HCV screening in a cohort of HIV infected and uninfected homeless and marginally housed women in San Francisco, California

Page et al. BMC Public Health (2017) 17:171 DOI 10.1186/s12889-017-4102-5 RESEARCH ARTICLE Open Access HCV screening in a cohort of HIV infected and uninfected homeless and marginally housed women in San Francisco, California Kimberly Page1*, Michelle Yu2, Jennifer Cohen3, Jennifer Evans2, Martha Shumway4 and Elise D. Riley5 Abstract Background: Hepatitis C virus (HCV) screening has taken on new importance as a result of updated guidelines and new curative therapies. Relatively few studies have assessed HCV infection in homeless populations, and a minority include women. We assessed prevalence and correlates of HCV exposure in a cohort of homeless and unstably housed women in San Francisco, and estimated the proportion undiagnosed. Methods: A probability sample of 246 women were recruited at free meal programs, homeless shelters, and low-cost single room occupancy hotels in San Francisco; women with HIV were oversampled. At baseline, anti-HCV status was assessed using an enzyme immunoassay, and results compared in both HIV-positive and negative women. Exposures were assessed by self-report. Logistic regression was used to assess factors independently associated th HCV exposure. Results: Among 246 women 45.9% were anti-HCV positive, of whom 61.1% were HIV coinfected; 27.4% of positives reported no prior screening. Most (72%) women were in the ‘baby-boomer’ birth cohort; 19% reported recent injection drug use (IDU). Factors independently associated with anti-HCV positivity were: being born in 1965 or earlier (AOR) 3.94; 95%CI: 1.88, 8.26), IDU history (AOR 4.0; 95%CI: 1.68, 9.55), and number of psychiatric diagnoses (AOR 1.16; 95%CI: 1.08, 1.25). Conclusions: Results fill an important gap in information regarding HCV among homeless women, and confirm the need for enhanced screening in this population where a high proportion are baby-boomers and have a history of drug use and psychiatric problems. Due to their age and risk profile, there is a high probability that women in this study have been infected for decades, and thus have significant liver disease. The association with mental illness and HCV suggests that in addition increased screening, augmenting mental health care and support may enhance treatment success. Keywords: Hepatitis C virus, HCV, Women, Homeless, HIV coinfection, Mental health Background Hepatitis C virus (HCV) infection is a widespread and chronic disease that is most prevalent among people who inject drugs (PWID) [1, 2], and which also disproportionately impacts racial and ethnic minorities [3–5], veterans [6], those who are incarcerated [7–9], the poor [10, 11], and unstably housed persons [12, 13]. A large number and proportion of HIV-infected patients are also * Correspondence: 1 Division of Epidemiology, Biostatistics & Preventive Medicine, Department of Internal Medicine, University of New Mexico Health Sciences Center, MSC10 5550; 1 University of New Mexico, Albuquerque, NM, USA Full list of author information is available at the end of the article co-infected with HCV [14]. Household-based surveillance puts estimates of the number of adult Americans ever infected with HCV at 3.6 million persons, and 2.7 million persons with chronic HCV [10]. However, since these surveys exclude the majority of high-risk populations, including incarcerated and homeless persons, the actual number is likely much higher, with an estimated 3.5 million current chronic infections (range 2.7 to 4.7 million) [15]. While a new generation of antiviral drugs (direct acting antivirals or DAAs) is transforming clinical outcomes, access remains a challenge, especially for these most affected groups, as a result of economic and © The Author(s). 2017 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Page et al. BMC Public Health (2017) 17:171 other barriers, including low rates of screening, diagnosis and linkage to care [3]. The lack of data regarding HCV in these populations adds to the uncertainty regarding the burden of HCV infection and the potential impact DAAs could have on population health and even potential eradication [16]. Testing and identifying those with HCV are the most significant first steps needed to engage infected patients in care and provide access to curative treatments. Riskbased HCV testing guidance issued by the Centers for Disease Control and Prevention (CDC) in 1998, and the U.S. Public Health Service and Infectious Diseases Society of America in 1999 [17, 18], was updated in 2012 by the CDC to include those born between 1945 and 1965 (the “baby boomers”) [19]. It was endorsed by the United States Preventive Services Task Force in 2013 after research showed this age group accounts for a large proportion (75%) of chronic HCV infections diagnosed and have elevated risk of mortality [20, 21]. While several studies have noted that HCV infection is elevated in homeless or unstably housed adult populations women are generally underrepresented in these studies [12, 13]. The purpose of this study was to determine the prevalence and correlates of HCV exposure in a wellcharacterized cohort of homeless and marginally housed women, and estimate the proportion of women with undiagnosed HCV exposure. Methods Participants and setting This study analyzed cross-sectional data from “Shelter, Health and Drug Outcomes among Women” (SHADOW), a prospective cohort study of homeless and unstably housed women in San Francisco [22]. Recruitment and enrollment occurred between June 2008 and August 2010. Using methods developed by Burman and Koegel [23], designed to recruit a representative sample of homeless individuals, women were systematically approached at free meal programs, homeless shelters, and low-cost single room occupancy (SRO) hotels selected with probability proportionate to the number of individuals served, and invited to participate in baseline screening at the study venue located in the Tenderloin neighborhood in downtown San Francisco. HIV-infected women were oversampled to meet the primary aims of the SHADOW study [22, 24]. Study inclusion criteria included female sex (biological), age ≥18 years, and a lifetime history of housing instability (slept in a public place, a shelter, or stayed with a series other people because they had no other place to sleep [“couch-surfed”]). Private interviews were conducted to collect data on demographic and social factors as shown in detail in the study survey (See Additional file 1). (...truncated)