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Correlates of Hepatitis C Virus Infection
in the Targeted Testing Program of the
New York City Jail System: Epidemiologic
Patterns and Priorities for Action
Matthew J. Akiyama, MD, MSc
, Fatos Kaba, MA
Zachary Rosner, MD
, Howard Alper, PhD
Aimee Kopolow, PhD
, Alain H. Litwin, MD, MPH, MS
Homer Venters, MD, MS
, and Ross MacDonald, MD
Objective: The objective of this study was to understand predictors of hepatitis C virus (HCV) antibody positivity in a large
urban jail system in New York City.
Methods: We examined demographic characteristics, risk behaviors, and HCV antibody prevalence among 10 790 jail inmates
aged 16 to 86 who were screened from June 13, 2013, to June 13, 2014, based on birth cohort or conventional high-risk
criteria. We used logistic regression analysis to determine predictors of HCV antibody positivity.
Results: Of the 10 790 inmates screened, 2221 (20.6%) were HCV antibody positive. In the multivariate analysis, HCV
antibody positivity was associated most strongly with injection drug use (IDU; adjusted odds ratio [aOR] ¼35.0; 95%
confidence interval [CI], 28.5-43.0). Women were more likely than men to be infected with HCV (aOR ¼1.3; 95% CI, 1.1-
1.5). Compared with non-Hispanic black people, Hispanic (aOR ¼2.1; 95% CI, 1.8-2.4) and non-Hispanic white (aOR ¼
1.7; 95% CI, 1.5-2.1) people were more likely to be infected with HCV. Non-IDU, recidivism, HIV infection, homelessness,
mental illness, and lower education level were all significantly associated with HCV infection. The prevalence rate of HCV
infection among a subset of inmates born after 1965 who denied IDU and were not infected with HIV was 5.6% (198 of
3529). Predictors of HCV infection among this group included non-IDU as well as being non-Hispanic white, Hispanic,
recidivist, and homeless.
Conclusion: These data reveal differences in HCV infection by sex, race/ethnicity, and socioeconomics in a large jail pop-
ulation, suggesting that a focused public health intervention is required and that universal screening may be warranted. Further
sensitivity and cost-benefit analyses are needed to make this determination.
HCV, jail, corrections
Hepatitis C virus (HCV) is a major public health problem in
the United States. The National Health and Nutrition Exam-
ination Survey (NHANES; 2003-2010) estimated that 1.3%
of the US population, or approximately 3.6 million people,
are HCV antibody positive.
A limitation of NHANES data,
which are based on national household surveys, is the exclu-
sion of high-risk populations, including people who are
incarcerated or homeless.
With the addition of these popu-
lations, the true number is conservatively estimated to be as
high as 4.6 million. The highest number of HCV-infected
people excluded by the NHANES are in correctional
Department of Medicine, Montefiore Medical Center/Albert Einstein
College of Medicine, Bronx, NY, USA
New York City Health þHospitals Correctional Health Services, New
York, NY, USA
New York City Department of Health and Mental Hygiene, Queens, NY,
Matthew J. Akiyama, MD, MSc, Montefiore Medical Center/Albert Einstein
College of Medicine, 3300 Kossuth Ave, Bronx, NY 10467, USA.
Public Health Re ports
2017, Vol. 132(1) 41-47
ª2016, Association of Schools and
Programs of Public Health
All rights reserved.
Reprints and permission:
institutions; >500 000 cases are excluded.
This exclusion is
particularly relevant because of the high rates of HCV in US
prisons and jails. In 2016, the national estimate of overall
HCV antibody prevalence in US prisons was 17.4%, ranging
by state from 9.6%in Nebraska to 41.1%in New Mexico.
Two studies conducted in jails demonstrated prevalence rates
of 16.4%(St Louis, Missouri) and 13%(San Francisco,
California; Chicago, Illinois; and Detroit, Michigan, com-
A more recent study examining an HCV testing
and linkage-to-care program in North Carolina and South
Carolina jails showed that 11.9%of people in jail were HCV
Because HCV prevalence rates in correc-
tional institutions are 10 to 20 times higher than the national
average, jails and prisons are an important reservoir for HCV
infection and crucial sites for public health interventions.
