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ASSESSING THE ASSOCIATION BETWEEN RISKY SEXUAL
BEHAVIORS AND HEPATITIS C AMONG DRUG USERS RECENTLY
RELEASED FROM INCARCERATION
_______________
A Thesis
Presented to the
Faculty of
San Diego State University
_______________
In Partial Fulfillment
of the Requirements for the Degree
Master of Public Health
with a Concentration in
Epidemiology
_______________
by
Christiane-Rayna R. Lopez
Summer 2013
iii
Copyright © 2013
by
Christiane-Rayna R. Lopez
All Rights Reserved
iv
DEDICATION
This thesis is dedicated to my parents, who have given me every opportunity to
succeed, as well as their unconditional support and constant encouragement.
v
ABSTRACT OF THE THESIS
Assessing the Association between Risky Sexual Behaviors and
Hepatitis C among Drug Users Recently Released from
Incarceration
by
Christiane-Rayna R. Lopez
Master of Public Health with a Concentration in Epidemiology
San Diego State University, 2013
Hepatitis C is the most common bloodborne infection in the United States, with the
primary mode of transmission being from injection drug use. Hepatitis C can also be
transmitted sexually, but whether this is an efficient means for transmission is unclear.
Although Hepatitis C transmission has been shown to be very low in low-risk, heterosexual,
long-term, monogamous relationships, higher prevalences have been found among groups
likely to be engaging in high-risk sexual behavior, such as men who have sex with men, sex
workers, and patients of STI clinics. As drug users and incarcerated populations have high
Hepatitis C prevalences compared to the general population, and have reported high rates of
risky sexual behaviors, it would be possible for sexual transmission of Hepatitis C to occur
within these vulnerable populations. This study uses cross-sectional data from the
HIV/HEPC study conducted as part of the National Institute for Drug Abuse's Criminal
Justice Drug Abuse Treatment Studies to assess the relationship between engaging in risky
sexual behaviors and Hepatitis C. Data from 614 participants recently released from
incarceration were analyzed. Risky sexual behavior was defined as the number of sexual
partners and engaging in unprotected sex with a casual partner, injection drug user, or while
self or partner exchanged sex for money, drugs, or gifts, within the six months before
incarceration. Hepatitis C status was determined using an ELISA antibody assay. Other
independent variables included were history of sexually transmitted infections, history of
injection drug use, ever having a tattoo, ever having a blood transfusion, total years
incarcerated, age, race, and sex. This study did not find a significant association between
risky sexual behaviors and Hepatitis C test result after adjusting for other variables; however,
its findings suggest that more research should be done to assess this relationship within
different groups, in the context of different drugs, and within correctional facilities
themselves.
vi
TABLE OF CONTENTS
PAGE
ABSTRACT ...............................................................................................................................v
LIST OF TABLES ................................................................................................................. viii
LIST OF FIGURES ................................................................................................................. ix
ACKNOWLEDGEMENTS .......................................................................................................x
CHAPTER
1
INTRODUCTION .........................................................................................................1
Background ..............................................................................................................1
Statement of the Problem .........................................................................................2
Purpose of the Study ................................................................................................2
Hypothesis................................................................................................................2
Basic Assumptions ...................................................................................................3
Definition of Terms..................................................................................................3
2
LITERATURE REVIEW ..............................................................................................4
Overview ..................................................................................................................4
Sexual Transmission of Hepatitis C .........................................................................5
Injection Drug Use and Hepatitis C .........................................................................7
Drug Use and Risky Sexual Behavior .....................................................................8
The Incarcerated Population ....................................................................................9
Hepatitis C in Incarcerated Populations .................................................................10
Drug Users in Incarcerated Populations ................................................................10
Risky Behaviors in Incarcerated Populations ........................................................11
Hepatitis C Prevention and Control in Correctional Facilities ..............................13
Conclusion .............................................................................................................14
3
METHODS ..................................................................................................................16
Study Design ..........................................................................................................16
Study Population and Eligibility ............................................................................17
Data Collection and Measures ...............................................................................17
vii
Study Variables ......................................................................................................19
Outcome and Main Variable of Interest...........................................................19
History of STIs .................................................................................................20
History of Injection Drug Use..........................................................................20
Other HCV Risk Behaviors .............................................................................21
Total Years Incarcerated ..................................................................................21
Sociodemographic Variables ...........................................................................21
Statistical Analysis .................................................................................................21
4
RESULTS ....................................................................................................................23
5
DISCUSSION ..............................................................................................................31
Key Findings ..........................................................................................................31
Limitations .............................................................................................................33
Strengths ................................................................................................................35
Implications and Future Research ..........................................................................35
REFERENCES ........................................................................................................................38
viii
LIST OF TABLES
PAGE
Table 1. Descriptive Statistics for Covariates of Interest in Drug Offenders Recently
Released from Incarceration, n=614 ............................................................................24
Table 2. Descriptive and Bivariate Statistics for Covariates of Interest in Drug
Offenders Recently Released from Incarceration, by Sexual Behavior
Category, n=614 ...........................................................................................................26
Table 3. Simple Logistic Regression of Covariates of Interest with Hepatitis C Test
Result a for Drug Offenders Recently Released from Incarceration, n=614 ................28
Table 4. Final Multivariable Logistic Regression Model of Variables of Interest with
Hepatitis C Test Result a for Drug Offenders Recently Released from
Incarceration, n=614 ....................................................................................................30
ix
LIST OF FIGURES
PAGE
Figure 1. Final sample size for present analysis. .....................................................................18
x
ACKNOWLEDGEMENTS
I would like to thank my committee members, Dr. Alcaraz, Dr. Ferran, and Dr.
Mobley, for their guidance and for sharing their knowledge with me. I would also like to
thank my family and friends for their amazing support these past two years.
1
CHAPTER 1
INTRODUCTION
This chapter will discuss background information on Hepatitis C in the U.S., state the
problem this thesis will address, and the describe the purpose and hypothesis of this study.
BACKGROUND
Hepatitis C (HCV) is the most common bloodborne infection in the United States,
with approximately 2% of the population, or 3.2 million people, chronically infected (Centers
for Disease Control [CDC], 2011a). HCV can be asymptomatic, and without treatment, it can
result in hepatic fibrosis, cirrhosis, and liver cancer. It is the leading cause for liver
transplantation and death from liver disease (Chak, Talal, Sherman, Schiff, & Saab, 2011;
United States Department of Health & Human Services [HHS], 2011). HCV is transmitted
through percutaneous exposure to blood from an infected person, and is usually spread by
blood transfusion from infected donors or the use of contaminated syringes for illicit drug
use. Occupational, perinatal, and sexual transmission of HCV can also occur.
In the U.S., injection drug use is the primary mode of transmission for Hepatitis C.
Injection drug use accounts for 68% of current infections and more than 60% of new cases
(Shepard, Finelli, & Alter, 2005; Thorpe et al., 2002). Injection drug users (IDU) are at a
much higher risk for HCV due to risky behaviors, such as sharing syringes and drug
paraphernalia, that increase their exposure to infected blood.
Research on the role of sexual behavior in the transmission of Hepatitis C has been
controversial. According to the CDC (2011a), sexual transmission of HCV is possible, but
inefficient. However, higher rates of HCV have been found among groups likely to be
engaging in high-risk sexual behaviors, such as men who have sex with men (MSM), sex
partners of people infected with HIV, prostitutes, and patients attending STD clinics (Thomas
et al., 1994). Rough sexual acts and sexually transmitted infections can increase exposure to
infected blood and create an opening for HCV to be transmitted.
2
The incarcerated population is disproportionately affected by HCV compared to the
general US population, with estimates of 16-41% of inmates infected versus 2% of the nonincarcerated population (CDC, 2011b). In correctional facilities, one out of every three
individuals is infected with HCV. The higher rates of HCV among the incarcerated
population are often attributed to a higher rate of injection drug users entering prison and
increased frequency of high-risk sexual behaviors, tattoos, and non-injection drug use among
those incarcerated (Burton, Reilly, & Penman, 2010).
STATEMENT OF THE PROBLEM
Both Hepatitis C and risky sexual behaviors are prevalent among illicit drug users and
incarcerated populations. It is possible for HCV to be acquired through injection drug use
and then spread through sexual activities. This represents an important public health problem
as drug offenders make up a significant proportion of those incarcerated and may continue to
engage in risky drug sharing and sexual behaviors after reentering the community. Given the
higher prevalence of Hepatitis C and the increased likelihood of behavioral risk factors in
drug users and incarcerated populations, understanding the role of risky sexual activity
behaviors on HCV transmission is important to develop and implement effective prevention
and control programs to screen, treat, and educate incarcerated drug users reentering the
community.
PURPOSE OF THE STUDY
The purpose of this thesis is to assess the relationship between positive Hepatitis C
status and risky sexual behavior in a population of drug users recently released from
incarceration. The goal of this thesis is to identify demographic and behavioral differences in
sexual and HCV risk behaviors between drug users who received a positive HCV test result,
compared to those who received a negative test result. This study uses data from the National
Institute on Drug Abuse's Criminal Justice Drug Abuse Treatment Studies (NIDA CJ-DATS)
HIV/HEPC study.
HYPOTHESIS
There is an association between risky sexual behaviors and positive HCV status.
