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Public Health Rep. 2007; 122(Suppl 2): 6–11.
PMCID: PMC1831808

Texas Statewide Hepatitis C Counseling and Testing, 2000–2005

Gary Heseltine, MD, MPHa and Jenny McFarlane, BAb

SYNOPSIS

In 1999, the Texas legislature funded a statewide hepatitis C education and prevention program. Hepatitis training was incorporated into training for all human immunodeficiency virus (HIV), sexually transmitted disease (STD), and substance abuse counselors. Hepatitis C virus (HCV) counseling and HCV-antibody (anti-HCV) testing services were integrated into 20 HIV/STD service provider programs. Hepatitis C counseling and testing became available in 2000. Through 2005, 38,717 tests were administered, with 8,964 (23.2%) anti-HCV positive. Injection drug use was reported by 7,105 people (79.3%) who tested positive. In Texas, a state-initiated and almost entirely state-funded program supported statewide HCV counseling and anti-HCV testing among high-risk adults.

With an estimated 350,000 Texans infected by the hepatitis C virus (HCV),1 the Texas Department of Health (TDH) convened a statewide HCV working group in 1998 to address growing concerns in the community. The working group included representatives from hepatitis advocacy organizations, the Texas Medical Association, the American Red Cross, the Texas Department of Criminal Justice, and staff from the TDH Bureau of Communicable Disease and the TDH Bureau of HIV and STD Prevention. TDH representatives developed a white paper entitled “Hepatitis C: An Emerging Health Concern for Texans”2 that described the extent of HCV infection in Texas, proposed interventions, and estimated the costs of comprehensively addressing this issue. A member of the Texas House Committee on Public Health used findings from the white paper as a basis for House Bill (HB) 1652, the Education and Prevention Program for Hepatitis C. With the passage of this bill in 1999, Texas became one of the first states to formally address hepatitis C. HB 1652 required TDH to: (1) establish voluntary hepatitis C counseling and testing sites within all 11 state public health regions; (2) conduct seroprevalence studies to determine the current and future impact of hepatitis C; (3) develop and implement provider training and public education; and (4) conduct community educational outreach about hepatitis risk factors and the value of early detection. For the 2000–2001 two-year state budget period (biennium), the legislature appropriated approximately $3 million for this program. This article describes the statewide hepatitis C counseling and testing component of the program.

IMPLEMENTATION

In 2000, TDH developed a hepatitis A, B, and C module for the state human immunodeficiency virus (HIV) counselor training program. The hepatitis training helped new HIV counselors provide hepatitis C risk-reduction counseling and deliver hepatitis C prevention messages during counseling sessions. A separate one-day course was developed to train current HIV/sexually transmitted disease (STD) prevention counselors and disease intervention specialists in techniques to incorporate hepatitis C into counseling sessions.

Using the 1998 Centers for Disease Control and Prevention (CDC) recommendations1 and TDH staff input, a training program was developed for counselors that emphasized testing only individuals at high risk for HCV infection. The hepatitis C program designated as high risk those who reported injecting drugs; sharing equipment used to snort drugs; having received a tattoo or piercing under unsanitary conditions; having 50 or more lifetime sexual partners; exchanging sex for money; or having sex with an HCV-positive person, as well as people with some medical exposures and occupations. The risk factors were ranked, with injection drug use being the highest-ranked and occupational exposure the lowest-ranked risk factor. A person with multiple risks was categorized by his highest-ranking risk.

TDH determined that integrating hepatitis C counseling and testing into the existing HIV and/or STD infrastructure, composed primarily of public health-care providers, was the most efficient way to reach people at risk of or infected with HCV. TDH identified HIV/STD service providers across the state with the capacity to integrate hepatitis C into their HIV and STD programs. In September 2000, sole-source contracts totaling approximately $733,000 were awarded to 20 service providers that served people at high risk for HCV infection. On average, each of the providers had four additional satellite or outreach sites.

For the 2002–2003 biennium, the legislature appropriated approximately $3 million for hepatitis C program activities. In August 2001, TDH released a competitive request for proposals for the hepatitis C counseling and testing contracts. Twenty-one applicants were awarded funds totaling approximately $1.1 million for operations in fiscal years (FY) 2002 and 2003. In the second round of funding, the service providers selected were, for the most part, the same ones funded in 2000. Because of a large state budget deficit during the 2002–2003 biennium, funding for public health programs, including the hepatitis C program, was cut. Providers were notified in February 2003 that the hepatitis C contracts would not be renewed.

In August 2003, the CDC Division of HIV/AIDS Prevention permitted TDH to use $250,000 of FY 2003 HIV prevention dollars to support hepatitis C counseling and testing in HIV testing sites through the end of calendar year 2003. The TDH Bureau of HIV/STD Prevention also requested approximately $900,000 in HIV prevention funds through its CDC cooperative agreement to continue hepatitis C counseling and testing programs after December 2003. The request was not funded.