To operationalize the response to the HCV epidemic in
the US correctional system, jails need to be differentiated
from prisons. Jails are shorter-term facilities for people
awaiting trial or serving sentences 1 year. More than
3000 jails in the United States hold 731 000 people at any
which approaches the population of San Fran-
cisco and is larger than the population of Detroit. Moreover,
US jails have 12 million admissions per year, which is 19
times the number of admissions in state and federal prisons.
Failure to intervene in US jails, coupled with high turnover
rates to and from the community, may facilitate the trans-
mission of HCV infection in the neighborhoods to which
inmates return after release.
A thorough understanding
of the correlates of HCV infection in jail settings is critical to
understanding patterns of community transmission and
developing targeted interventions to reduce the risk of trans-
mission after release.
The New York City jail system is the second largest in the
United States, with approximately 60 000 admissions per
year and an average daily census of 10 000. The Bureau of
Correctional Health Services of New York City Health þ
Hospitals is responsible for the medical and mental health
care of inmates in New York City jails. People receive a
comprehensive medical intake at jail admission and subse-
quent preventive and acute medicine and mental health
encounters. The large volume of high-risk people circulating
through the jail system affords a critical opportunity for
identifying cases of HCV infection. Short lengths of stay,
however, complicate the identification process. About half
of inmates are released after <2 weeks, and one-quarter are
released after <72 hours.
Guidelines for HCV screening in correctional institutions
are evolving. The US Preventive Services Task Force
combined Infectious Diseases Society of America and Amer-
ican Association for the Study of Liver Diseases guidelines
recommend HCV screening for all people who were ever
The Federal Bureau of Prisons Clinical Prac-
tice Guidelines recommend opt-out screening for all sen-
tenced inmates, as well as inmates regardless of sentencing
status who (1) have a reported history of HCV infection
without previous medical records to confirm the diagnosis,
(2) have elevated alanine aminotransferase levels of
unknown etiology, (3) have evidence of extrahepatic mani-
festations of HCV infection, or (4) are on chronic hemodia-
No HCV screening guidelines are available
specifically for jail settings. In 2012, a minority of correc-
tional institutions provided routine HCV screening, and
screening strategies were a mix of opt-in, opt-out, or man-
HCV screening practices in correctional
settings have not been summarized since the release of
highly effective, direct-acting antiviral medications for HCV
In 2012, the Centers for Disease Control and Prevention
recommended testing for people born between 1945 and
1965 (ie, the birth cohort) because the prevalence rate of
HCV infection based on NHANES data was 3.3%in this
group; this rate was 5 times higher than among adults born
in other years and accounted for 76.5%of the total preva-
lence in the United States.
Birth cohort screening was ini-
tiated in June 2013 in the New York City jail system. After
implementation of birth cohort screening, we identified a
prevalence rate of 20.6%among those screened based on
birth cohort and risk factor criteria. Additionally, although
we found that HCV antibody prevalence was correlated over-
all with increasing age, a substantial number of HCV cases
were identified among people who were born after 1965.
The objective of this study was to describe the correlates
of HCV infection in the New York City jail population after
the initiation of birth cohort screening. To date, the corre-
lates of HCV infection in jail settings have been poorly
characterized. Because of rapid, frequent turnover between
jail populations and the community, we argue that under-
standing the correlates of HCV infection in jail populations
is crucial to (1) identify transmission patterns in the sur-
rounding community and (2) target high-risk groups for
focused public health intervention.
This cross-sectional study focused on people who were
incarcerated in the New York City jail system and tested
by correctional health providers using a targeted opt-out birth
cohort and risk factor–based screening strategy from June 13,
2013, to June 13, 2014. We extracted data on demographic
characteristics, jail admission, and discharge dates from elec-
tronic health records (EHRs). We abstracted data on medical
health, mental health, and substance use directly from med-
ical intakes in the EHR. We performed testing using the
Abbott EIA 2.0 HCV antibody test (Abbott Laboratories,
Abbott Park, Illinois) and transmitted the results to the EHR.