Among drug users recently released from incarceration, those reporting risky sexual
3
behaviors were more likely to have tested positive for HCV, compared to those who reported
no risky sexual behaviors.
BASIC ASSUMPTIONS
This study assumes participants answered the survey questions truthfully, and their
responses were coded and entered correctly.
DEFINITION OF TERMS
The following is a list of terms commonly used in this thesis:
1. HCV: Hepatitis C virus--causes liver disease that often becomes a chronic condition
and can lead to cirrhosis and liver cancer.
2. HIV: Human immunodeficiency virus--severely damages the immune system by
infecting CD4+ T cells, leaving the body more susceptible to infections. This can lead
to acquired immune deficiency syndrome (AIDS).
3. IDU: Injection drug user--an individual who uses syringes to administer illicit drugs
4. NIDU: Non-injection drug user--an individual who takes illicit drugs, but does not
administer the drugs using syringes
5. MSM: Men who have sex with men
6. STI/STD: Sexually transmitted infection or sexually transmitted disease
7. NIDA CJ-DATS: National Institute on Drug Abuse's Criminal Justice Drug Abuse
Treatment Studies
8. ELISA: Enzyme-linked immuno assay--a laboratory test commonly used to detect
antibodies in a sample of blood
9. Anti-HCV: Antibodies to Hepatitis C
4
CHAPTER 2
LITERATURE REVIEW
This chapter will discuss key findings in the literature on Hepatitis C and its
relationship with sexual behavior, drug use, and incarcerated populations.
OVERVIEW
Hepatitis C is the most common bloodborne infection in the United States. Of the
estimated 3.2 million people infected nationwide, 65-75% are unaware of their infection
status and are not receiving care and treatment (HHS, 2011). HCV is a leading cause of
chronic liver disease and can lead to hepatic fibrosis, cirrhosis, and hepatocellular carcinoma.
It is also the leading cause for liver transplantation, liver cancer, and death from liver disease,
with Hepatitis C-related mortality increasing by 123% from 1995 to 2004 (Awofeso, 2010;
Chak et al., 2011; HHS, 2011). Between 60 and 70% of acute HCV infections are
asymptomatic and 60-85% of acute cases progress to chronic infection. Of those chronic
Hepatitis C infections, between 10 and 20% will develop complications of chronic liver
disease within 20 to 30 years and 1-5% will develop liver cancer. There are more than
500,000 new cases of liver cancer each year, 22% of which can be attributed to HCV
infection (Ghany, Strader, Thomas, & Seeff, 2009; Lavanchy, 2011). There is no vaccine and
no effective post-exposure prophylaxis for HCV. Chronic Hepatitis C can be treated, usually
with a combination of interferon and ribavirin. But the price of current treatment regimens is
high; a typical 48-week course of therapy for the most common genotype of HCV would cost
$25,000 (Shepard et al., 2005). The annual costs of acute and chronic Hepatitis C are
currently estimated to be over $600 million, and total costs are estimated to be $184 billion
between 2010-2019 (Lavanchy, 2011).
Hepatitis C is primarily transmitted through percutaneous exposure to infected blood.
Before blood screening became available in 1992, HCV was most commonly transmitted
through blood transfusion; currently, the leading means of HCV transmission in the U.S. is
injection drug use (CDC, 2012). HCV can also be transmitted through needle-stick injuries,
5
during birth to an HCV-infected mother, and infrequently through sex with an HCV-infected
partner and sharing of personal items contaminated with infectious blood. Risk groups for
Hepatitis C include injection-drug users (IDUs), men who have sex with men (MSM), and
incarcerated populations. Higher prevalence of HCV is also seen among African-Americans
and persons born between 1945-1965. The CDC (2012) recently recommended that all
persons in this age range be tested for Hepatitis C as this age group is five times more likely
than those in other adult age groups to be infected, though the reasons why there are such
high rates among baby boomers is not completely understood.
SEXUAL TRANSMISSION OF HEPATITIS C
Research on sexual transmission of Hepatitis C has been controversial. According to
the CDC (2011a), sexual transmission of HCV is possible, but not efficient. Studies in lowrisk heterosexual relationships with long-term monogamous partners have shown the
frequency of sexual transmission of HCV to be very low (Hahn, 2007; van de Laar et al.,
2007). A cross-sectional study of 80 patients with chronic HCV-associated liver disease and
their spouses found sexual transmission to be possible in only 2 (2.5%) spouses, despite the
high percent of long sexual relationships and the high frequency of unprotected sex
(Neumayr, Propst, Schwaighofer, Judmaier, & Vogel, 1999). The HCV Partners Study found
the prevalence of infection among sexual partners of 500 HCV-positive persons to be 4%
(Terrault et al., 2013). The prevalence of infection potentially attributable to sexual contact
was 0.6%, as 3 couples had partners infected with the same HCV strain as their HCVpositive counterparts. As the risk of sexual transmission of HCV in long-term monogamous
heterosexual couples reporting no other HCV risk factors has been shown to be low, the CDC
advises that such couples do not need to change their sexual practices (CDC, 2010).
However, higher rates of HCV have been found among MSM, sex partners of people
infected with HIV, prostitutes, and patients attending STD clinics. These groups are likely to
be engaging in high-risk sexual behaviors, such as having unprotected anal intercourse,
having multiple sex partners, and using rough sexual techniques, and may be co-infected
with other STIs. Risky sexual behaviors and STI co-infection have been identified as
potential risk factors for sexual transmission of HCV as such behaviors can lead to blood-toblood contact and STIs can create a portal of entry through the anal or genital mucosal
6
barrier. A study by Thomas et al. (1994) determined the seroprevalence of HCV among noninjection-drug using patients attending Baltimore STD clinics to be 9.7%. In men, the
presence of Hepatitis C antibodies was found to be associated with age, failure to use
condoms, having a history of gonorrhea, and the presence of HIV antibodies or Hepatitis B
antibodies. For women, the presence of HCV antibodies was significantly associated with
having more than one male sex partner in the month before their visit and the presence of
antibodies for Hepatitis B or HIV.
The frequency of sexual transmission of HCV has been shown to increase in the
setting of HIV. In the U.S., HCV co-infection occurs in 15-30% of HIV-infected individuals
(Burton et al., 2010). HCV and HIV share common routes of transmission, and while IDU is
considered the most important risk factor for being infected with both viruses, HCV is
increasing in HIV-infected men who have sex with men. Results from a large prospective
longitudinal cohort study looking at HCV prevalence and incidence in MSM in Amsterdam
from 1984-2003 suggest an increase in HCV incidence over time among HIV-positive MSM,
but not among HIV-negative MSM (van de Laar et al., 2007). MSM who were infected after
2000 and reported no injection drug use were found to carry MSM-specific HCV strains
significantly different from strains circulating among IDUs. In a case control study of HIV
positive MSM, cases co-infected with HCV had significantly more sexual partners than
controls, reported more high-risk mucosally traumatic sexual behavior, and were more likely
to have had a STI (Danta et al., 2007). HIV infection facilitates HCV transmission by
increasing both viral infectiousness due to higher viral loads, and viral susceptibility through
its detrimental effects to the immune system. Compared to HIV negative persons, HIV
positive persons have higher HCV load in the blood and semen (Hahn, 2007). Worse health
outcomes are associated with HIV/HCV co-infection than HCV infection alone. In coinfected persons, the rate of spontaneous clearance of HCV is lower, occurring in only 5%10% of co-infected persons compared to 15%-35% in those only infected with HCV (Strader,
2005). Co-infection is also associated with accelerated progression of cirrhosis, liver failure,
and hepatocellular carcinoma, and less favorable outcomes to HCV treatment (Ghosn et al.,
2008).
7
INJECTION DRUG USE AND HEPATITIS C
For over 30 years, the primary mode of transmission for Hepatitis C in the U.S. has
been injection drug use, accounting for 68% of current infections and more than 60% of new
cases (Shepard et al., 2005; Thorpe et al., 2002). Current estimates of HCV incidence in
young IDUs in the US are between 9-35% a year, with one in five IDUs becoming infected
within the first two years of injection drug use and more than one in three becoming infected
within the first five years. (Amon et al., 2008; Hahn, 2007). The prevalence of HCV has been
found to be associated with increases in age, years injecting, and frequency of injection drug
use, with HCV prevalence among long term IDUs ranging between 70-90% (Hagan, Thiede,
& Des Jarlais, 2005; Thorpe et al., 2002).
Sharing syringes and drug paraphernalia used in the injection process, such as
cookers (used to heat and melt the drug for injection), cotton (used to filter the drug as it is
drawn up into a syringe), and rinse water, and the process of backloading (using one syringe
to squirt the drug solution into the back of other syringes) have been found to increase the
risk of HCV transmission in IDUs. A prospective study of young IDUs in San Francisco
found that needles and other equipment were commonly shared among young IDUs; 67%
reported having ever borrowed a needle/syringe, and 85% reported having ever shared drug
equipment (Hahn et al., 2002). The study also found that sharing needles with an HCVinfected person and sharing nonsterile drug equipment were independent risk factors for
HCV, and forming injection or sexual partnerships involving the sharing of drug
paraphernalia were common among young IDUs. Young IDUs may engage in such risk
behaviors due to paraphernalia laws that might discourage them from carrying their own
sterile equipment, and sharing needles may demonstrate reciprocity and trust in relationships.
