Hepatitis B virus (HBV) prevalence was 7 to 10 times higher in a homeless population compared to the general population of the United States, according to study results published in Family & Community Health, emphasizing a need for enhanced screening and counseling in homeless communities and other populations with opiate use.
According to investigators, the prevalence of HBV in the homeless population is underestimated despite numerous behavioral risks. Using data from a sample of 534 homeless adults from downtown Los Angeles, California, the researchers examined the prevalence and predictors of HBV in this community.
Overall, the prevalence of exposure (hepatitis B core antibody) was 30.9% and chronic exposure (HBV surface antigen) was 2.6%. Vaccine-induced immunity (HBV surface antigen alone) was 11.2%. The rates of HIV and hepatitis C virus (HCV) infection were 3.9% and 26.6%, respectively, whereas the rate of coinfection of chronic HBV with HCV or HIV was 0.5% and 0.1%, respectively. Prevalence of chronic infection was highest in Latinos at 6.6% and was significantly higher in those who with previous history of gonorrhea, chlamydia, or syphilis and those who had 5 or more sexual partners in the previous 12 months.
The risk of HBV exposure was significantly higher in individuals younger than 40 years and of black or Latino ethnicity than in individuals of other ethnicities, individuals with lower than 10th-grade education, and former prison inmates. Exposure risk was also significantly higher in individuals who had ever injected drugs, with up to a 5-fold increase in the odds if they had injected drugs in the previous 12 months. A 7-fold increase in odds of exposure occurred in individuals with lifetime opioid dependence and a 2.5-fold increase in those with lifetime amphetamine dependence.
In terms of sexual behavior, exposure risk was significantly higher in individuals who previously engaged in sexual activities in exchange for cash or drugs, had 5 or more sexual partners in the last year, and reported a previous history of syphilis or gonorrhea. However, HBV exposure was not associated with gender, severity of homelessness, mental illness, sexual orientation, history of psychiatric hospitalization, or having multiple tattoos.
Independent predictors of HBV exposure according to multivariate logistic regression were younger age (18-39 years), being born outside the United States, history of intravenous drug use or opiate dependence, and history of infection with syphilis or gonorrhea. Independent predictors for chronic infection were lifetime history of
syphilis or gonorrhea, history of more than 5 sexual partners, and being Latino.
Overall, the percentage of patients reporting having ever received counselling for HBV or HIV was 36.5% and 66.1%, respectively (P ≤.0001). In terms of perception of sex as a risk, 22.6% of participants were not aware of the risk association with HBV, compared with only 2.3% who were not aware of the risk association with HIV (P ≤.0001). For needle sharing, 13.0% did not perceive it as a risk for HBV, whereas only 4.1% did not perceive it as a risk for HIV (P ≤.0001). In this population, 54.8% reported previous HBV testing, whereas 81.3% reported previous testing for HIV (P ≤.0001).
The investigators did note several limitations to the data, including a lack of generalizability owing to the limited sample frame that included only downtown Los Angeles. Data were also subject to recall and reporting bias as the study relied on self-reporting. The sample size itself might also be too small to detect significant correlations, specifically for chronic HBV disease where only 14 participants tested positive. Finally, the data were collected between 2003 and 2004 and may not reflect current demographics and policy changes.
These results highlight a high prevalence of HBV and the inadequate rates of screening, immunization, and awareness about HBV in the urban homeless population. The findings also support “the need to improve awareness among health care providers caring for these communities, inclusive of larger communities of opioid use, and call for a more current assessment and for public health interventions that specifically target challenges relevant to the homeless and those with opioid use, including safe needle injecting facilities and clean needle exchange and medication-assisted treatment with buprenorphine or methadone rather than heroin.”
Khouzam N, Gelberg L, Guo R, Tseng C-H, Bhattacharya D. Opiate dependence: a risk factor for hepatitis B virus exposure in homeless adults. Fam Community Health. 2020; 43(2):161-169.