We included people who were tested whether the result was
reported as positive or negative. We removed indeterminate
results. For people who were tested more than once during
the study period, we used the most recent antibody test result.
We excluded from analysis people with missing intake data
or information that was not available within 30 days of
intake. We obtained institutional review board approval for
42 Public Health Reports 132(1)
this study from the New York City Department of Health and
We examined the association between HCV infection and
variables of interest for the screened population using logis-
tic regression analysis. We defined our dependent variable
dichotomously as a positive or negative HCV antibody test.
Independent variables included birth year, sex, race/ethni-
city, recidivism, self-reported drug use, infection with human
immunodeficiency virus (HIV), homelessness, mental ill-
ness, and education level. We analyzed age in 2 ways. First,
we created a dichotomous variable to compare those born
after 1965 with the 1945-1965 birth cohort. Second, we
grouped birth years by decade (after 1985, 1976-1985,
1966-1975, 1956-1965, 1946-1955, and before 1946) to pro-
vide additional detail. To preserve a fixed duration in birth
intervals, we included 1945 (the first year of the birth cohort)
in the category ‘‘before 1946.’’ We categorized race/ethni-
city as non-Hispanic black, Hispanic, non-Hispanic white,
Asian American/Pacific Islander, or other. We defined drug
use as using any illicit substance by any route currently or
historically, including marijuana, and coded it as no drug use,
non–injection drug use (non-IDU), or injection drug use
(IDU). We defined recidivism as having >1 incarceration
from April 15, 2011 (date of EHR initiation), until the end
of the study period (June 13, 2014). We dichotomized edu-
cation level by whether or not the respondent completed high
school (12th grade).
We determined significance in bivariate analyses by using
tests, with significance defined as P<.05.We
examined multivariate logistic regression models to estimate
odds ratios and 95%confidence intervals for predictors asso-
ciated with HCV antibody positivity. The models incorpo-
rated independent variables that were significant in bivariate
analyses at P< .05. We examined these models for the entire
study sample and also for those born after 1965 without well-
established risk factors or associations frequently used as
markers for HCV screening, including IDU and HIV infec-
tion. The first model adjusted for birth years in decades, sex,
race/ethnicity, substance use, recidivism, homelessness, HIV
status, homelessness, mental illness, and high school gradua-
tion. The second model adjusted for birth years in decades,
race/ethnicity, IDU status, recidivism, and homelessness. We
performed statistical analysis using SAS version 9.3.
During the study period, 56 590 people were incarcerated in
New York City jails, 8560 of whom (15.1%)wereborn
between 1945 and 1965. As reported elsewhere, correctional
health providers ordered 12 365 HCV antibody tests during
the study period, 1509 of which were duplicate, indetermi-
nate, or refused.
Additionally, 66 people were missing ele-
ments of intake data. Therefore, 10 790 people were screened
and had complete intake data, including positive or negative
results, 5456 (50.6%) of whom were part of the birth cohort,
5269 (48.8%) of whom were born after 1965, and 65 (0.6%)
of whom were born before 1945.