In another prospective study of young IDUs in Chicago, 74% of IDUs reported sharing
injection drug paraphernalia in the 6 months prior to the study (Thorpe et al., 2002). The
study also found that sharing cookers and sharing rinse water were independent predictors of
seroconversion, indicating IDUs who share paraphernalia other than syringes are at increased
risk for HCV seroconversion. Cookers have been found to be shared among IDUs more often
than other equipment as cookers are kept and reused longer than cotton filters and rinse
water.
8
Because of shared routes of transmission, many people infected with HIV are also coinfected with HCV, with the majority of co-infected patients being injection drug users
(Strader, 2005). As HCV can be transmitted through small-volume percutaneous exposure
more easily than HIV, data suggests that more than half of people infected with HIV via
percutaneous exposures are also infected with HCV. In the U.S., IDUs are more likely than
other HIV-positive groups to be co-infected; 50 to 90% of HIV-positive IDUs are co-infected
with HCV, compared with less than 20% among those infected with sexually transmitted
HIV (Hagan et al., 2005; Strader, 2005). HIV/HCV co-infection has been associated with
lower rates of spontaneous clearance of HCV and more rapid progression to cirrhosis, liver
failure, and liver cancer, making co-infection among IDUs of increasing public health
concern.
DRUG USE AND RISKY SEXUAL BEHAVIOR
Studies have shown drug users to frequently engage in risky sexual behaviors, such as
having multiple partners, having unprotected sex, and exchanging sex for money or drugs. In
a study of 101 IDUs in Milwaukee, Wisconsin, 72 reported having sex with multiple partners
in the three months before the study; more than half reported having three or more different
sexual partners and one-third reported having six or more partners (Somlai, Kelly,
McAuliffe, Ksobiech, & Hackl, 2003). Ninety-seven of the 100 participants who reported
having vaginal intercourse reported not using protection. In a study of drug users in
Baltimore, 40% reported having a sex partner who was an IDU and less than half reported
consistent condom use (Sherman & Latkin, 2001). In a study of 407 patients at three drug
treatment clinics in Texas, those who preferred crack as their drug of choice were more likely
to report previous STIs, have bought or sold sex for drugs or money, and have had double the
number of sexual partners in the past four weeks (Ross, Hwang, Zack, Bull, & Williams,
2002). As sexual transmission of HCV has been found in groups likely to be engaging in
risky sexual behaviors, such activities increase their susceptibility to infection with HIV, and
STIs and may play a role in the transmission of HCV among drug users.
There may be differences in the likelihood of engaging in risky sexual behaviors
between IDUs and NIDUs. A prospective study of non-injection drug users (NIDUs), found
that transition to injection drug use was associated with increased likelihood of risky sexual
9
behaviors (Mackesy-Amiti, Boodram, Williams, Ouellet, & Broz, 2012). In men, transition to
injection drug use was associated with increased likelihood of unprotected vaginal or anal
sex, unprotected sex with casual partners, trading and buying sex, and having an IDU sex
partner. In women, transition to injection drug use was associated with increased likelihood
of trading sex and having an IDU sex partner. Engaging in riskier drug behaviors may lead to
engaging in riskier sexual behaviors, increasing the risk of transmission of HCV, HIV, and
STIs in drug-using populations.
THE INCARCERATED POPULATION
The main correctional institutions holding incarcerated persons are jails and prisons.
Jails are usually run by counties and municipalities and hold individuals awaiting trial or
serving short-term sentences for misdemeanors; prisons are often run by state or federal
governments and hold individuals convicted of crimes and receiving sentences of a year or
more (Binswanger, Krueger, & Steiner, 2009). At the end of 2011, over 2.2 million
Americans were incarcerated (Glaze & Parks, 2012). Over 1.5 million adults, or 1 in every
107, were in prison. Over 700,000 adults were in jail at the end of 2011 and from midyear
2009 to midyear 2010, almost 13 million persons were admitted to local jails (Minton, 2011).
Compared to the general population, the incarcerated population has a higher burden
of most chronic medical conditions and infectious diseases (CDC, 2003a). In a crosssectional study using data from the 2002 Survey of Inmates in Local Jails, the 2004 Survey
of Inmates in State and Federal Correctional Facilities, and the 2002-2004 National Health
Interview Survey Sample Adult Files, inmates were found to have a higher prevalence of
hypertension, diabetes, myocardial infarction, asthma, arthritis, cervical cancer and Hepatitis
(Binswanger et al., 2009). Inmates are at increased risk for poor health outcomes due to
circumstances before and during incarceration. Inmates are more likely to come from
disadvantaged backgrounds, have low levels of education, and lack health care coverage.
Inmates are exposed to infectious diseases through risky drug injection and sexual behaviors,
and are more likely to have high levels of smoking, drinking, and illicit drug use. Inmates are
more likely to have mental health and neurological disorders such as schizophrenia,
depression, and epilepsy, and more than half of inmates show symptoms of psychiatric
disorders, with the prevalence of major depression and psychotic disorders being four to
10
eight times higher among inmates than the general population (Rich, Wakeman, & Dickman,
2011). In correctional facilities, inmates can suffer from poor nutrition and limited physical
activity, high levels of stress, anxiety, and sleep deprivation (Binswanger et al., 2009). These
factors leave inmates susceptible to becoming chronically ill, acquiring infections, and
transmitting diseases, both within correctional facilities and the communities into which they
are released.
HEPATITIS C IN INCARCERATED POPULATIONS
As there are no mandated screening programs for Hepatitis C, it is difficult to obtain
its true prevalence in the incarcerated population. In a review of several studies investigating
HCV in high risk populations, Chak et al. (2011) found the prevalence of HCV in
incarcerated populations to range from 23.1% to 39.4%. According to the CDC, between
16% and 41% of inmates have ever been infected with HCV, and 12-31% of inmates have
chronic HCV infection (CDC, 2011b). Of the more than 3 million people infected with HCV
in the U.S., 29-43% pass through a correctional system each year (Spaulding & Thomas,
2012). HCV mortality among the incarcerated population has been increasing. A study of
mortality of male prisoners in the Texas Department of Criminal Justice found that the
proportion of deaths accountable to HCV increased from 1% in 1994-1997 to 8% in 2003
(Harzke et al., 2009). HCV was recorded as the underlying cause of death for over 3% of
prisoner deaths and as an intervening or contributing cause for 9% of deaths in the sample
during the study period.
DRUG USERS IN INCARCERATED POPULATIONS
The higher rates of HCV among the incarcerated population compared to the general
population is often attributed to a higher rate of IDUs entering prison (Burton et al., 2010). A
study of male prisoners in Rhode Island found the prevalence of HCV to be 23.1%, and HCV
infection was found to be significantly associated with injection drug use (Macalino et al.,
2004). More serious drug users are housed in the correctional system than in any other
institution (Freudenberg, 2001). Seventeen percent of state and 48% of federal prison
populations are made up of drug offenders, and about half of state and federal prisoners meet
criteria for drug dependence and substance abuse (Carson & Sabol, 2012; Mumola &
11
Karberg, 2006). Between 73-83% of prison inmates report a history of drug use, and 45-57%
reported drug use in the month prior to incarceration (Weinbaum, Sabin, & Santibanez,
2005).
Although a significant number of inmates are in need of substance abuse treatment,
only 7-17% of inmates who reported regular drug use before being incarcerated participated
in some form of treatment (Chandler, Fletcher, & Volkow, 2009). Having substance abuse
treatment programs available to inmates has the potential to prevent future incarcerations and
transmissions of HCV infection as a link has been demonstrated between substance abuse,
incarceration, and recidivism; in state prisons, 41% of first-time offenders used drugs
regularly compared with 63% of second-time offenders and 81% of those who had five or
more previous convictions (Spaulding et al., 2006). More effective drug treatment programs
in correctional facilities targeting all inmates in need of treatment could reduce drug use
among repeat offenders and reduce risk behaviors associated with transmitting HCV.
RISKY BEHAVIORS IN INCARCERATED POPULATIONS
The risk of sexual transmission of disease is higher in incarcerated populations
compared to the non-institutionalized population. High rates of gonorrhea, Chlamydia, and
syphilis have been found among entering inmates, and many inmates have reported multiple
sex partners and inconsistent condom use both before incarceration and after release
(Weinbaum et al., 2005). In a prospective study of 106 male prisoners by Morrow and the
Project START Study Group (2009), 40% reported having multiple sex partners one month,
three months, and 6 months after being released from prison. Around half of the participants
reported having unprotected vaginal sex with casual female partners during the six-month
follow up period following release from prison. Despite reporting engaging in risky sexual
behaviors, most of the participants did not think they were at high risk for HIV. In another
prospective study, 178 male prisoners in Mississippi, Rhode Island, and Wisconsin had urine
and blood screening 6 months after being released from prison (Sosman et al., 2011). Twenty
six percent of men were found to be infected with gonorrhea, chlamydia, trichomoniasis,
HBV, or HCV. During the six-month period after release, 72% reported having multiple
sexual partners, 32% reported having unprotected sex with multiple partners, and 75%
reported having at least one risky sexual partner. A cross-sectional study of 111 HIV infected
12
patients receiving care in two Mississippi clinics found that having a history of incarceration
was independently associated with HIV/HCV co-infection, and co-infected participants were
more likely to report a history of gonorrhea (Burton et al., 2010).
