Hepatitis C Awareness and Risky Injection Behaviors among Injection Drug Users in Treatment PT Korthuis 1, D Feaster 2, Z Gomez 2, M Das-Douglas 3, S Tross 4, K Wiest 5, A Douaihy 6, RN Mandler 7, JL Sorensen 3, G Colfax 8, PE Penn 9, D Lape 5, L Metsch 2. 1 Oregon Health and Science University; 2 University of Miami Miller School of Medicine; 3 University of California, San Francisco; 4 Columbia University; 5 CODA; 6 University of Pittsburgh School of Medicine; 7 National Institute on Drug Abuse; 8 San Francisco Department of Public Health; 9 La 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 risk 2 HCV: – Survey of 197 IDU’s in Denver : HCV-aware engaged in fewer HCV risk behaviors 3 – Survey of 213 Swedish IDU: knowledge of HCV not associated with change in risky behaviors 4 – Survey of 337 IDU in Seattle: HCV-aware more likely to “sero-sort” needle sharing 5 1 Marks G, JAIDS 2005;39:446 2 Avants SK, JSAT 200;19:15 3 Kwiatkowski CF Addiction 2002;97: Norden, Scan J Infect Dis 2009;41: Burt RD, Drug & Alc Dep 2009;105: 215

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, HIV- negative 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) HCV Positive (n = 92) HCV Negative (n = 153) Total (n = 245) p-value Mean Age (SD)45.3(8.80)35.6(10.6)39.3(11.0)<.001 Male Gender (%)4447.8% % Race/Ethnicity (%).251 White5559.8% % % Hispanic1711.1%1819.6%3514.3% Black99.8%1711.1%2610.6% Other1010.9%138.5%239.4% Employed (%)2123.1%3019.6%5120.9%.519 Education (%).927 < High School2830.4%4328.1%7129.0% High School3234.8%5535.9%8735.5% ≥ Some College3234.8%5535.9%8735.5% Court Mandated Treatment (%) %3220.9%4920.0%.644 Jailed last 6 mo (%)2021.7%5535.9%7530.6%.019

Non-Injection Use in Past 6 Months, by HCV Self Report (n=245) HCV PositiveHCV NegativeTotalp-value Ecstasy 44.3%2214.4%2610.6%.014 Opioid % % %.963 Powder Cocaine %5535.9%7430.2%.012 Crack %6743.8% %.653 Pot %8152.9% %.078 Tranquilizer %5737.3%8735.5%.462 Painkillers %7549.0% %.019 Speed %3724.2%5422.0%.297 Hallucinogens 22.2%1811.8%208.2%.008 Alcohol to Intoxication % % %.001

Injection Drug Use in Past 6 Months, by HCV Self Report (n=245) HCV PositiveHCV NegativeTotalp-value Powder Cocaine2223.9%4328.1%6526.5%.472 Crack99.8%117.2%208.2%.473 Heroin & Powder Cocaine1010.9%1811.8%2811.4%.831 Heroin & Crack55.4%32.0%83.3%.138 Cocaine4831.4%2729.3%7530.6%.739 Heroin & Speed88.7%117.2%197.8%.670 Speed1213.0%1912.4%3112.7%.887 Dilaudid66.5%138.5%197.8%.576 Heroin6368.5%8454.9% %.036 Painkillers66.5%2315.0%2911.8%.046 Methadone22.2%95.9%114.5%.175 Opioids6975.0% % %.337 Barbiturates11.1%21.3%31.2%.879 Tranquilizers & Barbiturates 11.1%32.0%41.6%.601 Injected Multiple Drugs at a Time % % %.133

Injection Frequency and Needle Source in Past 6 Months, by HCV Self Report Positive (n = 91)Negative (n = 152)Total (n = 244)p-value Frequency of injection.206 Less than once a month %3523.2%5522.6% 1-3 times a month %2113.9%3715.2% About once a week %74.6%187.4% > Once a week, but not every day %4429.1%6928.4% Every day %4429.1%6426.3% Where Needles Obtained Diabetic %3422.4%5120.8%.485 Street %2516.3%3815.5%.644 MS/Hepatitis 33.3%21.3%52.0%.295 Drug store %8454.9% %.161 Shooting gallery 55.4%53.3%104.1%.407 Needle exchange program %2818.3%6124.9%.002 Other %2315.0%3915.9%.625

Needle Cleaning in Past 6 Months, By HCV Self Report PositiveNegativeTotalp-value Needle Cleaning Habits (n=244).310 Always use new needles %7751.3% % Always clean before shooting up %1912.7%3514.5% Always clean after shooting up %3724.7%5924.5% Sometimes clean needle %149.3%2811.6% Never clean needle 33.3%32.0%62.5% Needle Cleaning Method (n=125) Clean with bleach %3446.6%7156.3%.009 Clean with soap and water %3142.5%4938.9%.334 Clean with alcohol 47.5%1824.7%2217.5%.013 Clean with boiling water 611.3%1317.8%1915.1%.315 Did not clean needles 0.0%11.4%1.8%.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

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 `Positive (n = 91)Negative (n = 152)Total (n = 244)p-value Sharing Needles/Works4144.6%5334.9%9438.5%

Multivariate Associations with Needle Sharing Participant Characteristics % Needle Sharing (n = 244) OR 95% Confidence Interval Agen/a 0.95 (0.92, 0.99) Male31.8% 0.52 (0.28, 0.96) Race/Ethnicity White 42.9% Ref 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) Education (%) < High School 51.4% Ref 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)

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. 1 Hagan 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