Of the 10 790 people in the cohort, 2221 (20.6%) were
HCV antibody positive (Table 1). Most were male (9275 of
10 790, 86.0%); 5631 (52.2%) were non-Hispanic black;
3439 (31.9%) were Hispanic; and 1368 (12.7%)were
non-Hispanic white. More than half of those tested (n ¼
6174, 57.2%) reported non-IDU; 2657 (24.6%) reported no
drug use; and 1959 (18.2%) reported IDU. Of these groups,
HCV antibody positivity was found in 1324 of 1959 (67.6%)
who reported IDU, 722 of 6174 (11.7%) who reported non-
IDU, and 175 of 2657 (6.6%) who reported no drug use. Of
the 10 790 respondents, 4599 (42.6%) reported not having a
high school diploma; 3744 (34.7%) reported mental illness;
and 998 (9.2%) reported being homeless. Of these groups,
HCV antibody positivity was found in 1038 of 4599 (22.6%)
respondents who reported not having a high school diploma,
1003 of 3744 (26.8%) who reported mental illness, and 298
of 998 (29.9%) who reported being homeless. HCV coinfec-
tion was present in 331 of 1197 (27.7%) people who reported
HIV infection. Recidivism was found in 1414 (13.1%) peo-
ple in the sample, and these people had the highest preva-
lence of HCV infection (497 of 1414, 35.1%).
The multivariate logistic regression model that included
the entire study sample showed a significant association
between HCV antibody positivity and being female, being
born before 1986 (with increasing odds ratios by decade,
with the exception of those born before 1946), being Hispa-
nic and non-Hispanic white rather than non-Hispanic black,
reporting IDU and non-IDU, having a history of recidivism,
being infected with HIV, homelessness, mental illness, and
not completing high school (P< .001; Table 2). In a multi-
variate logistic regression analysis for the subset of inmates
born from January 1, 1945, onward, with age as a dichoto-
mous variable for those born between 1945 and 1965 and
those born after 1965, the adjusted odds ratio for birth cohort
membership was 3.0 (95%confidence interval, 2.7-3.5).
For the 3529 inmates who were born after 1965 and
denied IDU and HIV infection, we conducted a second multi-
variate logistic regression analysis to understand the preva-
lence of HCV antibody positivity and predictors among this
group. The prevalence of HCV antibody positivity was 5.6%,
and a second logistic regression analysis showed that HCV
antibody positivity was significantly associated with being
born before 1986, being non-Hispanic white or Hispanic
rather than non-Hispanic black, homelessness, non-IDU, and
having a history of recidivism (Table 3).
These data from a large urban jail population reinforce IDU
as the best predictor of HCV antibody positivity. More than
two-thirds of those who reported IDU were HCV antibody
positive, a rate that is similar to rates reported in noncorrec-
Because low HCV-related case fatality rates
and long-lasting serostatus result in a direct correlation
Akiyama et al 43
between duration of IDU and HCV prevalence,
observed age-related increase in HCV antibody positivity
may be a function of cumulative risk resulting from
increased exposure to IDU over time. Nearly 60%of people
with HCV infection in our study reported IDU: because fear
of self-incrimination and lack of confidentiality may prevent
inmates from reporting IDU, this percentage may underesti-
mate the number of inmates who inject drugs.
of drug administration were more weakly associated but may
have also contributed to cumulative exposure to HCV infec-
tion over time. Biological and epidemiologic associations
have been demonstrated for snorting
cit substances, particularly crack and cocaine.
We observed a higher prevalence of HCV infection
among incarcerated females than among incarcerated males.
This epidemiologic pattern has been reported elsewhere in
the United States
and is thought to
be caused by the higher rates of IDU and exchange of sex for
money and drugs among females.
Data were not available
on sexual partnerships or histories of transactional sex for our
sample; however, these relationships may be more prominent
in jail settings because of prostitution- and drug-related
arrests. Another possible explanation is iatrogenic transmis-
sion through blood transfusions before widespread screening
in the early 1990s.
This transmission might have affected
women disproportionately because of transfusions during
childbirth. Further characterization of these relationships in
this population should be studied to refine priorities for
action among jailed women.