Risky sexual contact can occur during incarceration and increase the risk of spreading
STIs among prisoners. A study on mandatory pre-release STD testing of 744 male inmates
from an Ohio prison identified 53 new cases of STDs not identified through testing at intake.
Of the 12% of inmates that reported having sex during the present prison term, 86% reported
having multiple partners (Sieck & Dembe, 2011). Outbreaks of syphilis, Hepatitis B, and
HIV have occurred among MSM within prison populations, and this represents a possible
means of HCV transmission (Burton et al., 2010). Also, male prison rape may increase
contact to infected blood and facilitate transmission of HCV as it often involves multiple
assailants and trauma to the rectal mucosa. Of 40,419 jail inmates surveyed in 2007, 0.7%
reported having nonconsensual sex with another inmate, an estimated 5,200 inmates
nationwide (Beck & Harrison, 2008). As HIV has been proposed as a co-factor that enhances
sexual transmission of HCV, HIV-infected prisoners may be more vulnerable to acquiring
HCV infection through sexual contact or assault during incarceration.
Tattooing is another risk behavior among inmates that can transmit HCV. Tattooing
in prison can transmit HCV through the use of unsterilized equipment, such as guitar strings,
paper clips, or sewing needles (Tohme & Holmberg, 2012). The prevalence of tattooing
among incarcerated persons has been found to be up to 40% and is especially popular among
drug users. Prisoners with a history of IDU have been found to be five times more likely to
have a tattoo and were significantly more likely to have received the tattoo while in prison. In
a study of 1062 injection drug users in New Mexico, 74.6% had tattoos and 37.6% reported
receiving tattoos while incarcerated (Samuel, Doherty, Bulterys, & Jenison, 2001).
As there is limited, if any, access to harm reduction methods such as condoms and
sterilized needles in prison, such risk behaviors among inmates present a greater risk of
transmission to other inmates and contacts in their communities after release.
13
HEPATITIS C PREVENTION AND CONTROL IN
CORRECTIONAL FACILITIES
Screening of individuals at risk for Hepatitis C, treatment of those with chronic HCV
infection, and HCV interventions are needed in correctional settings in order to identify
inmates with asymptomatic infection, reduce chronic liver disease and disability, and prevent
further transmission to others. It is currently recommended that incarcerated persons with
risk factors for HCV infection be screened (CDC, 2003a). However, in jails, HCV screening
has not been routinely conducted as treatment could not realistically be provided for shortterm inmates (Spaulding & Thomas, 2012). HCV therapy may last for up to 48 weeks,
whereas the median length of stay is 48 hours in short term correctional facilities. As time
does not permit the majority of these individuals to start treatment before discharge, only
about 1% could realistically be treated. As for prisons, 49 states have at least one prison that
tests inmates, with 10 states offering routine testing in all facilities (Beck & Maruschak,
2004). Of 1584 state prison facilities, the majority (88%) reported testing targeted groups of
inmates who were at risk, inmates who requested testing, or inmates who showed clinical
symptoms; only 4% reported testing incoming inmates. Screening would have costly
consequences for correctional facilities, as treating eligible patients could represent a 15% to
60% increase in the average state correctional system medical budget (Spaulding et al.,
2006).
Treatment for HCV is available in many prisons. In the 2000 Census of State and
Federal Adult Correctional Facilities, 70% (1,104) of 1584 state adult correctional facilities
reported having a policy to treat inmates, and most reported having a policy to treat HCVpositive inmates recommended for treatment (Beck & Maruschak, 2004). Between midyear
1999 and midyear 2000, 17,911 inmates had confirmed positive HCV tests; 4,750 inmates
total were treated, and 3,082 of those were treated in 18 facilities in nine states and the
District of Columbia. Although many prisons have policies to treat inmates for chronic
Hepatitis C, not all inmates with HCV receive treatment. In order to receive treatment,
inmates need to have enough time to complete treatment and have adequate follow-up during
their sentence, which could take up to a year (Spaulding et al., 2006). For inmates at some
facilities, this may require sentences of at least 15-18 months or deferring early-release
programs into parole (Maru, Bruce, Basu, & Altice, 2008; Tan, Joseph, & Saab, 2008). Other
14
barriers to treatment include clinical contraindications, unstable mental or chronic illness,
substance dependence, ongoing high risk behaviors, and lack of insurance once released.
Effective transitional programs linking post-release inmates to community-based medical
services are needed to ensure completion of treatment and follow-up. The Hepatitis C
Continuity Program in New York is one example of a statewide program that operates
through referral resources to provide released prisoners with access to health care facilities to
continue treatment (Klein et al., 2007).
Interventions for Hepatitis C could reduce the incidence of infections by giving
inmates the knowledge and skills to prevent transmission to others after they are released.
HCV prevention programs could be done at entry, before release, and integrated into other
programs for HIV prevention and substance abuse treatment. An intervention study on 745
soon-to-be-released prisoners participating in the Prevention Case Management program for
HIV prevention in Maryland found that over a four-year period, participants had significant
increases in positive attitudes toward condoms and self-efficacy to use condoms and reduce
injection drug use risk (Bauserman et al., 2003). A study of 522 soon-to-be-released male
prisoners from four states participating in the Project START intervention for HIV, Hepatitis,
and STI risks found significantly lower rates of unprotected sex after 6 months post-release
for men in the multisession intervention compared to those in the single-session intervention
(Wolitski & the Project START Writing Group, 2006). Despite the need for interventions
addressing Hepatitis C, not all prisons have programs to implement them; only 20% of
prisons reported having an HIV prison-based peer program, and 74% reported having drug
and alcohol dependency, counseling, and awareness programs (Collica, 2007; Stephan,
2008). There is a need for comprehensive interventions available to inmates that integrate
substance abuse services with HIV and Hepatitis C prevention programs to promote changes
in risky drug and sexual behaviors in the community.
CONCLUSION
Sexual transmission of Hepatitis C can occur in groups engaging in risky sexual
behaviors and has been found to be associated with having multiple partners, having
unprotected sex, having rough sex, and being co-infected with STIs. IDUs and incarcerated
persons are high risk groups for HCV and have reported higher rates of risky sexual behavior
15
than the general population. With at-risk drug users representing a significant proportion of
the incarcerated population and entering jails and prisons at high rates, correctional
institutions can serve to screen this vulnerable population, catch asymptomatic cases, start
treatment, and run intervention programs before returning them to their communities.
Prevention and control of HCV within correctional settings requires collaboration between
prisons, local governments, public health departments, and community health care facilities
as well as funding in order to ensure testing and treatment in-house and continuity of care
after release. Research into the role of sexual transmission of HCV among incarcerated drug
users can help to improve prevention and control programs and prevent transmission of
infection in correctional settings and out in the community.
16
CHAPTER 3
METHODS
This chapter will describe the design of the present study, the study population, how
the data was collected and measured, the variables of interest, and the statistical analysis.
STUDY DESIGN
This thesis is a cross-sectional study using baseline survey data from the HIV/HEPC
study conducted as part of the National Institute on Drug Abuse's Criminal Justice Drug
Abuse Treatment Studies (NIDA CJ-DATS) (Inciardi, 2011). As this thesis conducts
secondary analysis of publicly available data, no IRB approval was required. The CJ-DATS
study was led by the University of Delaware and implemented by the University of
Delaware, the University of Kentucky, and George Mason University from 2006 to 2008.
The purpose of the CJ-DATS HIV/HEPC study was to evaluate the CJ-DATS Targeted
intervention, a peer-based DVD intervention for risky drug and sexual behaviors for drug
offenders about to reenter the community.
After screening and obtaining consent, enrolled participants were given the intake
questionnaire, randomized into intervention groups, and were offered HIV and HCV testing.
Subjects tested for HIV and HCV received post-test counseling two weeks later. The study
used a three-group randomized clinical trial to compare changes in risky behaviors in
subjects receiving the CJ-DATS Targeted intervention with those receiving the NIDA
standard intervention and the control group receiving "standard practice" post-release. Those
assigned to the standard practice treatment attended a group session and were shown a video
on HIV and Hepatitis awareness; those in the NIDA standard intervention received a HIV
prevention session with a health educator using cue cards in a one-on-one setting; and those
in the CJ-DATS Targeted intervention group were shown an interactive DVD in a peerfacilitated one-on-one setting. Follow-up interviews were conducted at 30 and 90 days postrelease. Subjects received $40 for participating in the baseline survey, $40 for the 30-day
17
follow up, and $60 for the 90-day follow up. Participation in all phases of the CJ-DATS
study was voluntary.
STUDY POPULATION AND ELIGIBILITY
The CJ-DATS study dataset contained intake data from 672 eligible subjects recruited
from two prisons in Kentucky, a halfway house in Delaware, and a local jail in Virginia
between September 2006 and May 2008. All persons to be released from incarceration or
work release to parole or probation at these participating sites during this time period were
given an introduction to the CJ-DATS study and were shown a basic HIV education video.
Those willing to participate in the study were screened within 30 days of being released and
given informed consent forms to sign. Eligible participants were released offenders who met
the TCU Drug Intake Screener criteria for substance abuse or dependence, were 18 years of
age or older, and had given consent to participate. Released offenders who had an existing
diagnosis of a DSM-IV-R psychotic disorder, had evidence of neuropsychological
dysfunction, or had a life expectancy of less than 6 months were excluded from the CJ-DATS
study.