From 2001 through 2003, program funding averaged approximately $1.45 million per year. Because of decreased funding in 2004, most program activities, including hepatitis C testing, were curtailed significantly or discontinued. In 2005, approximately $230,000 was budgeted for viral hepatitis activities, which supports limited hepatitis C counseling and testing, adult hepatitis A and B vaccinations, and educational activities in existing public health programs. From 2000 to 2005, the program received a total of approximately $6 million in state funding.

In early 2003, the TDH Bureau of HIV/STD Prevention, Epidemiology Division, deployed a new data system to track and monitor hepatitis C testing across the state. This Web-based system allowed service providers to submit hepatitis C counseling and testing data via the Internet and to access these data through a virtual private network. This system allowed providers to submit the data on their own computers rather than compiling paper reports to be sent to TDH. This system enabled the providers to develop site-specific reports for their own use.

REACTION TO INTRODUCTION OF HEPATITIS C SERVICES

In early 2004, an outside evaluator assessed the response of counselors and managers to the introduction of hepatitis C services. This qualitative assessment was based on interviews with 13 counselors and 13 managers at different types of counseling and testing sites across the state.3

Overall, interviewees reported that the integration of hepatitis C services was not difficult and fit easily into the existing counseling infrastructure. For example, one interviewee noted, “It was instinctively [sic] that the two [HIV and HCV] meshed well and that we did not have any problems with staff and clients and it just flowed smoothly'”

In addition, interview participants reported that these services addressed an unmet need in their community. One interviewee stated, “We had to kinda push them away' We had more than we could test, believe me. No, we didn't have to use incentives, at all.”

One major concern for managers was program capacity to handle the increased workload, as noted by a manager: “Administration's biggest concern was that it would take more time to do a counseling and testing session.”

The lack of referral resources for medical treatment, vaccination, and substance abuse treatment was the most challenging and, at times, frustrating issue reported. One interviewer noted, “We had to refer them to [the hospital] and then it would take awhile sometimes to get that to happen. So the biggest thing for clients was, ‘How do we get help?’”

In summary, the qualitative assessment found the reactions of both managers and counselors to the introduction of HCV services to be overwhelmingly positive.3

HEPATITIS C TESTING

The analysis of data from a series of HCV antibody (anti-HCV) seroprevalence studies conducted in Texas in 2000 led to the development of an HCV testing algorithm based on the signal-to-cutoff ratio (unpublished data). Ortho version 3 enzyme-linked immunosorbent assay (ELISA) test results with a ratio greater than 4.0 were reported as strongly reactive, and a supplemental anti-HCV recombinant immunoblot assay (RIBA) was not done. Reactive ELISA tests with a ratio less than 4.0 were sent to a commercial laboratory for RIBA testing (Chiron RIBA). The algorithm is similar to what CDC recommended in 2003.4 Reducing the need for the costly RIBA confirmatory testing increased the number of individuals tested statewide.

From 2000 through 2005, 8,964 positive anti-HCV tests were reported, amounting to 23.2% of the 38,717 tests performed (Table 1). For comparison, during this period, the same sites reported 5,078 positive HIV tests, or 1.3% of the 397,260 tests performed (data not shown). The proportion of positive anti-HCV tests decreased from 33.5% in 2000 to 17.4% in 2005. Because of fiscal problems, the number of tests performed dropped sharply from 11,713 in 2003 to 1,351 in 2004. From 2000 through 2005, 74.7% of all people tested and 75.8% of people with positive anti-HCV tests learned the results of their anti-HCV tests and received post-test counseling.

Table 1
Hepatitis C virus antibody testing and outcomes in Texas, by year, 2000–2005

For reported risks and exposures, people reporting injection drug use had the largest number of tests—16,391, or 42.3% of all tests—followed by people reporting risky tattoos/piercings (11,056, or 28.6%) and people with no disclosed HCV risk (4,311, or 11.1%) (Table 2). The highest proportion of positive anti-HCV tests (43.3%) was among people reporting injection drug use followed by people reporting medical exposure (11.7%), people reporting risky sex (10.5%), and people reporting risky tattoos/piercings (7.9%). Injection drug use was associated with more than three-quarters, or 79.3% (7,105/8,964) of all positive anti-HCV tests.

Table 2
Hepatitis C virus antibody testing and outcomes in Texas, by risk factor, 2000–2005

For type of setting where testing was conducted, the largest number of tests were completed in HIV counseling and testing sites (10,169 tests, or 26.2% of all tests), followed closely by drug treatment facilities (9,130 tests, or 23.6%), and field visit/outreach sites (9,046 tests, or 23.4%). Among people tested in these settings, the proportion of positive test results was 27.5% in corrections facilities, 25.7% in drug treatment facilities, 25.3% each in STD clinics and field/visit outreach sites, and 17.9% in HIV counseling and testing sites (Table 3). Four settings—corrections, drug treatment, HIV counseling and testing, and field isit/outreach—accounted for 92% of positive tests.

