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HCV (hepatitis C virus) pre-test and post-test counseling services at drug treatment programs: missed opportunities for primary prevention.

Article Excerpt
The World Health Organization (2000) estimates that there are 170 million individuals infected with hepatitis C virus worldwide. In the U.S., approximately four million have contracted the virus (Alter, Kruszon-Moran, Nainan, McQuillan, Gao, Moyer, Kaslow & Margolis, 1999), and an estimated 35,000 acute new HCV infections occur each year (National Institutes of Health, 2002). The vast majority of individuals who contract acute HCV infection (85%) will develop chronic hepatitis, and 20% of these individuals will eventually develop cirrhosis of the liver (Centers for Disease Control and Prevention, 1998; Liang, Rehermann, Seeff & Hoofnagle, 2000). Past and current intravenous drug users (IDUs) are the group most at risk for acquiring HCV infection (Alter & Moyer, 1998; Edlin, 2002; Garfein, Vlahov, Galai, Doherty & Nelson, 1996; Hagan, Thiede, Weiss, Hopkins, Duchin & Alexander, 2001). There is also evidence that noninjectors are at an increased risk for contracting HCV, particularly individuals with a history of snorting cocaine or smoking crack cocaine (Rosenblum, Nuttbrock, McQuistion, Magura & Joseph, 2001; Tortu, Neaigus, McMahon & Hagan, 2001).

While drug users are clearly at increased risk for contracting HCV, there is some controversy regarding whether or not adults at risk for the virus should be routinely screened for HCV infection. On the one hand, the U.S. Preventive Services Task Force (2004) recently found insufficient evidence to recommend for or against routine HCV screening for adults at high risk of infection. The task force states that there is "... no evidence that newer treatment regimens for HCV infection, such as pegylated interferon, plus ribavirin, improve long-term health outcomes (page 462, 4th paragraph)" and cautions that there are potential risks to widespread screening and treatment (i.e., labeling, adverse treatment effects, and potentially unnecessary medical procedures). On the other hand, the Centers for Disease Control (1998) and the National Institutes of Health (2002) have issued recommendations at the federal level that encourage targeted HCV screening among high risk individuals, in part because infected persons serve as a source of transmission for HCV (particularly through injection drug use) and are at risk for developing HCV-related chronic liver problems. The National Institutes of Health (NIH) also suggest that: 1) The recent introduction of combination therapy (interferon with ribavirin), as well as pegylated interferon, are important advances in therapeutic treatment for HCV that have been shown to result in better treatment outcomes. 2) Active drug users should not be excluded from antiviral therapy on the basis of their current drug use alone, but rather, considered for HCV treatment on a case-by-case basis.

Whatever their position regarding this controversy, drug treatment programs throughout the United States and elsewhere have, in fact, been providing HCV testing to many of their clients (Strauss, Astone, DesJarlais & Hagan, 2004; Winstock, Sheridan, Lovell, Farrell & Strang, 2000). To some extent, these programs are likely responding to the fact that many drug users remain uninformed about their HCV serostatus (Best, Noble, Finch, Gossop, Sidwell & Strang, 1999; Dhopesh, Taylor & Burke, 2000; Kwiatkowski, Corsi & Booth, 2002; Stein, Maksad & Clarke, 2001), are often medically underserved (Chitwood, McBride, French & Comerford, 1999; Contoreggi, Rexroad & Lange, 1998), and are not likely to receive many opportunities for HCV testing elsewhere. Drug treatment programs may therefore be an especially important setting for the delivery of critical HCV testing services (Dhopesh et al., 2000; Edlin, 2004; Sorensen, Masson & Perlman, 2002; Stein et al., 2001; Strauss, Falkin, Vassilev, DesJarlais & Astone, 2002).

In addition to being unaware of their HCV serostatus, many drug users also remain uninformed about how the disease is transmitted and how to prevent contracting the virus if uninfected (Davis & Rhodes, 2004; Dhopesh et al., 2000; Heimer, Clair, Grau, Bluthenthal, Marshall & Singer, 2002; Rhodes, Davis & Judd, 2004; Stein et al., 2001). Importantly, the pre-test and post-test counseling that often accompanies HCV testing provides an opportunity to share timely information that may decrease the likelihood that infected individuals will transmit the virus to other people, and prevent new infection among those most at risk (Sorensen et al., 2002). In fact, recognizing the role that antibody testing and counseling can play in HCV primary prevention efforts, the Centers for Disease Control and Prevention (2003) recommends that test procedures should include the communication of risk reduction and prevention messages for all high-risk clients in a pre-test "prevention" session and a post-test counseling session. In the event that clients test HCV negative, counselors are urged, in the post-test session, to both clearly inform individuals of their negative test results and emphasize the need for patients to initiate risk reduction in order to remain negative. Counselors are also reminded to: 1) Remain aware of the possibility that individuals who receive a negative test result may minimize the likely consequences of their previous risk behaviors and, in turn, feel more inclined to engage in risky behavior. 2) Take advantage of the prevention opportunity with those individuals who test negative by reemphasizing the risk reduction and prevention messages that were delivered in the pre-test session. In fact, these procedures are consistent with the HIV testing and related counseling procedures that are so familiar to counselors and service providers (Centers for Disease Control and Prevention, 2001).

In spite of the importance and critical need for the suggested pre-text and post-test counseling at the time of HCV testing, little is currently known about whether HCV testing in drug treatment programs is generally accompanied by this counseling. In addition, we remain uninformed about the degree to which this testing is consistent with the recommendations of the Centers for Disease Control for promoting the communication of HCV prevention messages, including to those clients that test antibody negative for HCV (many of whom will...