Original Article

Hepatitis C and HIV Screening, Testing, and Risk Perceptions among South-Central Appalachian County Health Department Staff

Authors: Chase Harless, MSW, Brunilda Lugo, PhD, Bayla Ostrach, PhD, CIP


Objectives: Hepatitis C virus (HCV) and human immunodeficiency virus (HIV) are significant public health concerns, especially given the risks for disease interactions. Rates of HCV and HIV are increasing, especially in rural areas. Local health departments (LHDs) play an important role in rural health care, offering screening, testing, and treatment for HCV and HIV. Gaps persist in LHD resources for meeting these demands, especially in Appalachia and the US South.

Methods: To explore HCV/HIV screening, testing, and treatment approaches and perspectives in south-central Appalachian North Carolina, structured telephone questionnaires were administered to communicable disease nurses and other health department staff directly involved in screening and testing. Mixed-methods data analyses were conducted and triangulated with stakeholders.

Results: Eighteen participants representing 19 counties completed the questionnaire, achieving a saturation sample. Participants reported barriers to screening and testing, including housing insecurity, lack of transportation and insurance, unemployment, and the isolation of living in a rural area. Divergence in perceptions of barriers between public health regions emerged, as did perceptions of who is at risk and use of stigmatizing language about people at risk for HCV/HIV.

Conclusions: This study highlights the impact of LHD behaviors and perceptions on screening and testing, and offers recommendations to improve HCV/HIV screening and testing accessibility in south-central Appalachia, a high-risk region.
Posted in: Infectious Disease97 Acquired Immunodeficiency Syndrome (AIDS) And Human Immunodeficiency Virus (HIV) Infection12

