primary and secondary prevention of hepatitis c virus among rural appalachian people who use

140 Pages·2017·0.96 MB·English

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Theses and Dissertations--Clinical and
Behavioral Science
Translational Science
2014
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Dustin B. Stephens
University of Kentucky, [email protected]
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Stephens, Dustin B., "PRIMARY AND SECONDARY PREVENTION OF HEPATITIS C VIRUS AMONG RURAL
APPALACHIAN PEOPLE WHO USE DRUGS" (2014). Theses and Dissertations--Clinical and Translational
Science. 1.
https://uknowledge.uky.edu/cts_etds/1
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Dustin B. Stephens, Student
Dr. Jennifer R. Havens, Major Professor
Dr. Anita Fernander, Director of Graduate Studies
PRIMARY AND SECONDARY PREVENTION OF HEPATITIS C VIRUS AMONG 
RURAL APPALACHIAN PEOPLE WHO USE DRUGS 

DISSERTATION 

A dissertation submitted in partial fulfillment of the requirements for the degree of 
Doctor of Philosophy in the College of Medicine at the University of Kentucky 

By 

Dustin B. Stephens 

Lexington, Kentucky 

Director: Dr. Jennifer R. Havens, Professor of Behavioral Science 

Lexington, Kentucky 

2014 

Copyright © Dustin B. Stephens 2014
ABSTRACT OF DISSERTATION 

PRIMARY AND SECONDARY PREVENTION OF HEPATITIS C VIRUS AMONG 
RURAL APPALACHIAN PEOPLE WHO USE DRUGS 

  Hepatitis C virus (HCV) remains a major cause of morbidity and mortality worldwide, 
with 3% of the global population chronically infected. Clinical impacts in the United States are 
projected to increase for two decades, and mortality attributed to HCV now exceeds HIV. 
Injection drug use (IDU) is the most common route of transmission in the developed world. 
Advances in treatment offer hope of mitigating HCV impacts, but substantial barriers obstruct 
people who inject drugs (PWID) from receiving care, particularly in medically underserved 
regions  including  Central  Appalachia.  This  study  assessed  IDU  paraphernalia  sharing 
longitudinally over 24 months in a sample of 283 rural PWID recruited by respondent‐driven 
sampling.  Medical  follow‐up  among  254  seropositive  participants  was  also  assessed  using 
discrete‐time survival analysis.  

  HCV‐positive screening  was associated with reduced IDU sharing frequency 18 months 
after testing compared to seronegative participants (adjusted OR [aOR]=1.4, 95% confidence 
interval [CI]: 1.0‐1.9), but this effect was not sustained. HCV‐positive participants were less likely 
to cease IDU 6 months after testing (aOR=0.4, 95% CI: 0.2‐0.7). Predictors negatively associated 
with decreased IDU sharing included recent unprotected sex, sedative use, and frequency of 
prescription opioid IDU; protective associations included female gender and religious affiliation. 
IDU cessation was negatively associated with ever being incarcerated, recent unprotected sex 
with  PWID,    heavy  alcohol  use,  lifetime  use  of  OxyContin®,  and  baseline  frequency  of 
prescription  opioid  IDU;  protective  associations  included  number  of  dependents,  receiving 
disability payments, and substance abuse treatment. Drug‐specific associations decreasing IDU 
cessation included recent illicit use of OxyContin®, other oxycodone, and cocaine.  

  150 of 254 (59%) seropositive participants saw a clinician after HCV‐positive screening 
and counseling, 35 (14%) sought treatment, and 21 (8%) received treatment. Positive predictors 
of following up with a clinician following testing and counseling included health insurance, 
internet  access,  past  substance  abuse  treatment,  generalized  anxiety  disorder,  and  recent 
marijuana use. Factors decreasing odds of follow‐up included major depression, lifetime illicit 
methadone  use,  and  recent  legal  methadone.  These  analyses  shed  valuable  light  on 
determinants  of  behavior  impacting  primary  and  secondary  HCV  prevention.  Integrated, 
multidisciplinary approaches are recommended to meaningfully impact epidemic levels of HCV 
among rural PWID in Eastern Kentucky.
KEYWORDS:  Hepatitis C, injection drug use, prevention, treatment uptake, rural Appalachia 

    Dustin B. Stephens 
     Student’s Signature 

    July 31, 2014 
    Date
PRIMARY AND SECONDARY PREVENTION OF HEPATITIS C VIRUS AMONG 
RURAL APPALACHIAN PEOPLE WHO USE DRUGS 

By 

Dustin B. Stephens 

    Jennifer R. Havens, MPH PhD 
    Director of Dissertation 

    Anita Fernander, PhD 
    Director of Graduate Studies 

    July 31, 2014
TABLE OF CONTENTS 

List of Tables……………………………………………………………………………………………………………………………....v 

List of Figures…………………………………………………………………………………………………………………………….vii 

Chapter 1  –  The Quiet Killer:  Overview of hepatitis C virus   
    1.1  Introduction……………………………………………………………………………………………………....1 
    1.2  Virology and taxonomy…………………………………………………………………………………......2 
    1.3  Epidemiology………………………………………………………………………………………………………4 
    1.4  Clinical course and public health impact……………………………………………………………..5 
    1.5  Screening and management………………………………………………………………………….……8 
      Medical assessment and indications for treatment……………………………………….…….9 
      Treatment guidelines………………………………………………………………………………………..13 
    1.6  Injection drug use in rural Appalachia……………………………………………………………….14  
    1.7  Rationale and aims of project……………………………………………………………………….....15 
Chapter 2  –  Routes of Transmission:  Risk factors for the spread of HCV 
    2.1  Overview…………………………………………………………………………………………………….….…18 
      Injection drug use……………………………………………………………………………………….…….19 
      Intranasal drug use……………………………………………………………………………………….…..20 
      Blood transfusion, transplantation, and other iatrogenic exposures………….........21 
      Vertical transmission………………………………………………………………………………………...22 
Tattooing, piercing, and folk medical practices………………………………………………....22 
Sexual transmission and other mucosal routes.…………………………………………………23  
2.2  Approaches to prevention…………………………………………….………………………………….24 

