Blinded Hepatitis C Antibody Serosurvey among clients using the Wisconsin HIV Counseling, Testing, and Referral Program Angela Russell, MS John Pfister, MS Neil Hoxie, MS Marjorie Hurie, RN, MS Brent Hasse, BS Jim Vergeront, MD Audrey Prieve, BS Joint project between the state lab hygiene and DPH CDC has recommended that HCV counseling testing and referral be integrated into HIV CTR programs Overall intent of the project was to determine if HCV screening should be integrated into HIV CTR program Wanted a picture of who has HCV among various groups using the CTR program

Presentation Overview Review Hepatitis C disease burden in WI Describe the purpose of the study Provide background on WI CTR Review the study methods Discuss the results of the study Discuss the study implications

Trends in HCV reporting, Wisconsin 1997-2002 HCV a reportable disease since 1990’s Previously reported as non-A non-B in the 1980’s Total Number of cases in the database: over 14,000 cases Overall reporting of hepatitis C in WI has increase nearly 5-fold since 1997. This is most likely due to an increase of in awareness of hepatitis C among health care providers The number of HCV in the WI state HCV will continue to increase as more people are tested for HCV and related to the LHD and state health department. Transition: Even though the number of cases reported to the state of Wisconsin health department is increasing, there are still many persons who are unaware that they have hepatitis C -- risks of unknowingly living with hepatitis C include inadvertently transmitted the virus to other, developing chronic hepatitis C that can lead to fibrosis or cirrhosis of the liver. Moreover, because of the similar modes of transmission between HIV and HCV, prevention strategies used for HIV such as publicly funded HIV counseling and testing sites can play a role in HCV testing and prevention.

Wisconsin Counseling, Testing and Referral (CTR) program Publicly funded program - administered through the WI AIDS/HIV Program (DPH) Offers free/low-cost anonymous and confidential HIV testing (~ 40 sites in WI) Include STD clinics, LHDs, CBOs, etc. Designed to serve individuals at increased risk for HIV (sexual and/or injection drug use behavior - esp. those w/o a health care provider)

Linkages: CTR and STDs 23% of CTR sites are STD clinics Clients who are HIV infected or at increased risk for HIV are at risk for other STDs In 2001, 28% of clients using CTR services had a hx of STD(s)

Purpose of the study Describe the prevalence of HCV infection among persons at risk for HCV infection using the WI CTR program To identify which HIV CTR should be offered testing Ultimately, results will help determine if publicly funded HIV CTR sited could play a role in HCV in WI In 2000, the CT Department of Public Health examined the HCV sero-prevalence among clients using their CTR program to evaluate the need for integrating HCV counseling and testing into the current HIC CTR program. Based upon the CT study results, the CT health department recommended that all persons visiting the HIV CTR sites should also receive HCV testing and prevention education. In WI, limited information was available regarding the prevalence of HCV among populations at risk for infection and there are not HCV prevalence data on persons using the HIV CTS program in WI.

How were the data collected and analyzed? Methods How were the data collected and analyzed?

Methods: Overview CTR questionnaire IRB approval: March 13, 2002 Study type: Cross-sectional Samples: Wisconsin CTR clients Year: 2000 Type: Risk factors for HIV and HCV infection AND persons at low risk CTR questionnaire IRB: B/C this was a joint project between the University of Wisconsin, State Laboratory of Hygiene and B/C this study involved human sera is was necessary to go through the institutional review board process - approval was obtained in March 2002. This is done to make sure that the study is ethical and that there is no harm to study participants. Study type: Cross-sectional study using existing serum specimens collected from clients seeking HIV testing services as part of the WI CTR program. Prior to receiving services, clients complete a CTR services questionnaire Demographic and behavioral information on clients was obtained from the CTR questionnaire.

Methods: Lab Testing and Statistical Analysis HCV testing: EIA @ SLH Repeatedly reactive specimens were considered presumptively anti-HCV seropositive. Statistical Analysis: Prevalence rates were stratified by IDU and non-IDU Sample: The study sample was selected from stored specimens from persons 18-65 years whose specimens were submitted to the WI State Laboratory of Hygiene pf HIV testing during 2000. 1,800 specimens were selected for HCV testing based upon reported risk factor (HIV+, IDU hx, MSM, STD hx, sex partner of IDU, and low risk (no reported risk factors). EIA tests were re-tested in duplicate - repeatedly reactive specimens were considered presumptively anitbody HCV seropositive. No confirmatory testing was performed. Data obtained from the self-administered demographic and behavior questionnaire were blinded (with personally indentifiers removed - and linked to the HCV serological results).

What is the prevalence of HCV among persons at risk for infection? Results What is the prevalence of HCV among persons at risk for infection? Of the 1,800 specimens to be selected for testing, 1,779 were tested fir anti-HCV. 22 of the samples not tested were either not located for did not have a sufficient volume for testing Among the persons tested, 60% were male, 57% were white, 60% were under 30 years of age Prevalence of HCV was nearly 18 times higher among persons with a history of infection drug use compared with persons with no history of injection drug use.

Prevalence of HCV by risk group Note: groups are based upon the sampling scheme defined groups This is based on the sampling scheme.

What is the HCV prevalence among IDUs by race and age? Results What is the HCV prevalence among IDUs by race and age? Overall, among persons with a hx of injection drug use, HCV prevalence varied by race, age, and metropolitan area.

IDU HCV prevalence by race Among IDUs the HCV prevalence is highest among blacks, this is consistent with other prevalence data However, race is not associated with HCV infection independently of socio- demographic, socioeconomic, and behavioral risk factors In this analysis, race may be a proxy for socioeconomic status and/or behavioral risk factors.

IDU HCV prevalence by age Among IDUs, HCV prevalence increased with increasing age, In the sample, by the time someone was 50-59 years of age, nearly 100% were HCV positive.

Results How does IDU history effect the HCV prevalence among different risk groups?

HCV prevalence by IDU history and HIV diagnosis

HCV prevalence by IDU history and MSM

HCV prevalence by IDU history and SPIDU history

HCV prevalence by IDU history and STD diagnosis history

Results Summary Highest prevalence of HCV: hx of IDU No history of IDU Among persons with IDU hx Persons aged 18 to 24 years had the lowest HCV prevalence Prevalence increased with increasing age No history of IDU Persons with a history of SPIDU had a higher HCV prevalence compared with other groups. No increased risk among MSM for HCV

Increased risk of HCV transmission among IDUs Parenteral transmission of HCV is very efficient Large reservoir of infected IDUs with potential for spreading the virus through parenteral contact HCV is also spread by sharing additional injection drug equipment (e.g. cookers, rinse water, cotton filters)

Increasing HCV with increasing age Age as proxy measurement for duration of injection drug use Effectiveness of HCV prevention programs (harm reduction) A great opportunity for prevention programs geared toward youth and young adults

Less HCV among MSM HCV most effective means of transmission is parenteral HCV inefficiently spread via sexual transmission Risk of HCV among MSM similar to risk among nonMSM High risk sexual behavior may increase risk for both MSM and nonMSM

Study Limitations The data are based upon self-reported risk factors Convenience sample Cannot be used to generalize about HCV in the general population May be an overestimate of the overall prevalence of HCV in CTR clients

Conclusion WI CTR program can identify persons with HCV HCV counseling and testing should be offered to: persons with an IDU hx persons who are sexual partners of persons with IDU hx persons who are HIV positive

Bottom Line HCV counseling and testing should be offered to persons at risk for HCV (IDUs, SPIDUs, HIV+s) at CTR sites WI Hep C and AIDS/HIV programs are determining methods to integrate HCV testing into the WI CTR program