For this analysis, only participants who completed the intake survey and were tested
for Hepatitis C were included. As the CJ-DATS dataset was made publicly available,
personal identifiers such as participant date of birth and research site were removed and
could not be included in this analysis. Participants with inconclusive HCV test results
('Unknown' or 'Pending') and missing data for sexual behavior and covariates were not
included in this analysis. The final sample size for this analysis was 614 participants after
removing those without a valid HCV result and those with missing data, as shown in Figure
1.
DATA COLLECTION AND MEASURES
Self-reported data from subjects was collected during an in-depth baseline interview
using the HIV/HEPC intake survey. These interviews were conducted face-to-face and took
place within 30 days of the participant's release from incarceration. The survey consisted of
several components:
18
Figure 1. Final sample size for present analysis.
1. The CJ-DATS core questionnaire supplemented with Brief Symptoms Inventory
(BSI) was used to collect baseline data on demographics, drug use, HIV/AIDs and
related risk behaviors, and mental health measures.
2. The AIDS Health Belief Scale was added to assess perceived susceptibility to AIDS,
perceived seriousness of AIDS, and perceived benefits and barriers to adopting safer
behaviors.
3. The AIDS Risk Behavior Knowledge was added to measure AIDS knowledge.
4. The NIDA Risk Behavioral Assessment (RBA) and Revised RBA was included to
collect baseline data related to HIV/AIDS and related risk behavior and health
measures.
The survey was modified to include questions related to HCV. Subjects were asked
questions relating to their sociodemographic background, relationships with friends and
family, criminal history, health and psychological status, substance abuse and treatment
history, risk behaviors, HIV/HCV knowledge, and attitudes toward condom use. Survey
questions asked at baseline referred to participants' activities before and during incarceration.
HIV testing was done using the OraSure rapid oral test.
HCV testing was done using Serum ELISA antibody assays to determine HCV
seropositivity, the presence of antibody to Hepatitis C virus. The ELISA assay is the most
widely used screening test for anti-HCV and can be used to screen large populations (Debois,
19
Vaghefi, Savary, Dussaix, & Roque-Afonso, 2008). Anti-HCV immunoassays indicate if a
person has a current infection or was infected in the past, but cannot differentiate between
acute, chronic, or resolved infection (CDC, 1998). Studies have estimated the thirdgeneration ELISA to have a sensitivity between 97.2% and over 99% and a specificity of
99% (Colin et al., 2001; Debois et al., 2008; Pawlotsky, 2002). The proportion of false
positives with this immunoassay averages about 35% in immunocompetent populations and
15% in immunocompromised populations when the prevalence of anti-HCV is less than 10%
(CDC, 2003b). It is recommended that a positive anti-HCV test be confirmed with a more
specific serologic test, such as a recombinant immunoblot assay, or a nucleic acid test.
STUDY VARIABLES
Variables included in this study are described and listed below. The outcome and
main variable of interest are detailed first, followed by demographic and other HCV risk
behavior variables.
Outcome and Main Variable of Interest
The outcome variable for this analysis is the Hepatitis C test result (Negative or
Positive). The main predictor for this analysis is reported sexual behavior in the 6 months
prior to the arrest that resulted in their incarceration, gathered from responses to survey
questions asking about the number of sexual partners and the frequency of unprotected sex
with various partners. Participants were asked:
'How many different people did you have sex with during the last 6 months prior to
the arrest date on the timeline?'
'During those months, how often did you have sex without using a condom with a
casual partner?' ('Never', ' Only a few times','1-3 times a month','1-5 times a week',
'About every day')
'During those months, how often did you have sex without using a condom with an
IDU?' ('Never', ' Only a few times','1-3 times a month','1-5 times a week', 'About
every day')
'During those months, how often did you have sex without using a condom with
either you or your partner exchanging sex for drugs, money, or gifts?' ('Never', ' Only
a few times','1-3 times a month','1-5 times a week', 'About every day')
For this analysis, these questions were combined and re-coded to create one sexual behavior
variable based on their number of partners and whether they reported having unprotected sex
20
with a casual partner, an IDU, or while they or their partner exchanged sex. Participants were
divided into the following categories:
Participants reporting having no partners in the 6 months prior to their arrest
Participants reporting having 1-3 partners and never having unprotected sex with a
casual partner, an IDU, or while they or their partner exchanged sex in the 6 months
prior to their arrest
Participants reporting 4 or more partners and never having unprotected sex with a
casual partner, an IDU, or while they or their partner exchanged sex in the 6 months
prior to their arrest
Participants reporting 1-3 partners and having unprotected sex with a casual partner,
an IDU, or while they or their partner exchanged sex in the 6 months prior to their
arrest
Participants reporting 4 or more partners and having unprotected sex with a casual
partner, an IDU, or while they or their partner exchanged sex in the 6 months prior to
their arrest
The following is a list of other variables included for this analysis:
History of STIs
Participants were asked if they had ever been told by a doctor, nurse, or health care
worker that they had Genital Herpes ('Yes' or 'No'), Gonorrhea ('Yes' or 'No'), Syphilis ('Yes'
or 'No'), or Chlamydia ('Yes' or 'No'). Participants reporting a history of at least one STI were
considered as having a history of STIs.
History of Injection Drug Use
The CJ-DATS survey asked participants to give the age they started injecting for
different drugs and how often in the 6 months prior to their arrest did they inject drugs.
Participants were asked:
How old were you the first time you injected: cocaine; heroin and cocaine; heroin and
methamphetamine; heroin; methadone; other opiates; methamphetamine;
librim/valium/minor tranquilizers; barbituates; other sedatives; non-prescription
GHB; ketamine; other (Age, '0' for those who never injected)
'In the last 6 months prior to the arrest date, how often did you inject illegal drugs
with a needle?' ('Never/Not used', 'Only 1-3 times', 'About 1 time per month', 'About
2-3 times per month', 'About 1 time per week', 'About 2-6 times per week', 'About 1
time per day', 'About 2-3 times per day', 'About 4 or more times per day')
21
For this analysis, these questions and participant responses were recoded to create one
categorical variable for injection drug use. Participants with a '0' response given for age of
first injection for all drugs and a 'Never/Not used' response for the frequency of injecting
drugs in the 6 months prior to their arrest were considered as reporting no history of injection
drug use; participants with at least one age response given for age of first injection for any
drugs or reported injecting drugs with any frequency in the 6 months prior to their arrest were
considered as reporting a history of injection drug use.
Other HCV Risk Behaviors
Participants were asked if they ever had a tattoo ('Yes' or 'No') and if they ever had a
blood transfusion ('Yes' or 'No').
Total Years Incarcerated
Participants were asked to give the total amount of time they had ever spent in jail,
prison, or juvenile lock-up (Number of months). The total time incarcerated was then
converted to number of years and divided into the following categories: less than 2 years, 2-5
years, and over 5 years.
Sociodemographic Variables
Age ('How old are you?'), race ('What race or ethnic background do you most
identify?' 'African American/Black', 'Asian', 'Native American', 'Pacific Islander', 'White',
'Other'), and gender ('Female' or 'Male') were also be included as covariates for this analysis.
Age was categorized into two groups: participants ages 18 to 40 and participants ages 41 and
older. The age limits for this variable were based on CDC recommendations that those born
during 1945-1965 be tested for Hepatitis C (CDC, 2012).
STATISTICAL ANALYSIS
All statistical analyses were performed using SAS Version 9.2 software. Descriptive
statistics were run to give frequencies for each of the categorical covariates: sexual
behaviors, history of STIs, history of injection drug use, age group, ever having a tattoo, ever
having a blood transfusion, race, gender, and total years incarcerated.
22
To assess the relationship between sexual behaviors and positive HCV status,
bivariate associations using chi-squared tests and simple logistic regression were performed
to give crude odds ratios, 95% confidence intervals, and p-values. Significance was
determined using p<0.05. Variables found to be significantly associated with sexual behavior
and HCV test result in the bivariate analysis were assessed for confounding and effect
modification. Potential confounders were assessed using the 10% rule of thumb, and were
placed in a simple logistic model with only sexual behavior and HCV result. Variables that
changed the odds ratio between sexual behavior and the outcome HCV status by 10% or
more were considered to be confounders and included in the final multivariable model.
Interactions between these covariates and the main variable of interest sexual behavior were
tested in the multivariable analyses with significance at p<0.10. All variables, regardless of
significance in the bivariate analysis, were included in the multivariable analyses. Backwards
stepwise logistic regression was run to identify variables independently associated with a
positive HCV result and obtain odds ratios and confidence intervals adjusting for all other
variables in the model. Covariates significant at p<0.05 and confounders were kept in the
final model.
23
CHAPTER 4
RESULTS
A total of 672 participants were included in the CJ-DATS dataset. Of these
participants, 43 had missing or invalid Hepatitis C test results and another 15 were missing
data on key variables. A final sample size of 614 participants was analyzed for this thesis.