Chapter 3  –  Primary Prevention:   HCV screening and transmission risk behavior among rural  
       Appalachian people who inject drugs   
    3.1  Introduction……………………………………………………………………………………………….…….27 
    3.2  Methods……………………………………………………………………………………………………..…….30 
      Sampling………………………………………………………………………………………………………..….30 
      HCV serotesting and data collection………………………………………………………………....32 
      Analysis……………………………………………………………………………………………………………..36 
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3.3  Results………………………………………………………………………………………………….………....40 
      Description of IDU risk behavior…………………………………………………………….….………40 
      Correlates of IDU sharing at baseline…………………………………………………….………….43 
      Predictors of change in IDU sharing frequency………………………………………………….45 
      Predictors of IDU cessation……………………………………………………………………….………51 
    3.4  Discussion………………………………………………………………………………………………….……..54 

Chapter 4 –  Secondary Prevention:  Factors impacting progression of chronic hepatitis C 
    4.1  Overview…………………………………………………………………………….…………………………….66 
    4.2  HCV treatment and barriers to care…………………………………….……………………………68 
       Individual‐level…………………………………………………………………….…………………………..71 
       Healthcare provider‐level………………………………………………………..………………………..74 
             Healthcare system and societal barriers…………………………………….……………………..76 

Chapter 5  –  Barriers to Care:  HCV treatment uptake and predictors of healthcare engagement    
        among rural Appalachian people who use drugs 
    5.1  Introduction………………………………………………………………………………………………………78 
    5.2  Methods………………………………………………………………………………………………….………..83 
      Sampling………………………………………………………………………………………………….………..83 
      HCV serotesting and data collection……………………………………………………….…………83 
      Analysis………………………………………………………………………………………………….……….…85 
    5.3  Results………………………………………………………………………………………………….…………..88 
    5.4  Discussion…………………………………………………………………………………………….…………..94 
    5.5  Conclusions………………………………………………………………………………………….……………99 

Appendix…………………………………………………………………………………………………………………………….…..102 

 References……………………………………………………………………………………………………………………………..109 

 Vita…………………………………………………………………………………………………………………………………………129  
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LIST OF TABLES 

Table 1.1:  Recommended guidelines indicating individuals should be screened for HCV…………...9 

Table 1.2:  Characteristics of individuals for whom HCV drug treatment is widely accepted……..11 

Table 1.3:  Absolute contraindications to drug treatment for HCV…………………………………………….12 

Table 3.1:  Guidelines for pre‐test counseling of individuals receiving an HCV antibody test…….33 

Table 3.2:  Guidelines for post‐test counseling of individuals testing HCV‐seropositive…………….34 

Table 3.3:  Drug‐related behavior and baseline HCV test result and counseling received (T&C)      
     among recent PWID (n=288)…………………………………………………………………………………….39 

Table 3.4:  Baseline sample characteristics of recent PWID and RDS‐adjusted bivariate  
     associations with any IDU sharing (n=283)...…………………………………………………………….42 

Table 3.5: Baseline correlates of IDU sharing among recent PWID (n=283)..................................45 

Table 3.6:  Description of sample and population‐averaged bivariate associations with  
     decreased IDU sharing among recent PWID with no previous HCV+ test (n=220)…….46 

Table 3.7:  Predictors of decreased IDU sharing among recent PWID with no previous HCV+  
     test (n=220)……………………………………………………………………………………………………………..49 

Table 3.8:  Predictors of increased IDU sharing among recent PWID (n=283)……………………………50 

Table 3.9:  Predictors of IDU cessation among recent PWID, excluding recent illicit drug use          
     measures (n=220)…………………………………………………………………………………………………….52 

Table 3.10:  Predictors of IDU cessation among recent PWID, including recent illicit drug use      
       measures (n=220)….……………………………………………………………………………………………...53 

Table 5.1:  Medical follow‐up, treatment seeking, and treatment receipt after HCV‐positive        
     serotest and counseling (n=254)………………………………………………………………………………88 

Table 5.2:  Life table with sample hazard and survival probabilities for receiving medical  
     follow‐up after HCV+ testing and counseling…………………………………………………………..89 

Table 5.3:  RDS‐adjusted population estimates for hazard and survival probabilities of  
     receiving medical follow‐up after HCV+ testing and counseling………………………………90 

Table 5.4:  Description of sample and bivariate associations with receiving medical follow‐up     
     after HCV‐positive test and counseling (n=254)……………………………………………………….91 

Table 5.5:  Predictors of medical follow‐up after HCV‐positive test and counseling: Linear  
     time model (n=254)………………………………………………………………………………………………….93 
v
LIST OF FIGURES 

Figure 3.1:  RDS‐adjusted population estimates and 95% confidence intervals for proportion  
       of PWID sharing any IDU paraphernalia………………………………………………………………….41 

Figure 5.1:  RDS‐adjusted population hazard functions of following up with a healthcare  
       provider after HCV‐positive testing and counseling……………………………………………….90 

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