx 526414813 46.42
Positive87 11338 5414
Negative 69389 371 91322 86
N may vary slightly according to missing data
HCV status: Self reported diagnosis versus biologically
490J Community Health (2014) 39:487–493
p\.0001)more likely toself-reportanHCV diagnosis than
those who reported no drug risk behaviors.
Unmet Need for HCV Treatment
Of those who reported an HCV diagnosis, 35 % reported
receiving treatment. Using logistic regression analysis we
forthosewho reportedreceiving treatmentversusthosewho
reported they did not receive treatment; however no signif-
icant differences were found between these groups.
The findings regarding HCV prevalence and lack of
awareness were considerable as expected. Of the 782 drug
users tested for HCV 48 % were HCV-positive. These
findings are similar to other high-risk groups. Urban
homeless in San Francisco had an infection rate of 73 %;
HIV-positive veterans on antiretroviral treatment had a
37 % HCV infection rate; and former heroin addicts in
treatment had a 26 % infection rate [20–22]. Interestingly,
HIV infection in the current sample was 11 %, and for
those infected with HCV the rate of HIV infection was
14 %, significantly lower than expected given the shared
routes of transmission. Of those infected with HCV in the
present study, 63 % were unaware of their positive HCV
status. These findings suggest that current screening prac-
tices are not reaching those at highest risk, leaving a sig-
nificant number of infected individuals unaware of their
diagnosis and need of treatment.
The literature indicates that patient knowledge gaps and
beliefs may interfere at multiple steps along the path from
diagnosis to treatment. In a sample of HCV? injection
drug users, only 22 % reported understanding that HCV is
Table 2 Demographic comparison: self reporting HCV diagnosis versus reporting no diagnosis (N = 376)
VariableHCV ? self reporting
HCV ? self reporting no
M or N S.D. or % M or NS.D. or %Odds ratio95 % CI p value
Age36.03 10.02 35.208.78 1.03 .995–1.060.09
Male 73 52141 61 Referent
Female67 48 90391.19 .709–2.000.509
White7251 100 43 Referent
African American 6144 117510.525 .279–.985 0.045
Other75 136 0.89.293–2.680.831
High school or GED
4331 89390.73.433–1.21 0.222
Some college20142191.24 .579–2.660.578
Single never married 96 6914965 Referent
Married/common law1072290.59 .322–1.090.096
Divorced/widowed/separated 342459 260.75 .314–1.800.527
Public assistance (no) Referent
Public assistance (yes)87 62 76331.71 .987–2.990.056
Sought help for emotional/behavioral problems (no)Referent
Sought help for emotional/behavioral problems (yes)9769142 622.11 1.29–3.470.003
Homeless in last 6 months (no)Referent
Homeless in last 6 months (yes) 36 2645 20 1.18.676–2.06 0.559
HIV? 1712 34 150.59.284–1.20 0.147
Drug risk behaviors (no) Referent
Drug risk behaviors (yes) 12388 13558 4.902.71–8.86 \.0001
N may vary slightly according to missing data
J Community Health (2014) 39:487–493491
curable, and in a sample of HIV? women, 58 % did not
have an opinion on the effectiveness of HCV treatment [16,
23]. Due to a combination of provider judgment and patient
beliefs, only 21 % of HCV? patients had a conversation
about treatment with their physician. Of those that dis-
cussed treatment, 30 % started treatment . Similarly,
we found that only 35 % of those who reported receiving
an HCV diagnosis received any treatment. Among a sam-
ple of HCV-infected injection drug users, the most com-
mon reasons for refusing or deferring treatment included
treatment-related perceptions (e.g., the side effects are
bad), lack of perceived need for treatment, and competing
Common barriers to HCV screening cited by physicians
include: other medical complaints that command priority
during time-constrained appointments; demonstrated patient
noncompliance; co-morbidities that are contraindicated for
specialist care . Access to a physician and attendance at
follow-up appointments is essential for both screening and
receiving a diagnosis. In addition to the financial and trans-
portation challenges to completing an initial appointment,
patient no-show at screening follow-up appointments means
that many HCV-positive individuals do not receive their
diagnosis or counseling [25, 26].
The implementation of oral swab, rapid HCV screening
could reduce many of the challenges of diagnosing infected
individuals. Without a need for a follow-up visit to receive
screening results, more individuals could learn their HCV
status. Additionally, the oral test may attract individuals
with concerns about undergoing a blood test (e.g., IDU’s
worried about locating a usable vein) [25, 27]. Diagnosis,
coupled with counseling about disease management, risk
reduction practices to limit spread to others, and referral to
treatment providers can begin to bridge the gap in HCV
status awareness and treatment initiation.
for treatment, based on the presence of medical and psychi-
atric co-morbidities or illicit drug use, may prevent specialist
referral, Morrill et al.  found through medical record
reviews and physician interviews that these cited reasons did
not correlate with actual patients’ treatment status [28, 29].
Increasing evidence suggests that individuals with contrain-
dicated conditions associated with decreased adherence to
medical treatments, such as depression, can have successful
outcomes with antiviral therapy under proper management
. Similarly, Cohen et al.  found that a majority of the
women who were referred for liver biopsy or HCV treatment
did follow physician recommendations despite ongoing pov-
erty, HIV infection, and substance use .
Our data indicates that those who have engaged in drug
risk behaviors are more likely to be aware of their positive
HCV status. Those who self-reported an HCV diagnosis
were 5 times more likely to acknowledge engaging in drug
risk behaviors during their lifetime. Programs that test
people who inject drugs (PWID) where they receive ser-
vices may be contributing to these results and serve as an
effective method of identifying and educating those with
HCV infection . Through needle exchange programs
(NEP), those who inject drugs may be tested at the site
where they receive services. In addition, NEP’s also pro-
vide participants with needed education about risk behav-
iors and its relationship to HCV disease. While it was a
small subset of the current sample, those at greatest risk
and those who encountered the healthcare system were the
most likely to be aware of their HCV status. This supports
the possible effectiveness of increasing public awareness
regarding risk factors and testing sources for HCV.
These findings should be evaluated in light of the
study’s limitations. Self-report was used to determine
treatment received, and it does not account for those
referred who did not follow-up. However, this study clearly
demonstrates that a critical need exists to improve public
knowledge of HCV risk factors, the need for testing, and
the availability of effective treatment.
Institute of Drug Abuse R01DA014498.
This research was supported by the National
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