Descriptive statistics on demographic variables and other covariates are listed in
Table 1. There were 488 men (79%) and 126 women (21%) in this sample. The median age
of participants was 34. There were 442 participants aged 18 to 40 (72%) and 172 participants
aged 41 to 76 (28%). For race, 246 participants identified as White (40%) and 368
participants identified as Black (60%). There were no participants reporting any other options
for race. The median total time incarcerated was 4 years, and almost 39% (n=237) of
participants reported their total time incarcerated to be over 5 years.
All study participants had a history of substance abuse, as defined by the TCU Drug
Intake Screener criteria for substance abuse or dependence used to determine participant
eligibility into the CJ-DATS study. History of injection drug use was reported by 147
participants (24%). Almost two-thirds (n=397) of the sample reported ever having a tattoo,
and less than 10% of participants (n=51) reported ever having a blood transfusion.
Regarding sexual behavior, over a third of participants (34%) reported having 4 or
more partners in the 6 months prior to their arrest, and half of the sample (50%) reported
having unprotected sex with a casual partner, an IDU, or while they or their partner
exchanged sex. Over a fourth of participants (26%) reported having unprotected sex and 4 or
more sexual partners. Just over one-fifth of the sample (22%) reported having a history of
STIs.
Almost one-fourth of the sample (23%) tested positive for Hepatitis C. Of the 11
participants that tested positive for HIV, 7 (64%) also tested positive for HCV. Regarding
sexual behavior, almost 46% (n=11) of those reporting having 0 partners in the 6 months
prior to arrest tested positive for HCV. The prevalence of HCV was lower in those reporting
1-3 partners and no unprotected sex (22%) compared to those reporting 1-3 partners and
24
Table 1. Descriptive Statistics for Covariates of Interest in Drug Offenders Recently
Released from Incarceration, n=614
Total
HCV Positive
HCV Negative
n (%)
n (%)
n (%)
614 (100%)
144 (23.4)
470 (76.6)
Negative
602 (98.0)
137 (22.8)
465 (77.2)
Positive
11 (1.8)
7 (63.6)
4 (36.4)
Result Pending
1 (0.2)
-
-
24 (3.9)
11 (45.8)
13 (54.2)
232 (37.8)
50 (21.5)
182 (78.5)
VARIABLES
HCV test result a
HIV test result
Sexual behavior
0 partners
1-3 partners and no unprotected sex
4 or more partners and no unprotected sex
54 (8.8)
4 (7.4)
50 (92.6)
1-3 partners and unprotected sex
147 (24.0)
44 (29.9)
103 (70.1)
4 or more partners and unprotected sex
157 (25.6)
35 (22.3)
122 (77.7)
No
479 (78.0)
112 (23.4)
367 (76.6)
Yes
135 (22.0)
32 (23.7)
103 (76.3)
No
467 (76.1)
48 (10.3)
419 (89.7)
Yes
147 (23.9)
96 (65.3)
51 (34.7)
No
217 (35.3)
43 (19.8)
174 (80.2)
Yes
397 (64.7)
101 (25.4)
296 (74.6)
No
563 (91.7)
128 (22.7)
435 (77.3)
Yes
51 (8.3)
16 (31.4)
35 (68.6)
18 to 40
442 (72.0)
68 (15.4)
374 (84.6)
41 to 76
172 (28.0)
76 (44.2)
96 (55.8)
Male
488 (79.5)
106 (21.7)
382 (78.3)
Female
126 (20.5)
38 (30.2)
88 (69.8)
White
246 (40.1)
84 (34.1)
162 (65.9)
Black
368 (59.9)
60 (16.3)
308 (83.7)
<2
166 (27.0)
32 (19.3)
134 (80.7)
2-5
211 (34.4)
40 (19.0)
171 (81.0)
>5
237 (38.6)
72 (30.4)
165 (69.6)
History of STIs
History of injection drug use
Tattoo
Blood transfusion
Age
Sex
Race
Total time incarcerated
(Years)
a
Outcome variable Hepatitis C test result coded Positive or Negative
25
unprotected sex (30%). This trend was also present in those reporting 4 or more partners: the
prevalence of HCV was 7% for those reporting no unprotected sex and 22% for those
reporting having unprotected sex. The prevalence of HCV in participants reporting a history
of STIs was the same as those reporting no history of STIs (23%).
Over 40% (n=76) of participants aged 41-76 tested positive for HCV, compared to
15% (n=68) of participants aged 18-40. Of those that reported a history of injection drug use,
65% (n=96) tested positive for HCV, compared to 10% (n=48) of those who reported no
history of injection drug use. The prevalence of positive HCV result was higher among
White participants (34%) than in Black participants (16%). HCV prevalence was also higher
among women (30%) than in men (22%). Thirty percent of participants (n=72) who reported
their total time incarcerated to be over 5 years were positive for HCV, compared to less than
20% of participants (n=32) who reported less than 2 years and less than 20% of participants
(n=40) who reported between 2-5 years.
The descriptive frequencies and chi-squared p-values for the associations between the
covariates and sexual behavior are shown in Table 2. Variables found to be significantly
associated with sexual behavior were having a positive HCV result, reporting a history of
STIs, reporting a history of IDU, age group, race, and total years incarcerated. Comparing
sexual behavior between those testing positive for HCV and those testing negative, the
frequency of having 4 or more partners and no unprotected sex was lower among those who
tested positive (3%, n=4) compared to those who tested negative (11%, n=50). There was
also a higher percentage of having 1-3 partners and unprotected sex among those who tested
positive (31%, n=44) compared to those who tested negative (22%, n=103). The frequency of
reporting 4 or more partners and unprotected sex was higher among those who had a history
of STIs (39%, n=52) compared to those who had no history of STIs (22%, n=105). Those
with a history of STIs also had a lower percentage of having 1-3 partners and no unprotected
sex (27%, n=36) compared to those reporting no history of STIs (41%, n=196). Those with a
history of IDU reported a lower frequency of having 1-3 partners and no unprotected sex
(29%, n=43) compared to those with no history of IDU (41%, n=189). Those with a history
of IDU also reported a lower percentage of having 4 or more partners and no unprotected sex
(3%, n=4) compared to those with no history of IDU (11%, n=50). Those with a history of
26
Table 2. Descriptive and Bivariate Statistics for Covariates of Interest in Drug
Offenders Recently Released from Incarceration, by Sexual Behavior Category, n=614
1-3 partners
0 partners
>4 partners
1-3 partners
>4 partners
and no
and no
and
and
unprotected
unprotected
unprotected
unprotected
sex
sex
sex
sex
n (%)
n (%)
n (%)
n (%)
n (%)
Negative
13 (2.8)
182 (38.7)
50 (10.6)
103 (21.9)
122 (26.0)
Positive
11 (7.6)
50 (34.7)
4 (2.8)
44 (30.6)
35 (24.3)
VARIABLES
HCV test result a
P-value
0.001
0.0004
History of STIs
No
22 (4.6)
196 (40.9)
44 (9.2)
112 (23.4)
105 (21.9)
Yes
2 (1.5)
36 (26.7)
10 (7.4)
35 (25.9)
52 (38.5)
<0.0001
History of IDU
No
16 (3.4)
189 (40.5)
50 (10.7)
95 (20.3)
117 (25.1)
Yes
8 (5.4)
43 (29.3)
4 (2.7)
52 (35.4)
40 (27.2)
0.39
Tattoo
No
12 (5.5)
86 (39.6)
19 (8.8)
52 (24.0)
48 (22.1)
Yes
12 (3.0)
146 (36.8)
35 (8.8)
95 (23.9)
109 (27.5)
0.42
Blood transfusion
No
20 (3.5)
215 (38.2)
51 (9.1)
136 (24.2)
141 (25.0)
Yes
4 (7.8)
17 (33.3)
3 (5.8)
11 (21.6)
16 (31.4)
18 to 40
9 (2.0)
166 (37.6)
46 (10.4)
102 (23.1)
119 (26.9)
41 to 76
15 (8.7)
66 (38.4)
8 (4.7)
45 (26.2)
38 (22.1)
Male
20 (4.1)
184 (37.7)
47 (9.6)
111 (22.8)
126 (25.8)
Female
4 (3.2)
48 (38.1)
7 (5.6)
36 (28.6)
31 (24.6)
White
11 (4.5)
101 (41.1)
12 (4.9)
73 (29.7)
49 (19.9)
Black
13 (3.5)
131 (35.6)
42 (11.4)
74 (20.1)
108 (29.4)
0.0004
Age
0.46
Sex
0.0007
Race
0.03
Total years
incarcerated
a
<2
5 (3.0)
68 (41.0)
13 (7.8)
50 (30.1)
30 (18.1)
2-5
10 (4.7)
82 (38.9)
20 (9.5)
51 (24.2)
48 (22.7)
>5
9 (3.8)
82 (34.6)
21 (8.9)
46 (19.4)
79 (33.3)
Outcome variable Hepatitis C test result coded Positive or Negative
IDU had a higher percentage of having 1-3 partners and unprotected sex (35%, n=52)
compared to those with no history of IDU (20%, n=95). Participants age 41-76 reported a
higher percentage of having 0 partners (9%, n=15) than those age 18-40 (2%, n=9).
