Hepatitis C Virus Infection in San Francisco's HIV-infected Urban Poor

High Prevalence but Low Treatment Rates


  • Received from the Epidemiology and Prevention Interventions Center (CSH, EDC, DRB), Division of Infectious Diseases, San Francisco General Hospital; Department of Epidemiology and Biostatistics (JAH, ARM); and the San Francisco General Hospital AIDS Program (DRB), University of California, San Francisco, Calif.

Address correspondence and requests for reprints to Dr. Bangsberg: Epidemiology and Prevention Interventions Center, Box 1347, University of California, San Francisco, CA 94143-1347 (e-mail: db@epi-center.ucsf.edu).


OBJECTIVE:  To measure Hepatitis C Virus (HCV) prevalence, incidence, and initiation of HCV therapy in a representative HIV-infected cohort of the urban poor.

DESIGN:  Cohort analysis.

SETTING:  The Research and Access to Care for the Homeless (REACH) Cohort is a systematic sample of HIV-infected marginally housed individuals identified from single-room occupancy hotels, homeless shelters, and free lunch programs in San Francisco.

PARTICIPANTS:  Two hundred forty-nine participants with 28.9 months (median) of follow-up were studied. Mean age was 44 (range 24 to 75, standard deviation 8.4) years. Eighty-two percent were male, 43% were African-American, 64% were lifetime injection drug users, and 24% had been on the street or in a shelter in the prior month.

INTERVENTIONS:  We measured HCV testing and treatment history with structured interviews; additionally, participants were tested for HCV antibodies (EIA-2) with RNA viral load confirmation.

MAIN RESULTS:  At baseline, 172 (69.1%) were HCV-positive and 182 (73.1%) were HCV-positive at follow-up, including 155 (62.2%) with viremia. HCV-positive status was associated with having injected drugs, elevated serum alanine aminotransferase, homelessness in the last 1 year, and more severe depressive symptoms. The incidence of new HCV infection was 4.63% per person-year (ppy; 95% confidence interval, 2.31 to 8.13) in the entire cohort and 16.77% ppy among injection drug users. The prevalence of HCV antibody-negative HCV-viremia was 13.2% (10/76). Nonwhites were less likely to receive HCV testing and subspecialty referral, controlled for drug use and other confounders. Sixty-eight percent (123/182) were aware treatment was available; however, only 3.8% (7/182) or 1.16% ppy received HCV treatment.

CONCLUSIONS:  While HCV infection is common, HCV treatment is rare in the HIV-HCV coinfected urban poor. Urban poor, nonwhite individuals are less likely to receive HCV testing and subspecialty referral than their white counterparts. Antibody-negative infection may complicate screening and diagnosis in HIV-infected persons.