In this cross-sectional survey of PWID in Wisconsin, we found that most respondents had been previously tested for HCV. Those who were tested for HCV in the past year were more likely to have a PCP, to have completed some education beyond high school, and to reside in the city of Milwaukee. Qualitative analysis of interview responses reinforced the important roles of HCV test availability and health care access in general to facilitate regular screening for PWID. The findings from our study may provide insight into individual- and structural-level barriers and facilitators to routine testing for high-risk individuals, and inform future efforts to promote HCV testing among PWID.
Compared with respondents from other Wisconsin cities, residents of Milwaukee had more than twice the odds of receiving HCV testing in the year prior to the study. Numerous factors may account for this disparity: Milwaukee is the largest and most densely populated city in Wisconsin and has a higher burden of communicable diseases such as HIV and sexually transmitted infections than most other areas of the state. Appropriately, prevention services such as the Lifepoint Needle Exchange are more numerous and accessible to Milwaukee residents, and PWID in this area may therefore have greater knowledge of available resources. Additionally, individuals living in cities with a higher burden of drug use and HCV may be more likely to encounter peers who have utilized prevention services in the past, to have medical providers who have greater familiarity with the needs of drug-using patients, and to have easier access to primary care or urgent care centers where testing can be performed. There may be unmet needs for community-based services and a paucity of health care providers with experience caring for PWID in less densely populated areas.
We found quantitative evidence that access to health care is an important determinant of regular HCV screening for PWID. Respondents who reported that they have a primary care provider had twice the odds of receiving a test for HCV in the past year as those without at PCP. Though there was no difference in past-year testing, both groups commonly identified access to healthcare professionals as a facilitator to testing. Previous research has noted that continuity of care with a provider has fostered regular screening and, in some cases, adherence to treatment . Our results suggest that PWID are more apt to receive HCV screening when it is offered as a part of routine care, rather than when it is only available “on-demand,” thereby requiring individuals to take initiative for screening themselves. This is consistent with a recent qualitative study indicating that provider-initiated HCV screening is substantially more successful than self-initiated screening among drug users in New York and San Francisco . The previous study, involving focus groups of drug users recruited in both clinical and non-clinical settings, found that while provider-initiated HCV screening was more successful, there was a perceived lack of settings for self-initiated HCV testing yet an eagerness to have access to voluntary testing. This differed from testing for HIV, which individuals perceived as much more easily accessible and were more likely to seek based on their own initiative. While we cannot determine from our data whether HCV testing in Wisconsin is more commonly provider-initiated or patient-initiated, our findings highlight a potentially important role that PCPs have in screening for HCV. Particularly, PCPs could initiate the discussion by talking about the benefits of testing, providing information regarding voluntary testing locations, and being explicit about the lack of judgment on the part of the practitioner.
Study participants reported a range of beliefs related to HCV testing, many of which are consistent with previous work on HIV and HCV testing [20–23]. Fear of a positive test result played a role in the decision of many respondents who were resistant to testing. Low perceived risk also contributed to past-year testing in some cases. Medical providers and SEP staff can be instrumental in supporting participants’ testing in both of these groups. Staff can allay fears about a positive result by citing new HCV treatments as well as support group if found to be HCV positive. Motivational interviewing techniques providing feedback regarding drug-injecting behaviors and actual HCV risk may be useful to help those with perceived low risk get tested .
Stigma was a theme in respondents’ discussion of barriers to HCV testing, which is consistent with previous research . Participants in our study did not frequently express concerns about stigma from medical professionals or needle-exchange staff, as has been reported previously [25–27]. In fact, nearly one-third of those tested in the past year in our study had been tested in primary care clinics. Based on our data, it does not appear that healthcare settings are a major impediment to testing. Rather, in depth analysis of “stigma” statements revealed that those respondents described perceiving a more generalized, societal stigma of HCV as a “junkie disease” . This perception highlights an opportunity for health care providers and community-based organizations to help foster safe and accepting environments for testing. This may include assurances of confidentiality, education campaigns regarding other risk factors for HCV, and improved provider-patient communication.
There are several limitations to our study. Despite having a large sample size and a reasonably high response rate of 64%, the respondents to our survey were a convenience sample, which may not be fully representative of PWID in the communities we targeted. Our study was performed in a single Midwestern state with a mix of rural, suburban, and urban participants. The findings, therefore, may not be generalizable to drug-using communities in other regions. As all participants were clients at a SEP, our study sample may exclude a subset of PWID who do not use prevention services and may have a higher risk of HCV. While we attempted to minimize bias due to socially-desirable responding by having participants privately self-administer most sections of the survey, the responses to the in-person interview questions may have been influenced by participants’ knowledge of the study’s main goal, which was to collect information useful for promoting HCV testing among PWID who have not been tested previously.
In theory, early detection of HCV can facilitate referrals to treatment and may reduce the future burden of morbidity from liver disease and even decrease HCV transmission . In the past, treatment for HCV has not been widely available or affordable to PWID, many of whom lack health insurance and generally have poor access to health services. Linking PWID who test positive for HCV to care and evaluating for treatment may, therefore, be difficult. However, currently evolving health insurance reforms could eventually make HCV treatment available to a growing number of patients. In this setting, strategies to improve detection of asymptomatic HCV infection as part of routine primary care could yield substantial public health benefit. Moreover, some evidence suggests that detection of asymptomatic infection and subsequent education may lead to safer injection practices and reduce frequency of injecting among high-risk PWID, thereby promoting HCV prevention even among those who do not access treatment [29, 30].