Hepatitis C prevention programs: assessment of local health department capacity

Local health department epidemiologic capacity: a stratified cross-sectional assessment describing the quantity, education, training, and perceived competencies of epidemiologic staff

Introduction: Local health departments (LHDs) must have sufficient numbers of staff functioning in an epidemiologic role with proper education, training, and skills to protect the health of communities they serve. This pilot study was designed to describe the composition, training, and competency level of LHD staff and examine the hypothesis that potential disparities exist between LHDs serving different sized populations.

Materials and Methods: Cross-sectional surveys were conducted with directors and epidemiologic staff from a sample of 100 LHDs serving jurisdictions of varied sizes. Questionnaires included inquiries regarding staff composition, education, training, and measures of competency modeled on previously conducted studies by the Council of State and Territorial Epidemiologists. Number of epidemiologic staff, academic degree distribution, epidemiologic training, and both director and staff confidence in task competencies were calculated for each LHD size strata.

Results: Disparities in measurements were observed in LHDs serving different sized populations. LHDs serving small populations reported a smaller average number of epidemiologic staff than those serving larger jurisdictions. As size of population served increased, percentages of staff and directors holding bachelors’ and masters’ degrees increased, while those holding RN degrees decreased. A higher degree of perceived competency of staff in most task categories was reported in LHDs serving larger populations.

Discussion: LHDs serving smaller populations reported fewer epidemiologic staff, therefore might benefit from additional resources. Differences observed in staff education, training, and competencies suggest that enhanced epidemiologic training might be particularly needed in LHDs serving smaller populations. Results can be used as a baseline for future research aimed at identifying areas where training and personnel resources might be particularly needed to increase the capabilities of LHDs.

HCV and HIV counseling and testing integration in California: an innovative approach to increase HIV counseling and testing rates

OBJECTIVES

In California, injection drug users (IDUs) comprise the second leading risk group for human immunodeficiency virus (HIV) infection and the majority of hepatitis C virus (HCV) cases. Innovative disease screening and prevention activities are needed to improve disease surveillance and to guide appropriate public health responses. This study tested the hypothesis that offering HIV counseling and testing (C&T) concurrently with HCV C&T will increase HIV C&T rates among IDUs.

METHODS

From February through June 2003, HIV and HCV C&T were integrated in five California local health jurisdictions. HIV C&T and disclosure rates among IDUs were monitored when HIV C&T was offered alone during a baseline phase and when offered with HCV C&T during an intervention phase

RESULTS

Among IDUs, HIV C&T rates were significantly higher when HIV and HCV C&T were offered together (27.1%, 354/1,305) than when HIV C&T services were offered alone (8.4%, 138/1,645) (p<0.05). HIV disclosure rates increased from 54.3% (75/138) when only HIV test results were disclosed to 71.8% (254/354) when HIV test results were disclosed concurrently with HCV test results (p<0.05). HCV prevalence among IDUs tested ranged from 23% to 75% at the five project sites. Integrating HIV and HCV C&T increased overall C&T time required for staff and clients and increased stress among counselors due to the number of positive test results (HCV) given to clients.

CONCLUSIONS

Study results suggest that integrating HIV and HCV C&T can increase disease screening rates among IDUs. Careful planning of integrated staff activities and schedules is recommended.

Overcoming barriers to prevention, care, and treatment of hepatitis C in illicit drug users

Injection drug use accounts for most of the incident infections with hepatitis C virus (HCV) in the United States and other developed countries. HCV infection is a complex and challenging medical condition in injection drug users (IDUs). Elements of care for hepatitis C in illicit drug users include prevention counseling and education; screening for transmission risk behavior; testing for HCV and human immunodeficiency virus infection; vaccination against hepatitis A and B viruses; evaluation for comorbidities; coordination of substance-abuse treatment services, psychiatric care, and social support; evaluation of liver disease; and interferon-based treatment for HCV infection. Caring for patients who use illicit drugs presents challenges to the health-care team that require patience, experience, and an understanding of the dynamics of substance use and addiction. Nonetheless, programs are successfully integrating hepatitis C care for IDUs into health-care settings, including primary care, methadone treatment and other substance-abuse treatment programs, infectious disease clinics, and clinics in correctional facilities.

Integrating hepatitis C services into existing HIV services: the experiences of a sample of U.S. drug treatment units

Hepatitis C virus (HCV) is the most prevalent blood-borne infectious disease in the United States, especially among drug users, and coinfection with HIV is common. Because drug users are often medically underserved, drug treatment units are important sites of opportunity for providing services for these infectious diseases. Given the commonalities in the routes of transmission of HIV and HCV, and the fact that many drug treatment units have established an infrastructure to provide HIV services, some have suggested integrating HCV services into those already established for HIV. Using data collected in a telephone survey with 89 drug treatment units throughout the United States, this paper examines the extent to which drug treatment units have expanded their HIV services to include those for HCV, and the extent to which this expansion was facilitated by having HIV services in place. Overall, a greater proportion of methadone maintenance than drug-free treatment units provided services for HIV and HCV. The majority of units in both modalities that provided HIV- and HCV-related services expanded their HIV service delivery to include similar HCV services, and one third expanded all of their HIV services. A large number of these units, however, indicated that having an HIV service infrastructure did not facilitate this expansion, often because the units wanted to emphasize differences in the two viral infections. Policy makers and individual treatment units need to develop strategies that capitalize on existing infrastructures while maintaining the distinction between HIV and HCV primary and secondary prevention efforts.

Hepatitis C Virus Infection Among Injection Drug Users

BACKGROUND

Time to hepatitis C virus (HCV) seroconversion in initially seronegative injection drug users has not been directly measured, and public health planning would benefit from specifying the window of opportunity for prevention of infection, and factors that affect timing of infection.

METHODS

Four hundred eighty-four HCV antibody-negative injection drug users in Seattle, Washington were followed a median of 2.1 years to observe seroconversion. We examined time to HCV seroconversion in relation to subject characteristics using the Kaplan-Meier method and Cox proportional hazards regression. A weighted-average time to HCV seroconversion was calculated among new injectors (injecting < or = 2 years) using seroprevalence and seroincidence data.

RESULTS

There were 134 HCV seroconversions (11.6 per 100 person-years at risk; the 25th percentile of time to seroconversion was 26.2 months). Injection with a syringe used by another injector (adjusted hazards ratio = 1.8; 95% confidence interval = 1.3-3.0) and sharing a cooker or cotton (1.8; 1.0-3.1) were associated with time to HCV seroconversion. Using the estimate of the mean time to seroconversion from first injection in new injectors who were HCV antibody-negative at enrollment (5.4 years), and the midpoint between first injection and study enrollment in new injectors who were HCV antibody-positive at enrollment (0.6 years), the weighted-average time to seroconversion after beginning to inject was estimated to be 3.4 years.

CONCLUSION

The period of susceptibility to HCV infection in the majority of drug injectors appears to be long enough to justify the allocation of substantial resources toward interventions to reduce injection-related risk behavior in these individuals.