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1. US Department of Health and Human Services. New state-level maps from HepVu dhow Impact of HCV Epidemic. https://www.thebodypro.com/ article/new-state-level-maps-hepvu-impact-hepatitis-c-us. Published 2019. Accessed May 22, 2020.
2. Centers for Disease Control and Prevention. HIV. HIV testing. Accessed November 12, 2020. https://www.cdc.gov/hiv/testing/index.html. Published June 9, 2020.
3. Bulled N, Singer M. Syringe-mediated syndemics. AIDS Behav 2009;15: 1539–1545.
4. Cabral N, Ostrach B. Summary of Findings—Structures of Risk for HCV-HIV Syndemics. Boston: Boston University School of Medicine; 2017.
5. Ostrach B, Singer M. At special risk: biopolitical vulnerability and HIV/STI syndemics among women. Health Sociol Rev 2012;21:258–271.
6. Singer M, Bulled N, Ostrach B. Whither syndemics? Trends in syndemics research, a review 2015–2019. Glob Public Health 2020;15:943–955.
7. Centers for Disease Control and Prevention. Viral Hepatitis Surveillance - United States, 2016. https://www.cdc.gov/hepatitis/statistics/2016surveillance/pdfs/2016HepSurveillanceRpt.pdf. Published 2017. Accessed April 11, 2022.
8. Mah’moud MA. Current management of hepatitis C virus infection. NC Med J 2016;77:188–193.
9. Brody W, Kimple KS, Stanley K, et al. 10 years later: the impact of the Affordable Care Act on prevention and public health in North Carolina. NC Med J 2020;81:377–380.
10. National Association of County and City Health Officials. Hepatitis C and local health departments educational series. https://www.naccho.org/programs/community-health/infectious-disease/hiv-sti/viral-hepatitis/viral-hepatitis. Accessed April 11, 2022.
11. Sutton M, Anthony M-N, Vila C, et al. HIV testing and HIV/AIDS treatment services in rural counties in 10 southern states: service provider perspectives. J Rural Health 2010;26:240–247.
12. Harris JK, Beatty K, Leider JP, et al. The double disparity facing rural local health departments. Annu Rev Public Health 2016;37:167–184.
13. Beatty KE, Harris JK, Leider JP, et al. The double disparity facing rural local health departments: a short report. Front Public Health Serv Syst Res 2016;5:1–8.
14. Ezell JM, Walters S, Friedman SR, et al. Stigmatize the use, not the user? Attitudes on opioid use, drug injection, treatment, and overdose prevention in rural communities. Soc Sci Med 2021;268:113470.
15. Hoover KW, Huang Y-LA, Tanner ML, et al. HIV testing trends at visits to physician offices, community health centers, and emergency departments— United States, 2009–2017. MMWR Morb Mortal Wkly Rep 2020;69:776–780.
16. Tran JN, Wong RJ, Lee JS, et al. Hepatitis C screening rates and care cascade in a large US insured population, 2010–2016: gaps to elimination. Popul Health Manag 2021;24:198–206.
17. Singer M, Page JB. The Social Value of Drug Addicts: Uses of the Useless. New York: Routledge; 2016.
18. Singer M, Ziegler J. The role of drug user stigmatization in the making of drug-related syndemics. In: Foundations of Biosocial Health: Stigma and Illness Interactions, Ginzburg SL, Ostrach B, Singer M, eds. Lanham, MD: Rowman & Littlefield; 2017.
19. Geter A, Herron AR, Sutton MY. HIV-related stigma by healthcare providers in the United States: a systematic review. AIDS Patient Care STDs 2018;32: 418–424.
20. Muncan B, Walters SM, Ezell J, et al. “They look at us like junkies”: influences of drug use stigma on the healthcare engagement of people who inject drugs in New York City. Harm Reduct J 2020;17:53.
21. Paquette CE, Syvertsen JL, Pollini RA. Stigma at every turn: health services experiences among people who inject drugs.Int J Drug Policy 2018;57:104–110.
22. Saab S, Le L, Saggi S, et al. Toward the elimination of hepatitis C in the United States. Hepatology 2018;67:2449–2459.
23. Zibbell JE, Iqbal K, Patel RC, et al. Increases in hepatitis C virus infection related to injection drug use among persons aged≤30 years—Kentucky, Tennessee, Virginia, and West Virginia, 2006–2012. MMWR Morb Mortal Wkly Rep 2015;64:453.
24. North Carolina HIV/STD/Hepatitis Surveillance Unit, North Carolina Department of Health and Human Services, Division of Public Health, Communicable Disease Branch. North Carolina HIV/STD/hepatitis surveillance report 2016. https://epi.dph.ncdhhs.gov/cd/stds/figures/std16rpt_rev3.pdf. Published 2017. Accessed April 11, 2022.
25. Adimora AA, Ramirez C, Schoenbach VJ, et al. Policies and politics that promote HIV infection in the southern United States. AIDS 2014;28:1393–1397.
26. Centers for Disease Control and Prevention. HIV in the southern United States. https://www.cdc.gov/hiv/pdf/policies/cdc-hiv-in-the-south-issue-brief.pdf. Published September 2019. Accessed April 11, 2022.
27. Hall HI, Li J, McKenna MT. HIV in predominantly rural areas of the United States. J Rural Health 2005;21:245–253.
28. Van Handel M, Rose CE, Hallisey EJ, et al. County-level vulnerability assessment for rapid dissemination of HIV or HCV infections among persons who inject drugs, United States. J Acquir Immune Defic Syndr 2016;73:323–331.
29. Prabhu S, Harwell JI, Kumarasamy N. Advanced HIV: diagnosis, treatment, and prevention. Lancet HIV 2019;6:e540–e551.
30. Wallace MR. Commentary on “Medical care of pregnant women in eastern North Carolina with human immunodeficiency virus”. South Med J 2013; 106:201.
31. Schranz AJ, Barrett J, Hurt CB, et al. Challenges facing a rural opioid epidemic: treatment and prevention of HIV and hepatitis C. Curr HIV/AIDS Rep 2018;15: 245–254.
32. North Carolina Department of Health and Human Services, HIV/STD/ Hepatitis Surveillance Unit, Department of Public Health. North Carolina 2018 HIV surveillance report. https://epi.dph.ncdhhs.gov/cd/stds/figures/hiv18rpt_02042020.pdf. Published 2018. Accessed November 13, 2020.
33. Ostrach B. Fieldnotes. Ethnographic fieldnotes, ongoing fieldwork; 2017.
34. Samoff E, Mobley V, Hudgins M, et al. HIV outbreak control with effective access to care and harm reduction in North Carolina, 2017–2018. Am J Public Health 2020;110:394–400.
