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27. Hepatitis C Virus (HCV) Prevalence, Access to Care, and Psychiatric Co-morbidities in the Northwest Network
KA Straits-Tröster, Center of Excellence in Substance Abuse Treatment and Education, VA Puget Sound Health Care System; Department of Psychiatry and Behavioral Sciences, University of Washington; KL Sloan, Center of Excellence in Substance Abuse Treatment & Education, VA Puget Sound Health Care System; Department of Psychiatry and Behavioral Sciences, University of Washington; JA Dominitz, Center of Excellence in Primary and Specialty Medical Care Service VA Puget Sound Health Care System; Department of Medicine University of Washington; DR Kivlahan, Center of Excellence in Substance Abuse Treatment & Education, VA Puget Sound Health Care System; Department of Psychiatry and Behavioral Sciences, University of Washington
Objectives: The purpose of this study was to determine the prevalence of hepatitis C virus (HCV) infection among veterans tested for HCV in the VHA Northwest Network (VISN 20). We contrasted demographic characteristics, comorbidity, treatment and service utilization patterns by HCV status among patients tested.
Methods: The VISN 20 data warehouse was utilized to identify a cohort of veterans tested for HCV between November 1, 1996 and August 1, 2000. Patients were divided into three groups according to HCV status: HCV antibody-negative (HCV-); HCV antibody positive, but no HCV-specific confirmatory testing done (HCVAb+) and; HCV confirmed positive by RIBA, PCR, or genotyping (Confirm+). Groups were examined for differences in abnormal hepatic enzymes, receipt of Gastroenterology (GI) or Infectious Disease (ID) services, interferon-based antiviral treatment, ICD-coded homelessness, and comorbid substance use and psychiatric diagnoses.
Results: Of the 25,080 veterans tested for HCV infection, 94.9% were male, average age was 53.9 years (SD 12.7), and 55.1% were either service-connected or receiving a VA pension. Among those tested, 19,674 (78.4%) were HCV-, 3061 (12.2%) were HCVAb+ only, and 2345 (9.4%) were Confirm+. Among those undergoing RIBA testing (n=568), 16.7% were RIBA negative. Among those receiving PCR testing (n=2608), 24.7% were PCR negative. The Confirm+ group was more likely to have had elevated ALT levels (81.4% vs. 64.3% for HCVAb+ only and 40.7% for HCV- groups), and to have received GI or ID services (54.4% vs. 29.0% for HCVAb+ only and 25.1% for HCV-). Of the Confirm+ individuals, 30.7% had no recorded inpatient or outpatient diagnosis of HCV. Only 7.7% of the Confirm+ veterans received anti-HCV medications. Among Confirm+ patients, the most common psychiatric diagnoses were drug dependence (64%), alcohol dependence (54%), and PTSD (32.2%). The HCV- group was less likely to be Vietnam era (46.5%) than the HCVAb+ only (69.0%) and Confirm+ groups (70.4%). The HCVAb+ only group was more likely to have diagnoses of alcohol abuse (59.8% vs. 54.0% for the Confirm+ and 32.0% for the HCV- groups), drug abuse (71.1% vs. 64.0% for Confirm+ and 40.9% for HCV-) and homelessness (32.9% vs. 30.4% for Confirm+ and 17.1% for HCV-). The HCVAb+ only veterans utilized more Emergency Room, Addictions, GI, and Primary Care services than did the other two groups.
Conclusions: Among veterans tested for HCV, 21.6% had evidence suggesting current or prior infection. The low proportion of patients receiving antiviral therapy may reflect the high proportion of HCVAb+ patients with psychiatric comorbidity and homelessness. The relatively high prevalence of psychosocial problems suggests that efforts to improve treatment access and adherence may need to target these issues. It is important to recognize that these results are not reflective of a population–based screening program. Consideration should also be given to standardizing confirmatory testing strategies, as there may be considerable false positive antibody results.
Impact: These results may guide improvements in consistency of diagnostic practices and adherence to VHA treatment guidelines for hepatitis C. High rates of substance use and psychiatric co-morbidity suggest multidisciplinary efforts are indicated for development of patient-specific interventions.