Table 3
Hepatitis C virus antibody testing and outcomes in Texas, by setting, 2000–2005

COUNSELING AND REFERRALS

Pre- and post-test counseling was offered to people requesting HCV testing. During 2000–2001, risk-reduction specialists were trained to perform HIV/HCV prevention counseling. Those with negative test results were counseled on the results and provided risk assessment and reduction strategies. Those with positive anti-HCV tests were assessed to ensure their understanding of the results, and counseled on risk reduction for HIV and STDs and the transmission of HCV. Education included secondary prevention measures such as abstaining from alcohol and not sharing personal items like razors. In 2003, sites were trained in performing a protocol based on HIV/HCV counseling that was adapted from the Project RESPECT protocol.5

Because TDH did not have the capacity to offer prevention case-management vaccinations, medical evaluation, or substance abuse counseling and treatment, referrals were made to public and private providers in the local community for these services. Many of the programs providing hepatitis C counseling and testing reported substantial problems finding care providers that would help evaluate and care for clients with positive anti-HCV test results. There were 776 substance abuse referrals with 390 (50%) confirmed, 4,410 medical evaluation referrals with 989 (22%) confirmed, and 2,299 vaccination referrals with 399 (17%) confirmed.

DISCUSSION

A history of injection drug use was the best predictor of a positive anti-HCV test, accounting for 79.3% of the total positive tests. The overall decrease in the percentage of positive tests from 2000 (33.5%) to 2005 (17.4%) is, in part, explained by decreases in the proportion of positive tests among people reporting injecting drugs during those years (data not shown).

Corrections and drug treatment settings had the highest proportion of positive test results—27.5% and 25.7%, respectively—and together accounted for 46.3% of the total positive test results (4,148/8,964). Although family planning clinics and primary health-care facilities had a smaller proportion of positive tests—9.8% and 5.5%, respectively—the rates exceeded the general population prevalence, 1.6%.6 A 2000 study found anti-HCV seroprevalence of 5.8% in STD clinics and 10.9% in HIV counseling and testing sites in Texas.7 The higher proportion of positives found during the hepatitis C program anti-HCV testing in STD clinics (25.3%) and HIV counseling and testing sites (17.9%) suggests that risk screening at these two settings identified high-risk people for testing.

The findings in this report are subject to the following limitations. First, information on exposures and risks was based on unconfirmed self-reports from the people being tested. Although we do not know to what extent people being tested did not disclose their true risks, because of stigma and other factors, some injecting drug users do not disclose their drug use.8 Second, we do not know how counselors actually decided which clients would be tested. That 11.1% of all tests was conducted for people with “no disclosed HCV risk” indicates that counselors tested people out of protocol. It is possible that some counselors did not record all risks and exposures reported. Third, because of the uncertainties about reporting of risks and exposures, the anti-HCV positivity rates for particular exposures (e.g., sharing drug-snorting equipment) cannot be interpreted as an indication of the true risk of that exposure. Finally, because the sites offering counseling and testing were a convenience sample, these findings cannot be generalized to Texas as a whole or other states.

With a shared mode of transmission and overlapping risk behaviors, integration of hepatitis C counseling and testing into STD,9 HIV/acquired immunodeficiency syndromee (AIDS),10 drug treatment,11 and correctional12, 13 settings makes sense. Using the existing HIV/STD prevention program infrastructure helped TDH reach people at risk without the need for a new infrastructure. Incorporating HCV record-keeping into the existing HIV data system, rather than creating a separate system, facilitated management and operations. Adding a hepatitis module to the existing HIV counselor training activities was a logical step. Both counselors and managers were pleased with the additional training and better able to serve their clients.

Despite the decrease in state funding because of a budget deficit, limited hepatitis C counseling and testing continued during 2004, with sites using local resources and the remaining laboratory inventory of test kits. With the return of limited funding in 2005, anti-HCV testing is now offered at 10 sites across the state, and a pilot project at two sites provides hepatitis A and B vaccine to people with a history of injection drug use or chronic liver disease.

Our experience in Texas demonstrates that: (1) hepatitis C is a public health threat that can motivate a state legislature to provide substantial funding for a statewide education and prevention program; (2) integrating hepatitis C prevention into HIV/STD programs is a good program strategy; (3) injection drug use is the predominant risk exposure for HCV infection; (4) hepatitis C counseling and testing in substance abuse treatment programs, corrections facilities, and through outreach is productive; (5) budget deficits can substantially reduce hepatitis C program activities; and (6) limited access to medical evaluation and treatment, substance abuse treatment, and adult vaccinations continues to be a challenge to fully addressing hepatitis C in Texas.

Acknowledgments

Thanks to Elizabeth Delamater, Jeffrey Hitt, and Alma Thompson at the Texas Department of State Health Services: Jeffrey Hitt for providing the data, Alma Thompson for her constructive comments, and Elizabeth Delamater for support in developing the testing protocol. Thanks also to Steve Jones and the two anonymous referees for their constructive comments.

REFERENCES

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