35. Centers for Disease Control and Prevention. Emergency preparedness and response: recent HIV clusters and outbreaks across the United States among people who inject drugs and considerations during the COVID-19 pandemic. https://emergency.cdc.gov/han/2020/han00436.asp. Published October 5, 2020. Accessed April 12, 2022.
36. Lyss SB, Buchacz K, McClung RP, et al. Responding to outbreaks of human immunodeficiency virus among persons who inject drugs—United States, 2016–2019: perspectives on recent experience and lessons learned. J Infect Dis. 2020;222(suppl 5):S239–S249.
37. Lazarus JV, Pericàs JM, Picchio C, et al. We know DAAs work, so now what? Simplifying models of care to enhance the hepatitis C cascade. J Intern Med 2019;286:503–525.
38. Cabral NM. Structures of risk: lived experiences of multi-syndemic clustering in the greater Boston area. https://open.bu.edu/handle/2144/23775. Published 2017. Accessed April 12, 2022.
39. Ghany MG, Morgan TR, AASLD-IDSA Hepatitis C Guidance Panel. Hepatitis C guidance 2019 update: American Association for the Study of Liver Diseases–Infectious Diseases Society of America recommendations for testing, managing, and treating hepatitis C virus infection. Hepatology 2020;71:686–721.
40. White BL, Carter YL, Records K, et al. Routine HIV screening in North Carolina in the era of the Affordable Care Act: update on laws, reimbursement, and tests. South Med J 2013;106:637–641.
41. Zhang HL, Rhea SK, Hurt CB, et al. HIV pre-exposure prophylaxis implementation at local health departments: a statewide assessment of activities and barriers. J Acquir Immune Defic Syndr 2018;77:72.
42. US Preventive Services Task Force. Final recommendation statement: human immunodeficiency virus (HIV) infection: screening. https://www.uspreventiveservicestaskforce.org/uspstf/document/RecommendationStatementFinal/human-immunodeficiency-virus-hiv-infection-screening. Published 2019. Accessed November 6, 2020.
43. Norton JW. General practice in public health through local health departments. South Med J 1953;46:807–811.
44. Santibañez S, Bellis KS, Bay A, et al. Strengthening rural states’ capacity to prepare for and respond to emerging infectious diseases, 2013–2015. South Med J 2019;112:101–105.
45. Kansagra SM, Herndon S, Kimple KS, et al. Redefining the team in team-based care: role of public health. NC Med J 2018;79:235–239. .
46. North Carolina Association of Local Health Directors. Map of North Carolina public health regions. https://www.ncalhd.org/map/. Accessed May 22, 2020.
47. University of North Carolina School of Government. Counties by local public health agency type. https://www.sog.unc.edu/sites/www.sog.unc.edu/files/doc_warehouse/Counties%20by%20LPHA%20type%20-%20Jan%202016.pdf. Published 2016. Accessed November 12, 2020.
48. Moore J, Berner M, Wall A. What types of local public health agencies presently exist in North Carolina? https://www.sog.unc.edu/resources/faqs/what-types-local-public-health-agencies-presently-exist-north-carolina. Accessed November 12, 2020.
49. North Carolina State University Center for Health Statistics. North Carolina social determinants of health by regions. https://www.arcgis.com/apps/MapSeries/index.html?appid=def612b7025b44eaa1e0d7af43f4702b. Published 2017. Accessed November 6, 2020.
50. University of North Carolina Sheps Research Center, Appalachian Regional Commission. Health disparities in Appalachia. https://www.arc.gov/research_eval_maps_data_type/research-report. Published 2017. Accessed November 6, 2020.
51. Psaltis K, North Carolina Department of Health and Human Services, Region 1 & 2 Stakeholders. Hepatitis C in western North Carolina. Stakeholder report. https://epi.dph.ncdhhs.gov/cd/hepatitis/Region1and2_HepCAssessment102016.pdf. Published online 2016. Accessed November 6, 2020.
52. Rhea S, Fleischauer A, Foust E, et al. Hepatitis C in North Carolina: two epidemics with one public health response. NC Med J 2016;77:190–192.
53. Seña AC, Willis SJ, Hilton A, et al. Efforts at the frontlines: implementing a hepatitis C testing and linkage-to-care program at the local public health level. Public Health Rep 2016;131(2 suppl):57–64.
54. Ostrach B, Buer L-M, Armbruster S, et al. COVID-19 and rural harm reduction challenges in the US southern mountains. J Rural Health 2021; 37:252–255.
55. Appalachian Regional Commission. Subregions in Appalachia. https://www.arc.gov/map/subregions-in-appalachia. Published 2021. Accessed April 12, 2022.
56. Bernard HR. Research Methods in Anthropology: Qualitative and Quantitative Approaches, 5th ed. Lanham, MD: AltaMira; 2011.
57. Creswell JW. Qualitative Inquiry and Research Design: Choosing among Five Approaches. Thousand Oaks, CA: Sage Publications; 2012.
58. Ostrach B. Human-centered design for a women’s health screening tool: participant experiences. South Med J 2020;113:469–474.
59. Broyles LM, Binswanger IA, Jenkins JA, et al. Confronting inadvertent stigma and pejorative language in addiction scholarship: a recognition and response. Subst Abuse 2014;35:217–221.
60. Hahn RA, Inhorn MC. Anthropology and Public Health: Bridging Differences in Culture and Society. New York: Oxford University Press; 2009.
61. Schillie S, Wester C, Osborne M, et al. CDC recommendations for hepatitis C screening among adults—United States, 2020. MMWR Recomm Rep 2020;69:1–17.
62. US Census Bureau. US Census regions. https://www2.census.gov/geo/pdfs/maps-data/maps/reference/us_regdiv.pdf. Accessed April 12, 2022.
63. Bennett KJ, Borders TF, Holmes GM, et al. What is rural? Challenges and implications of definitions that inadequately encompass rural people and places. Health Affairs 2019;38:1985–1992.
64. HIV/STD/Hepatitis Surveillance Unit, Division of Public Health, North Carolina Department of Health and Human Services. 2019 North Carolina HIV surveillance report. https://epi.dph.ncdhhs.gov/cd/stds/figures/hiv19rpt_11302020.pdf. Accessed April 12, 2022.