Hepatitis C Virus: Patients’ Risk Factors and Knowledge in an Urban Clinic Providing Wound Care

Introduction. Affecting about 3.2 million people in the United States, hepatitis C virus (HCV) is the primary cause of chronic liver disease and a global health challenge. Hepatitis C virus can affect the functioning of the liver, the health of the person, and thus wound healing.Objective. This quality project explores risk factors of HCV; self-reported screening, occurrence, and treatment; and knowledge of HCV in patients seeking wound care in an urban clinic. Materials and Methods. Demographic risk factors, HCV history, and responses to a 22-item true-false-don’t know HCV Knowledge Test were obtained from 58 patients. Risk factors included age (mean, 61.07 years), male sex (n = 41), non-Hispanic black race/ethnicity (n = 51), and history of injection drugs (n = 38). Results. Thirty-nine (67.2%) stated they had been screened for HCV; 31 were told they were infected. Only 14 went to a clinic for HCV care and 11 reported they were treated. The mean number of correct answers on the HCV Knowledge Test was 14.4 (standard deviation, 5.7). Conclusions. This urban clinic had patients with multiple HCV risk factors; they often lacked HCV screening and/or referral for treatment. Their HCV knowledge was generally low. As a major public health problem that could impact wound healing, wound care practitioners should ask patients about their HCV status, encourage HCV screening and care, and provide HCV information.

Hepatitis C virus (HCV) infection is a worldwide health problem affecting about 185 million people, with approximately 3.2 million in the United States.^1-5 Only 32% to 38% of patients with known HCV have received any HCV care and less than 18% have been treated for it.¹ In addition, 55% to 85% of untreated individuals may develop chronic liver disease.² Although it is not completely understood, baby boomers (born between 1945 and 1965) are 5 times more likely to have HCV than other adults⁶; many of them are unaware of their status.⁷ 

The function of the liver has a profound effect on the body. The liver is the central organ of glucose homeostasis; it stores glucose, is the site of gluconeogenesis, and is able to convert fructose and galactose into glucose for use by the body.⁸ Most serum proteins are synthesized in the liver with extravascular leakage of albumin leading to edema and ascites. Blood coagulation requires clotting factors produced by hepatocytes.⁹ The liver is important for storage (glycogen, triglycerides, iron, copper, lipid-soluble vitamins, etc), catabolism of endogenous substances, and detoxification of foreign compounds.⁹ The liver also plays a key role in hepatic and systematic immune functions; Kupffer cells are resident macrophages that line the sinusoids and remove pathogens, toxins, and aging red blood cells from systematic circulation.¹⁰ Morphology and function of the liver change with aging, as liver volume and blood flow are reduced and hepatic drug metabolism and liver regeneration decline.¹¹

First discovered in 1989, HCV is a bloodborne pathogen with many modes of transmission: blood transfusions, organ transplants (before widespread screening of blood supply prior to 1992), blood products prior to 1987, body piercings and tattoos, and injection drug use. Injection drug use is the primary mode of transmission of HCV; the virus has a prevalence as high as 80% in persons who inject drugs.^5,6 Other significant risk factors are male gender and non-Hispanic black race/ethnicity.^12,13 Because of the chronic nature of HCV infection and increasing life expectancy, a growing number of advanced-age patients with HCV are expected to be part of the health care system.¹² Since 2013, both the Centers for Disease Control and Prevention and the US Preventive Services Task Force recommend a one-time universal HCV antibody screening for all baby boomers.^6,7,13 Serologic tests are sensitive and specific,¹⁴ and algorithms are available for diagnosis.¹⁵ 

For the majority of patients, the clinical course of chronic HCV infection is benign but can be associated with substantial morbidity and mortality.^13,14 Symptoms, if present, include mild arthralgia, myalgias, and fluctuation of liver enzymes.¹⁴ The prevalence of advanced liver fibrosis and cirrhosis is greater in the elderly population compared with the younger population, and the proportion of elderly with advanced liver disease is expected to rise in the next 10 years.^12,16 Hepatitis C virus infection has been associated with insulin resistance and diabetes, dermatological manifestations, and cardiovascular disease, to name a few.¹⁷ 

Therapy for HCV is rapidly changing and should be supervised by practitioners experienced in treating HCV infection.¹⁵ Although costly, treating HCV at the early stages of fibrosis appears to improve health outcomes and be cost-effective for the long term.¹⁸ In a study 5-years posttreatment, Smith-Palmer et al¹⁹ found medical costs for patients achieving sustained viral response were 13-fold lower than patients not achieving sustained viral response. There also was an improved quality of life.¹⁹

Data about HCV screening or treatment remains minimal. Self-reported HCV screening in baby boomers was only 12.3% in 2013 and increased to 13.8% in 2015.²⁰ Men reported greater testing than women, and those with less than or a high school diploma had fewer HCV tests than college graduates.²⁰ Denniston et al²¹ reported 49.7% of their large sample from the National Health and Nutrition Examination Survey were unaware of being infected. Walley et al²² reported only 34% of clients in a methadone treatment program knew about HCV treatment, 30% were ever evaluated for treatment, and 54% and 22% were definitely or probably interested in HCV treatment, respectively.

