To understand increasing rates of hepatitis C virus (HCV) infection in Tennessee, we conducted testing, risk factor analysis and a nested case-control study among persons who use drugs. During June-October 2016, HCV testing with risk factor assessment was conducted in sexually transmitted disease clinics, family planning clinics and an addiction treatment facility in eastern Tennessee; data were analysed by using multivariable logistic regression. A nested case-control study was conducted to assess drug-using risks and behaviours among persons who reported intranasal or injection drug use (IDU). Of 4753 persons tested, 397 (8.4%) were HCV-antibody positive. HCV infection was significantly associated with a history of both intranasal and IDU (adjusted odds ratio (aOR) 35.4, 95% confidence interval (CI) 24.1-51.9), IDU alone (aOR 52.7, CI 25.3-109.9), intranasal drug use alone (aOR 2.6, CI 1.8-3.9) and incarceration (aOR 2.7, CI 2.0-3.8). By 4 October 2016, 574 persons with a reported history of drug use; 63 (11%) were interviewed further. Of 31 persons who used both intranasal and injection drugs, 26 (84%) reported previous intranasal drug use, occurring 1-18 years (median 5.5 years) before their first IDU. Our findings provide evidence that reported IDU, intranasal drug use and incarceration are independent indicators of risk for past or present HCV infection in the study population.

Testing and linkage to care are important determinants of hepatitis C virus (HCV) treatment effectiveness. Public health clinics serve populations at high risk of HCV. We investigated their potential to serve as sites for HCV testing, initiation of and linkage to HCV care. Cross-sectional study of patients accessing sexually transmitted infection (STI) care at the Baltimore City Health Department (BCHD) STI clinics, from June 2013 through April 2014 was conducted. Logistic regression was used to assess factors associated with HCV infection and specialist linkage to care. Between 24 June 2013 and 15 April 2014, 2681 patients were screened for HCV infection. Overall, 189 (7%) were anti-HCV positive, of whom 185 (98%) received follow-up HCV RNA testing, with 155 (84%) testing RNA positive. Of 155 RNA-positive individuals, 138 (89%) returned to the STI clinic for HCV RNA results and initial HCV care including counselling regarding transmission and harm reduction in alcohol, and 132 (85%) were referred to a specialist for HCV care. With provision of patient navigation services, 81 (52%) attended an offsite HCV specialist appointment. Alcohol use and lack of insurance coverage were associated with lower rates of specialist linkage (OR 0.4 [95% CI 0.1-0.9] and OR 0.4 [95% CI 0.1-0.9], respectively). We identified a high prevalence of HCV infection in BCHD STI clinics. With availability of patient navigation services, a large proportion of HCV-infected patients linked to off-site specialist care.

Data on viral hepatitis B (HBV) testing and vaccination in primary care settings among persons at sexual risk for HBV infection have been sparse. We examined rates and factors associated with HBV serologic testing and vaccination rates in adults infected with sexually transmitted infections. We conducted a retrospective cohort study of adults diagnosed with chlamydia, gonorrhea, or syphilis in Kaiser Permanente Southern California in 2008-2011. The vaccine series initiation was examined in subjects who were tested susceptible. The 90-day hepatitis B surface antigen (HBsAg) testing rate was 28.1% in 15 357 adults. Testing rates increased through the study period. Only 8.8% of patients received both HBsAg and hepatitis B surface antibody tests to determine prior exposure and susceptibility to HBV. Among those who were tested susceptible, 116 (10.6%) subjects initiated the vaccine series. In multivariable logistic regression analysis, the odds of receiving testing was inversely associated with female sex, black race, other/unknown race, or having prespecified chronic comorbidities. In survival analysis, adults aged 25-34 years and ≥55 years were more likely to initiate hepatitis B vaccine series compared with those aged 18-24 years. There are missed opportunities in HBV testing and vaccination in primary care. Implementation of provider decision-making support tools in the electronic medical record system may potentially improve hepatitis B testing and vaccination rates.

Effective screening programs are urgently needed to provide undiagnosed hepatitis C virus (HCV)-infected individuals with therapy. This systematic review of characteristics and outcomes of screening programs for HCV focuses on strategies to identify HCV risk groups hidden in the general population.

We conducted a comprehensive search of MEDLINE and EMBASE databases for articles published between 1991-2010, including studies that screened the general population using either a newly developed (nonintegrated) screening program or one integrated in existing health care facilities. Look-back studies, prevalence studies, and programs targeting high-risk groups in care (e.g., current drug users) were excluded.

After reviewing 7052 studies, we identified 67 screening programs: 24 nonintegrated; 41 programs integrated in a variety of health care facilities (e.g., general practitioner); and 2 programs with both integrated and nonintegrated strategies. Together, these programs identified approximately 25,700 HCV-infected individuals. In general, higher HCV prevalence was found in programs in countries with intermediate to high HCV prevalence, in psychiatric clinics, and in programs that used a prescreening selection based on HCV risk factors. Only 6 programs used a comparison group for evaluation purposes, and 1 program used theory about effective promotion for screening. Comparison of the programs and their effectiveness was hampered by lack of reported data on program characteristics, clinical follow-up, and type of diagnostic test.

A prescreening selection based on risk factors can increase the efficiency of screening in low-prevalence populations, and we need programs with comparison groups to evaluate effectiveness. Also, program characteristics such as type of diagnostic test, screening uptake, and clinical outcomes should be reported systematically.