Non-Hispanic black people had the highest prevalence of
HCV infection in the United States in the NHANES data
In our sample, however, non-Hispanic white peo-
ple had the highest prevalence of HCV infection overall,
followed by Hispanic people. In the multivariate logistic
regression analysis, Hispanic people had the highest adjusted
odds for HCV infection. Recent data from the Hispanic Com-
munity Health Study / Study of Latinos help elucidate this
This study found an HCV prevalence rate of 4.5%
in the Bronx, New York, which was substantially higher than
the HCV prevalence rate in the other study sites, including
San Diego, Chicago, and Miami. Men and women of Puerto
Rican descent who lived in the Bronx had the highest HCV
Table 1. Demographic characteristics and bivariate associations of New York City jail inmates testing antibody positive for HCV, June 13,
2013, to June 13, 2014
Inmates, No. (%)
(n =10 790) Testing HCV Antibody Positive
(n =2221) PValue
Median age (range), y 48 (16-86) 50 (18-86)
Birth year <.001
>1985 1400 (13.0) 83 (5.9)
1976-1985 1652 (15.3) 367 (22.2)
1966-1975 2217 (20.5) 525 (23.7)
4566 (42.3) 876 (19.2)
868 (8.0) 341 (39.3)
<1946 87 (0.8) 29 (33.3)
Male 9275 (86.0) 1856 (20.0) <.001
Female 1515 (14.0) 365 (24.1)
Non-Hispanic black 5631 (52.2) 712 (12.6) <.001
Hispanic 3439 (31.9) 1017 (29.6)
Non-Hispanic white 1368 (12.7) 461 (33.7)
Asian American/Pacific Islander 138 (1.3) 9 (6.5)
Other 214 (2.0) 22 (10.3)
Injection drug use 1959 (18.2) 1324 (67.6) <.001
Non–injection drug use 6174 (57.2) 722 (11.7)
No drug use 2657 (24.6) 175 (6.6)
998 (9.2) 298 (29.9) <.001
Recidivism 1414 (13.1) 497 (35.1) <.001
3744 (34.7) 1003 (26.8) <.001
Never completed high school
4599 (42.6) 1038 (22.6) <.001
Human immunodeficiency virus infection 1197 (11.1) 331 (27.7) <.001
Abbreviation: HCV, hepatitis C virus.
Significance between risk groups.
Percentages may not total to 100 because of rounding.
Based on self-report.
44 Public Health Reports 132(1)
prevalence rates overall: 14.1%for men and 4.2%for
Hispanic people constitute 33%of the inmate pop-
ulation in the New York City jail system, and >70%of
people released to the community from New York City jails
return to areas with the greatest socioeconomic and health
disparities, particularly the Bronx and Central Brooklyn.
The interrelationship of poverty, substance use disorders, and
incarceration among Hispanic people, particularly in the
Bronx, may account for the observed independent risk for
HCV infection conferred by Hispanic ethnicity in this large
urban jail setting.
In contrast, the regression analysis for the subset of non-
IDU, non-HIV-infected people in jail who were born after
1965 demonstrates that non-Hispanic white race/ethnicity
best predicted HCV antibody positivity. Similar trends were
demonstrated in other correctional settings and likely
represent shifts in the epidemiology of IDU in surrounding
Increases in HCV infection among young
non-Hispanic white people transitioning from prescription
opioids to IDU in particular have been reported.
the second regression analysis included only those denying
IDU, fear of incrimination may be particularly prevalent in
this group. However, further investigation is required to
make that determination.
Other than IDU and birth during 1946 to 1955, recidivism
was most predictive of HCV infection in the adjusted regres-
sion model, followed by homelessness and mental illness.
The relationship among recidivism, homelessness, and men-
tal illness has been described
and linked to increased
rates of HCV infection.
The association between these
factors and HCV infection in our study provides further evi-
dence that homeless and mentally ill people who are caught
in cycles of active drug use and reincarceration are at high
risk for HCV infection.
Although the ability to comment on universal screening
using these data is limited, a substantial percentage of HCV
antibody–positive people were younger than the birth
cohort and denied a history of IDU. This group represents
a large number of jailed people who appear to lack well-
recognized risk factors for HCV infection. This finding may
support recent calls for universal screening in correctional
; however, further sensitivity analyses of the
current targeted screening strategy in correctional settings
should be performed to assess the efficacy of this strategy in
identifying HCV antibody–positive people. Because dupli-
cate HCV antibody testing in correctional settings has been
increased efforts in patient notification, use of
EHRs, and health system integration will be required to
be cost effective. Birth cohort screening in correctional
settings needs to be further scrutinized because the largest
proportion of the incarcerated population in the United
States was born between 1976 and 1980 and the HCV birth
cohort will age out.
