Recent government studies show that hepatitis C, which can destroy the liver and necessitate a liver transplant, now kills more American adults than AIDS, and new UCLA research shows just how prevalent the disease is among homeless adults in downtown Los Angeles.
In a study published in the July/August issue of Public Health Reports, researchers found that 26.7 percent of homeless adults tested and surveyed in downtown Los Angeles' skid row were infected with the hepatitis C virus (HCV) more than 10 times the 2 percent rate among the general U.S. population. Of those surveyed, 46.1 percent were unaware that they were infected. Four percent of the sample were HIV-positive.
Few of the infected homeless adults surveyed had ever received any treatment for their HCV, says Dr. Lillian Gelberg, professor of family medicine at the David Geffen School of Medicine at UCLA, who led the study with Dr. Marjorie Robertson of the Public Health Institute's Alcohol Research Group. Less than 3 percent of those who knew they were infected had ever been treated.
"Their hepatitis C can result in high costs to the public and the healthcare system if progression of their disease is not halted through treatment," says Gelberg, who is also a professor of public health at the UCLA Fielding School of Public Health. "The costs of their untreated hepatitis C may start escalating soon, as many are approaching 20 years of infection, which is the point at which we see escalating risk for liver cirrhosis and end-stage liver disease, requiring expensive health services utilization and liver transplantation."
The study surveyed 534 homeless adults from 41 shelters and meal programs in the skid row area between June 2003 and February 2004. Most were males and the majority were African Americans. Each was tested for hepatitis B and C and for HIV. Overall, the researchers found that HCV prevalence was significantly higher among those homeless individuals who had injected drugs or been in prison; who were 40 years of age and older; who had less education; or who were U.S.-born.
Among the other key findings:
20.4 percent of those surveyed had injected illicit drugs; of those, 77.6 percent tested positive for HCV. Among those who had injected drugs, HCV infection was associated with older age and a prison history.
Among those who never used injection drugs, 13.6 percent had HCV. Infection rates were significantly higher among non-injectors if they were older, had less education, used serious non-injection drugs (excluding marijuana), had three or more tattoos, or had been in prison.
Overall, after controlling for other factors, sexual behaviors were not significantly related to HCV infection.
There are some limitations to this study. For instance, though HCV infection rates were based on blood tests, many of the other measures used were based on self-reporting, which is subject to recall bias and other errors. In addition, the findings may not be applicable beyond the population and geographic area the researchers studied, though the researchers noted that their sample's demographics were similar to those of other urban homeless populations that have been studied, and rates of IV drug use and HCV among injectors were similar to those of a general homeless sample.
"This and previous studies demonstrate that urban homeless adults in the U.S. are at high risk for HCV infection," the researchers concluded. "About half of those infected with HCV were unaware of their infection status. Homeless adults need interventions that include HCV education, counseling, voluntary testing and treatment services. HCV prevention and treatment programs could be modeled after relevant successful interventions developed for U.S. homeless persons with HIV/AIDS."
Other researchers included Lisa Arangua, Ardis Moe, Ronald M. Andersen, Barbara D. Leake, Gerald Sumner and Adeline Nyamathi, all of UCLA, and Hal Morgenstern of the University of Michigan.
The National Institute on Drug Abuse of the National Institutes of Health (RO1-DA14294) and the Centers for Disease Control funded this study. Gelberg received additional support as a Robert Wood Johnson Foundation Generalist Physician Faculty Scholar and as UCLA's George F. Kneller Chair in Family Medicine. Robertson received additional support from the National Alcohol Research Center (P60-AA05595) at the Alcohol Research Group of the Public Health Institute. Andersen received additional support from the UCLA/DREW Project EXPORT (funded by the National Center on Minority Health and Health Disparities, P20MD000148/P20MD000182).