Participants age 41-76 also had a lower percentage of having 4 or more partners and no
27
unprotected sex (5%, n=8) than those age 18-40 (10%, n=46). Black participants reported a
lower percentage of having 1-3 partners and unprotected sex (20%, n=74) compared to White
participants (30%, n=73). However, Black participants reported a higher percentage of
having 4 or more partners and unprotected sex (29%, n=108) compared to White participants
(20%, n=49). Comparing sexual behavior between those incarcerated less than 2 years, 2-5
years, and over 5 years, those incarcerated for less than 2 years reported the highest
percentage for having 1-3 partners and unprotected sex (30%, n=50) and the lowest
percentage for 4 or more partners and unprotected sex (18%, n=30); those incarcerated for
more than 5 years reported the lowest percentage for having 1-3 partners and unprotected sex
(19%, n=46) and the highest percentage for 4 or more partners and unprotected sex (33%,
n=79).
The unadjusted odds ratios, confidence intervals, and p-values for the bivariate
associations between the independent variables and HCV test result are shown in Table 3.
Sexual behavior, history of injection drug use, age group, race, and total years incarcerated
were significantly associated with HCV result. Without adjusting for other variables,
participants reporting 1-3 partners and no unprotected sex with a casual partner, IDU, or
while they or their partner exchanged sex in the 6 months prior to arrest, were less likely (OR
0.3, 95% CI 0.1-0.8) to test positive for HCV than those reporting 0 partners. Participants
reporting 4 or more partners and no unprotected sex were less likely (OR 0.1, 95% CI 0.030.4) to test positive for HCV than those reporting 0 partners. Participants reporting 4 or more
partners and unprotected sex with a casual partner, IDU, or while they or their partner
exchanged sex, were less likely (OR 0.3, 95% CI 0.1-0.8) to test positive for HCV than those
reporting 0 partners.
Without adjusting for other variables, participants reporting a history of injection drug
use were more likely (OR 16.4, 95% CI 10.5-25.8) to test positive for HCV than those
reporting no injection drug use. Participants ages 41 to 76 were more likely (OR 4.4, 95% CI
2.9-6.5) to test positive for HCV than those ages 18 to 40. Black participants were less likely
(OR 0.4, 95% CI 0.3-0.6) to have a HCV positive test than White participants. Participants
with over 5 total years incarcerated were more likely (OR 1.8, 95% CI 1.1-2.9) to have a
positive HCV test than those incarcerated less than two years. And women were more likely
28
Table 3. Simple Logistic Regression of Covariates of Interest with Hepatitis C Test
Result a for Drug Offenders Recently Released from Incarceration, n=614
VARIABLES
Crude Odds Ratio
95% Confidence Interval
P-value
0.002
Sexual behavior
0 partners
1.0*
-
1-3 partners and no unprotected sex
0.3
(0.1, 0.8)
0.1
(0.03, 0.4)
0.5
(0.2, 1.2)
0.3
(0.1, 0.8)
vs 0 partners
4 or more partners and no unprotected sex
vs 0 partners
1-3 partners and unprotected sex
vs 0 partners
4 or more partners and unprotected sex
vs 0 partners
<0.0001
History of injection drug use
No
1.0*
Yes
16.4
(10.5, 25.8)
0.12
Tattoo
No
1.0*
Yes
1.4
(0.9, 2.1)
0.17
Blood transfusion
No
1.0*
Yes
1.5
(0.8, 2.9)
0.94
History of STI
No
1.0*
Yes
1.0
18 to 40
1.0*
41 to 76
4.4
(0.6, 1.6)
<0.0001
Age
(2.9, 6.5)
0.05
Sex
Male
1.0*
Female
1.6
White
1.0*
Black
0.4
(1.0, 2.4)
<0.0001
Race
(0.3, 0.6)
0.006
Total time incarcerated (Years)
a
<2
1.0*
2-5
1.0
(0.6, 1.6)
>5
1.8
(1.1, 2.9)
Outcome variable Hepatitis C test result coded Positive or Negative
* Indicates reference group for categorical variables
29
(OR 1.6, 95% CI 1.0-2.4) to have a HCV positive test than men, but this association was
borderline significant (p=0.05).
Table 4 shows the results of the final multivariable logistic regression model with
adjusted odds ratios for variables associated with HCV test result. History of injection drug
use, age group, race, and total years incarcerated were found to be confounders in the
association between sexual behavior and HCV test result and were kept in the final model.
Interactions between these covariates and sexual behavior were tested at p<0.10 and none
were found to be significant. A Hosmer and Lemeshow Goodness-of Fit Test was performed
and confirmed the goodness of fit of this model (p=0.86).
Adjusting for all other variables, sexual behavior was not significantly associated
with HCV result (p=0.42). History of injection drug use and age group had significant
independent associations with HCV test result. Adjusting for all other variables in the model,
participants who reported injection drug use were more likely (OR 15.5, 95% CI 9.0-26.7) to
have a positive HCV test than participants who reported no injection drug use. Participants
ages 41-76 were more likely (OR 4.1, 95% CI 2.5-6.7) to have a positive HCV test result
than participants ages 18-40.
30
Table 4. Final Multivariable Logistic Regression Model of Variables of Interest with
Hepatitis C Test Result a for Drug Offenders Recently Released from Incarceration,
n=614
VARIABLES
Adjusted Odds
95% Confidence Interval
P-value
Ratio
0.42
Sexual behavior
0 partners
1.0*
-
1-3 partners and no unprotected sex
0.5
(0.2, 1.5)
0.2
(0.05, 1.1)
0.5
(0.1, 1.5)
0.4
(0.1, 1.3)
vs 0 partners
4 or more partners and no unprotected sex
vs 0 partners
1-3 partners and unprotected sex
vs 0 partners
4 or more partners and unprotected sex
vs 0 partners
<0.0001
History of injection drug use
No
1.0*
-
Yes
15.5
(9.0, 26.7)
18 to 40
1.0*
-
41 to 76
4.1
(2.5, 6.7)
White
1.0*
-
Black
0.8
(0.5, 1.4)
<0.0001
Age
0.43
Race
0.13
Total time incarcerated (Years)
a
<2
1.0*
-
2-5
0.7
(0.4, 1.3)
>5
1.2
(0.7, 2.2)
Outcome variable Hepatitis C test result coded Positive or Negative
* Indicates reference group for categorical variables
31
CHAPTER 5
DISCUSSION
This chapter will discuss the key findings of this analysis, how these results compare
to those found in other studies, and the public health implications of these results. The
limitations and strengths of this thesis and directions for future research will also be
discussed.
KEY FINDINGS
The current study examined the association between positive HCV test result and
risky sexual behaviors in a sample of drug users recently released from incarceration. Almost
a fourth of participants tested positive for HCV. Risky sexual behaviors were common in
this sample with almost 50% reporting having unprotected sex with a casual partner, IDU, or
while they or their partner exchanged sex, over 30% reporting having 4 or more partners, and
25% reporting having unprotected sex and 4 or more partners. Surprisingly, the prevalence of
positive HCV status was highest in those reporting having 0 partners in the 6 months prior to
arrest. The direction of the association between sexual behavior and HCV result in the
bivariate analysis was also unexpected; participants reporting 1-3 partners and no
unprotected sex, 4 or more partners and no unprotected sex, and 4 or more partners and
unprotected sex with a casual partner, IDU, or while they or their partner exchanged sex,
were less likely to have a positive HCV test than those reporting 0 partners. Although sexual
behavior was only found to be significantly associated with HCV test result in the bivariate
analysis, the association was not significant after adjusting for history of injection drug use
and age group. These findings do not support the hypothesis that participants reporting risky
sexual behaviors were more likely to have tested positive for HCV, compared to those who
reported no risky sexual behaviors. In this study, there was no evidence of a significant
association between sexual behavior and HCV test result in drug users recently released from
incarceration after adjusting for other HCV risk variables.
32
Other studies in drug-using populations have found similar results regarding the
association between sexual behaviors and HCV. A study in New York City asked 722 noninjecting drug users if they had IDU sex partners, sex partners with hepatitis, or had traded
sex in the past 2 months (Howe et al., 2005). Although the bivariate analyses of the New
York study suggested sex with a partner with hepatitis was associated with HCV, this
association was not significant after adjusting for age. A study of 178 men recently released
from incarceration found no significant associations between reporting unprotected vaginal
or anal sex with multiple partners and HCV infection (Sosman et al., 2011). And, in a study
of 1003 injection drug users conducted in New Mexico from 1995-1997, the seroprevalence
of HCV was found to be highest in participants reporting 0 partners (91%), and the
prevalence decreased in those reporting 1 (88%), 2 (86%), 3-4 (78%), and 5-9 sexual partners
(67%) (Samuel et al., 2001). However, in those reporting 10-49 and 50+ sexual partners, the
prevalence of HCV increased (68% and 83%, respectively).
Although high rates of risky sexual behavior have been found among drug users,
other factors relating to drug use, drug addiction, and previous incarceration may play a role
in this trend. Different drugs may have different effects on sexual desire and behavior, and
these effects may be influenced by duration of drug use, mental state, setting, and variation
between individuals. For example, while cocaine has been reported by some studies to
prolong arousal and delay or produce spontaneous orgasm, other research has shown chronic
cocaine use to reduce sexual desire and ability and increase the difficulty of achieving
orgasm (Rawson, Washton, Domier, & Reiber, 2002). Sexual behavior may also affect drug
use behaviors. A prospective study of IDUs conducted over 10 years found that male IDUs
who reported having no heterosexual partners were more likely to become infected with HIV,
and this finding was not explained by homosexual or bisexual activity (Strathdee et al.,
2001). Not having a partner who can provide social support may be associated with high-risk
injection practices and could also be a marker of severe drug dependence.