Less than half of gay and bisexual men indicated they had received some doses of hepatitis B virus vaccine. Hepatitis B virus vaccination was higher among men who were 18 to 29 years old (compared to those 50-59 years old), gay, or had received flu vaccine within the last year.

This study assessed the long-term economic implications of a national program to vaccinate all adults treated at sexually transmitted disease (STD) clinics in a single year.

A model was developed to track the long-term disease outcomes and costs among a hypothetical cohort of 2 million STD clinic clients accessing services in one year, using data from published sources and demonstration projects at STD clinics in San Diego (California), Illinois, and Denver (Colorado). The model estimated net economic benefits of a routine hepatitis B vaccination policy at STD clinics nationwide compared with no vaccination.

Without a vaccination program, an estimated 237,021 new hepatitis B virus (HBV) infections would occur over the lifetimes of the 2 million STD clinic clients seen in a single year. HBV-related medical costs and productivity losses would be $1.6 billion. In a national program for routine vaccination at STD clinics, 1.3 million adults would be expected to receive at least one vaccine dose, and an estimated 45% of the new HBV infections expected without vaccination would be prevented. The vaccination program would cost $138 million, HBV infections occurring despite the program would cost $878 million, and clients' time and travel would cost $45 million. The net economic benefit (savings) of routine vaccination would be $526 million. If the indirect costs of lost productivity due to HBV infection are not considered, routine vaccination would have a net cost of $28 million.

Estimates from this model suggest a national program for routine hepatitis B vaccination of adults at STD clinics would be a cost saving to society.

To estimate the cost and cost-effectiveness of testing sexually transmitted disease (STD) clinic subgroups for antibodies to hepatitis C virus (HCV).

HCV counseling, testing, and referral (CTR) costs were estimated using data from two STD clinics and the literature, and are reported in 2006 dollars. Effectiveness of HCV CTR was defined as the estimated percentage of clinic clients in subgroups targeted for HCV antibody (anti-HCV) testing who had a true positive test and returned for their test results. We estimated the cost per true positive injection drug user (IDU) who returned for anti-HCV test results and the cost-effectiveness of expanding HCV CTR to non-IDU subgroups.

The estimated cost per true positive IDU who returned for test results was $54. The cost-effectiveness of expanding HCV CTR to non-IDU subgroups ranged from $179 to $2,986. Our estimates were most sensitive to variations in HCV prevalence, the cost of testing, and the rate of client return.

Based on national data, testing IDUs in the STD clinic setting is highly cost-effective. Some clinics may find that it is cost-effective to expand testing to non-IDU men older than 40 who report more than 100 lifetime sex partners. STD clinics can use study estimates to assess the feasibility and desirability of expanding HCV CTR beyond IDUs.

Hartford Dispensary, a private, not-for-profit behavioral health care organization specializing in opioid treatment program services, serves more than 4,200 clients per day in seven licensed facilities. In May 2002, the Dispensary began offering free combined hepatitis A and B vaccine for all eligible clients in two Hartford clinics. Initial eligibility criteria required a client to be hepatitis C antibody positive, hepatitis B virus (HBV) surface antigen (HBsAg) negative, not pregnant, and not have a contraindication due to a medical condition. From May 2002 through April 2005, 5,419 doses of combined vaccine were given. Of the 2,072 clients who received a first dose, 92% (1,914) received the second dose and 69% (1,433) completed the series. Long treatment duration, frequent client visits, availability of medical staff, and counseling support contributed to high rates of combined vaccine series completion in the two programs. Opioid treatment programs appear to be good settings in which to provide hepatitis vaccination for high-risk adults.

Project Extension for Community Healthcare Outcomes (Project ECHO) is a telemedicine and distance-learning program designed to improve access to quality health care for New Mexicans with hepatitis C. Project ECHO links health-care providers from rural clinics, the Indian Health Service, and prisons with specialists at the University of New Mexico. At weekly clinics, partners present and discuss patients with hepatitis C with specialists. Partners can receive continuing education credits for participating. Since June 2003, 173 hepatitis C clinics have been conducted with 1,843 case presentations. Partners have received 390 hours of training and 2,997 hours of continuing education credits. And in 2006, the State Legislature approved $1.5 million in annual funding for the project. Project ECHO has increased access to state-of-the art hepatitis C virus care for patients living in rural areas or prisons. Because of its success with hepatitis C, this project is being expanded to other chronic medical conditions.

Hepatitis B vaccination is recommended for clients of sexually transmitted disease (STD) clinics. The Healthy People 2010 goal is for 90% of STD clinics to offer hepatitis B vaccine to all unprotected clients. This report describes hepatitis B vaccination trends in six STD clinics in the United States and discusses implications for policy and practice.

We conducted a retrospective study in six STD clinics to evaluate hepatitis B vaccination. We collected data on client visits and hepatitis B vaccinations for the period 1997-2005. To compare clinics, we calculated vaccination rates per 100 client visits. We interviewed staff to explore factors associated with hepatitis B vaccination trends.

STD clinic client visits ranged from 2,883 to 23,109 per year. The median rate of hepatitis B vaccination was 28 per 100 client visits. Vaccination rates declined in all six clinics in later years, which was associated with eligibility restrictions caused by fiscal problems and increasing levels of prior vaccination. The median rate of vaccine series completion was 30%. Staff cited multiple provider- and client-level barriers to series completion.

This study shows that STD clinics can implement hepatitis B vaccination and reach large numbers of high-risk adults. Adequate funding and vaccine supply are needed to implement current federal recommendations to offer hepatitis B vaccine to adults seen in STD clinics and to achieve the Healthy People 2010 objective.