of people who inject drugs in the United States missed opportunities for HIV or
hepatitis C virus testing between 2010 and 2017, a review of more than 840,000
healthcare visits shows. Men in rural America seeking care for skin infections
or endocarditis were most likely to miss out on testing.
HIV testing for
people at high risk of infection is recommended at least once a year in the United
States and the Centers for Disease Control and Prevention also recommends that
people who inject drugs should be tested for hepatitis C.
The study looked
at commercial health insurance databases to identify people with probable
markers of injecting drug use including overdose, endocarditis, skin infections
or abscesses normally indicative of injecting drug use, substance use or
prescription of opioid substitutes, naltrexone or naloxone. The researchers
calculated the likelihood of testing for hepatitis C according to demographic
estimated that 844,242 people who inject drugs attended healthcare facilities
and were covered by an insurance claim. This population only covers people who were
covered by employer or commercial insurance, not people covered by public insurance
(Medicare), so it will underestimate the number of people who inject drugs who
came into contact with health services in the United States during the study period.
two-thirds of injecting drug users attended medical facilities for treatment of
skin infections or endocarditis and 31% attended for drug dependence treatment.
Women made up half the population and around 40% of the study population were
under 30 years old.
Only 8% were tested for HIV and men were significantly less likely to have an
HIV antibody test than women (adjusted odds ratio 0.50, 95% CI 0.49-0.50,
p < 0.001). HIV testing was less likely to take place if a person visited a
general medical practice than other forms of healthcare visit. People receiving
treatment for skin infections associated with injecting drug use were less likely
to be tested for HIV than people diagnosed with a substance use disorder.
were tested for hepatitis C. Just under 8% had a test for hepatitis C
and it was more likely to have taken place if the visit occurred more recently or
if the person was diagnosed with a substance use disorder or overdose, or if
they made frequent healthcare visits. People treated for skin infections indicative
of injecting drug use were less likely to be tested for hepatitis C than those
without (aOR 0.90, 95% CI 0.86–0.95,
p < 0.001).
People in rural
areas were less likely to be tested for HIV or hepatitis C, as were people outside
the north-eastern United States. The study investigators note that 31% of acute
hepatitis C infections are estimated to occur in rural counties of the United States.
In an accompanying editorial in the Journal of Infectious Diseases,
Benjamin Linas of Boston University School of Medicine proposes that venue-based
testing might be an effective way of increasing the proportion of people who
inject drugs who are tested for hepatitis C and HIV.
Routine testing of everyone who attends an addiction treatment clinic,
a needle and syringe programme or a residential drug detoxification clinic
would increase the number of people tested and would be more effective than
risk-based testing in the United States, he argues. “Risk-based
targeted testing does not work. Many times, providers do not identify the risk
behavior.” What’s more, routine one-time testing does not address the needs of
people at ongoing risk of infection.
is clear—we cannot end any epidemic among PWID [people who inject drugs] unless we take concrete steps to
address underperformance in identifying and treating new infections. It is time
for a new approach to HIV and HCV [hepatitis C virus] testing among PWID,” Dr Linas concludes.