However, there may be an association between sexual behavior and HCV among
incarcerated women. One study among 469 prisoners entering California State correctional
facilities found that the odds of HCV infection for women reporting having sex with an IDU
were more than 4 times higher than for women reporting not having sex with an IDU (Fox et
al., 2005). A study of 542 incoming inmates from a jail in Northern Virginia also found that
33
in the 6 months before incarceration, women were more likely than men to report having
unprotected sex with an IDU, ever using injection drugs, and using dirty needles (Adams et
al., 2011). In regards to this sexual partnership, women may be initiated into injection drug
use, increase the frequency of injection drug use, and share needles to build and maintain
trust with male partners, increasing their risk of acquiring HCV (Evans et al., 2003). Female
inmates may also be more likely than male inmates to be incarcerated for prostitution,
injection drug use, crack/cocaine use, and other behaviors associated with an increased HCV
risk (Baillargeon et al., 2003).
The current study also found age and history of injection drug use to be independent
correlates for HCV seropositivity, and the prevalence of HCV to be higher among
participants who were White, female participants, and participants with higher cumulative
years incarcerated. These findings are consistent with those from other studies of HCV in
incarcerated populations. The relationship between increased age and increased HCV
prevalence in incarcerated and drug-using populations has been attributed to higher
cumulative exposure to HCV through the use of injection drugs over a longer period of time
(Solomon, Flynn, Muck, & Vertefeuille, 2004). Lower HCV prevalence among Blacks in this
population may be explained by a decreased frequency of injection drug use among this
racial group than among Whites and other racial groups. A study by Khan et al. (2012) found
that among young adults, Blacks were much less likely to report non-injection crack-cocaine
and injection drug use compared to Whites, Latinos, Native Americans, and Asian
Americans. A study by Broz and Ouellet (2008) found that admissions to publicly-funded
drug treatment programs between 1992 and 2004 among White IDUs increased, whereas
admissions among Black IDUs declined, and there was a substantial decline in young Black
heroin IDUs enrolling in research studies. Among IDU-related acute hepatitis C cases
reported to 6 U.S. county health departments from 1982 to 2006, the lowest proportion of
cases was reported by Blacks (28%) compared to Whites (34%) and Hispanics (40%)
(Williams, Bell, Kuhnert, & Alter, 2011).
LIMITATIONS
This study had several limitations that should be considered in interpreting its
findings. The eligibility criteria to participate in the NIDA CJ-DATS study excluded those
34
with an existing and diagnosed DSM-IV-R psychotic disorder, leaving out an important atrisk group for HCV. The prevalence of HCV is higher among people with severe mental
illness compared to the general population, and people with severe mental illness are likely to
engage in risky behaviors that put them at risk for blood-borne infections such as HIV, HBV,
and HCV(Rosenberg et al., 2001). People with severe mental illness are likely to engage in
high-risk behaviors such as having multiple sexual partners and high-risk partners, infrequent
condom use, same-sex sexual activity, trading sex for money or drugs, engaging in sex while
using psychoactive substances, and injecting drugs. Severe mental illness is more prevalent
in incarcerated populations than in the general population; results from the Survey of Inmates
in State and Federal Correctional Facilities, 2004, and the Survey of Inmates in Local Jails,
2002, found that 15% of State prisoners, 10% of Federal prisoners, and 24% of jail inmates
had a psychotic disorder, compared to 3% of adults in the U.S. general population (James &
Glaze, 2006). Fifty percent of adults in the U.S. with severe mental illness are 'dually
diagnosed' with co-occurring substance abuse disorders, elevating their risk for HCV
(Rosenberg et al., 2005). Mental problems have also been linked to substance abuse in
incarcerated populations; 74% of State prisoners and 76% of local jail inmates with a mental
health problem also met criteria for substance dependence or abuse (James & Glaze, 2006).
Survey administration was done using interviews, which could have resulted in
nonresponse bias or social desirability bias if participants declined to report or underreported
risk behaviors. Recall bias may have occurred as it may have been difficult for participants at
the end of their incarceration to remember their sexual behaviors in the 6 months before they
were arrested. Misclassification bias may have occurred if participants failed to report or
underreported sexual behaviors they engaged in during those 6 months. Misclassification of
those who were infected with HCV may have also occurred if the HCV antibody test was
administered during the "window period" of 1-3 weeks after infection during which the test
would not be able to detect HCV antibodies in the blood. Positive HCV tests were not
followed up with confirmatory tests, so the occurrence of false positives, although rare in
populations with HCV prevalence over 10%, is possible.
Although HIV is an important risk factor for HCV infection, this variable was not
included in the analysis beyond descriptive statistics due to the small number of HIVinfected participants (n=11). As this analysis used an existing data set, questions on risky
35
sexual behaviors were limited. Information collected for participants' sexual behavior was
limited only to the period of 6 months before their arrest that resulted in their incarceration;
information regarding participants' sexual behaviors during their incarceration was not
collected. As participants were tested for HCV within 30 days of being released from
incarceration, sexual behaviors occurring during incarceration or after release that may have
played a role in HCV transmission were unaccounted for in this analysis. No data was
collected on sexual behaviors with increased trauma and blood-to-blood contact, such as anal
sex and rape, during the 6 months before arrest. The study data also did not have available
information on which sites participants were recruited from, so differences in the association
between sexual behavior and HCV test result between the sites could not be assessed. And as
this secondary analysis was a cross-sectional study, causality and temporality between sexual
behavior and HCV could not be assessed.
STRENGTHS
Because this study was restricted to drug users and injection drug use is a significant
risk factor for HCV, it is important to correctly classify those who have ever injected drugs
from those who have never injected drugs to assess the association between sexual behavior
and HCV status. To reduce misclassification of participants who ever injected drugs and
those who never injected drugs, participant responses to two survey questions asking about
age of first injection drug use of any drug and frequency of injecting drugs in the 6 months
before arrest were combined to determine whether or not participants ever injected drugs.
HCV status was assessed using a HCV ELISA antibody test rather than through self-report.
The HCV ELISA antibody test is highly sensitive and specific and rarely produces false
positives when the prevalence in the population in which it is administered is greater than
10% (CDC, 2003b). A large sample size of 614 allowed for a multivariate analysis.
IMPLICATIONS AND FUTURE RESEARCH
Age and injection drug use are known risk factors for HCV and were found to be
significantly associated with positive HCV result in this study. Screening those born during
1945-1965 and injection drug users upon entry into correctional settings represents an
opportunity to detect and treat undiagnosed cases and prevent transmission to others. In
36
situations where screenings are not implemented due to incarcerated persons having shorter
sentences than the length of HCV therapy, prisons and jails can provide links to community
health clinics to prevent interruption of care and increase completion of treatment when
persons being treated for HCV are released from incarceration. Offering substance abuse
treatment to drug users would also reduce the risk of HCV transmission through injection
drug use, as well as prevent recidivism from drug-related offenses. Substance abuse
programs in correctional facilities and in communities could collaborate to provide
counseling and treatment to individuals when they are incarcerated and after they are
released to prevent relapsing into substance abuse. Needle-exchange programs in
communities can help reduce the risk of acquiring and transmitting HCV and HIV in IDUs
who are released from incarceration and continue to use drugs.
This study also found that risky sexual behaviors were common in this population.
Incarcerated populations would benefit from STI screening upon entry, in-house sexual
health education on preventing HIV, STIs, and hepatitis, and referral to community STI
clinics and sexual health services upon release. Incarcerated persons may also benefit from
provision of condoms and other safe sex supplies such as lube and dental dams within
correctional facilities. Although this intervention is controversial due to concerns about
adverse consequences, including that access to condoms might be seen as allowing and
condoning sexual activity or that condoms could be used to conceal drugs, research has not
found access to condoms to constitute a threat to security or operations, and condom access
has not been found to result in increased sexual activity (World Health Organization, 2007).
Correctional facilities should also have strategies in place to enhance detection, prevention,
and reduction of sexual violence. Such strategies include ways of documenting and reporting
sexual assault, inmate and staff education, staff training, and counseling and post-exposure
prophylaxis treatment for victims. Prevention services in correctional facilities and linkages
to community health services are needed to screen and treat undiagnosed cases, educate and
counsel at-risk groups, and prevent transmission among marginalized population with high
disease burdens and high rates of risk behaviors. Having integrated substance abuse
treatment and sexual health education available during incarceration and after release are
essential to prevent and control diseases that can be spread through risky drug use and sexual
behaviors in a population that engages in high rates of both.
37
Future research should investigate the causal relationship between sexual behaviors
and hepatitis C in incarcerated populations. To examine this relationship in correctional
settings, prospective studies are needed to determine whether engaging in risky sexual
behavior while incarcerated increases the risk of HCV. Research on this relationship should
also include incarcerated persons with mental illness as mental health issues are prevalent in
incarcerated populations and those with severe mental illness are at increased risk for HCV
and are more likely to engage in risky sexual and drug behaviors. It would also be interesting
to examine the differences in risky sexual behaviors between IDUs, NIDUs, and users of
different types of drugs, and what factors are driving these differences.
38
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