A major limitation of this study was that screening was based
on birth cohort and health care providers’ assessments of
risk. Therefore, the prevalence of HCV infection was likely
Table 2. Multivariate regression analysis showing adjusted odds
ratios of hepatitis C virus antibody positivity for New York City
jail inmates tested from June 13, 2013, to June 13, 2014 (n ¼10 790)
(95% Confidence Interval)
After 1985 1.0 [Reference]
1976-1985 3.2 (2.4-4.2)
1966-1975 5.0 (3.8-6.7)
Before 1946 23.8 (11.8-43.9)
Male 1.0 [Reference]
Female 1.3 (1.1-1.5)
Non-Hispanic black 1.0 [Reference]
Hispanic 2.1 (1.8-2.4)
Non-Hispanic white 1.7 (1.5-2.1)
Asian American/Pacific Islander 0.6 (0.3-1.3)
Other 0.6 (0.4-1.1)
No drug use 1.0 [Reference]
Injection drug use 35.0 (28.5-43.0)
Non–injection drug use 2.0 (1.6-2.4)
Recidivism 1.7 (1.4-2.0)
HIV infection 1.5 (1.3-1.8)
Homelessness 1.4 (1.2-1.7)
Mental illness 1.2 (1.1-1.4)
Never completed high school 1.2 (1.1-1.4)
Abbreviation: HIV, human immunodeficiency virus.
Adjusted for birth years in decades, sex, race/ethnicity, substance use,
recidivism, homelessness, human immunodeficiency virus status, homeless-
ness, mental illness, and high school graduation status.
Table 3. Multivariate regression analysis showing adjusted odds
ratios of hepatitis C virus antibody positivity for non-IDU, non-
HIV-infected patients born after 1965, New York City jails, June
13, 2013, to June 13, 2014 (n ¼3529)
(95% Confidence Interval)
Before 1985 1.0 [Reference]
1976-1985 4.1 (2.3-7.2)
1966-1975 5.5 (3.2-9.4)
Non-Hispanic black 1.0 [Reference]
Hispanic 3.6 (2.5-5.2)
Non-Hispanic white 5.6 (3.5-8.9)
Non-IDU 2.4 (1.6-3.8)
Recidivism 3.6 (2.4-5.5)
Homelessness 2.0 (1.3-3.2)
Abbreviations: HIV, human immunodeficiency virus; IDU, injection drug use.
Adjusted for birth years in decades, race/ethnicity, IDU status, recidivism,
Akiyama et al 45
overestimated, particularly among those born after 1965. We
were also unable to describe the number of people with
chronic HCV infection because we used HCV antibody posi-
tivity for this analysis rather than HCV viral loads. Addition-
ally, we based risk factor data on self-report, and intake
screenings lacked key elements, such as duration of IDU,
sex with people who inject drugs, exchange of sex for drugs
or money, and a history of tattoos, piercings, or transfusions.
Therefore, the relative contribution of these factors to HCV
antibody positivity in this population is unclear.
This study provides a breadth of data on demographic char-
acteristics and correlates of HCV antibody positivity in a
large jail setting; many of these data are missing in other
studies, and they are especially important for developing
further guidelines on HCV testing for the cohort of people
born after 1965. Additionally, the correlates of HCV infec-
tion identified in our study support targeted public health
interventions, such as HCV education, harm reduction, and
treatment as prevention, among certain subgroups. Last,
higher HCV prevalence rates among the homeless, the men-
tally ill, those with lower education levels, and those with
histories of recidivism should be viewed as an opportunity
for intervention because, for HIV infection,
engaging these groups to HCV care may have collateral ben-
efits if services such as addiction medicine, psychiatry, and
primary care are integrated after inmates are released from
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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