Knowledge of HCV is often reported to be low.^23-25 Allison et al⁷ administered a HCV knowledge test to 427 baby boomers in an emergency department; most knew the natural history, complications, and bloodborne risk factors for HCV. Less than one-third of participants, however, identified the baby boomer birth cohort as being at greater risk for HCV than other age groups. Many (52%) thought a vaccine was available to prevent it.⁷ There was no association between answering HCV knowledge questions correctly and agreement to have an HCV rapid test.⁷ Balfour et al²⁶ reported HCV knowledge was positively correlated with length of time since HCV diagnosis. Participation in educational classes improved knowledge, behaviors, and willingness to begin and adhere to treatment.^24,27-29 Chen et al²⁴ examined the relationship between knowledge and attitudes towards HCV among persons infected with the virus (N = 292) in a cross-sectional survey. Some of the attitudes were fear of consequences of HCV (57%), believing HCV was not fatal (37%), believing they did not need HCV medication (27%), being ashamed (21%), and believing treatment was not important (16%). The presence of the attitudes of indifference and shame were associated with lower knowledge scores. 

Needless to say, HCV is a condition that should be considered when caring for patients with wounds, yet little is known about the occurrence of HCV screening, the presence of HCV infection, and the treatment of these patients. No reports about the occurrence of HCV in persons seeking wound care could be found. The purpose of this project is to examine the risk factors; self-reported HCV screening, occurrence, and treatment in patients seeking wound care in an urban clinic; and their knowledge of HCV. This was developed as a quality improvement project to examine the magnitude of the HCV problem for patients seeking outpatient care for venous ulcers.

Design. This project was developed as a quality improvement project to explore the magnitude of the HCV problem at an inner city, outpatient clinic that provided wound care to patients who had venous ulcers. A form was developed to tabulate risk factors; except for age and education, information was generally recorded as dichotomous (ie, yes/no) without identification of the patient. Because this was a quality project and not a human subjects research study, it was not necessary to request Institutional Review Board approval. Patients seen from June 2016 to September 2016 were included. The information learned would be used to inform the need of assessment of HCV in patients seeking wound care, encourage screening for HCV and subsequent discussion with their primary provider about treatment, and review HCV information from the HCV Knowledge Test.

Patients were asked about their background (age, sex, race, education [less than high school, high school graduation, some college]) as well as a number of health problems (tabulated for a total number), history of injected drug use, and HCV status (ever tested, results, ever treated, etc). The HCV Knowledge Test consisted of 22 true-false-don’t know questions about HCV.  The questions included items about the spread of HCV, diagnosis, clinical manifestations, and treatment. The items were found in other reported projects about HCV knowledge.^{4,23-25,29,31-34} The items were read to all patients so as to not frustrate those who had difficulty reading. The patient’s risk factors, HCV reported screening, and HCV knowledge were reviewed with the patient. The time to collect information was about 10 minutes.

Patient risk factors. For the 58 patients, risk factors included age (mean, 61.07 years; standard deviation [SD], 7.98), male sex (n = 41), non-Hispanic black race/ethnicity (n = 51), and previous street drug use whether injected (n = 38) and/or by other routes (N = 37); 30 (51.7%) had a high school education. In addition to the HCV risk, these patients had multiple chronic health problems (mean, 2.69; SD, 1.39); the most common were hypertension, obesity, and arthritis. Risk and demographic factors are summarized in Table 1. 

Patients screened for HCV. Thirty-nine (67.2%) patients reported they had been screened for HCV; 31 were told they were HCV infected. Only 14 went to a HCV clinic for care and 11 reported they had undergone treatment.

HCV knowledge. The mean number correct on the HCV Knowledge Test was 14.4 (SD, 5.7; range, 0–22); the mean percentage correct was 67.4% (SD, 25.9%). Items with the highest correct scores by responders tended to be about spread: spread by talking with someone who has it (False; 94%), spread through sharing equipment to inject drugs (True; 86%), and spread through blood and body fluids of someone who is infected (True; 85%; Table 2). Items with the lowest correct scores by responders were vaccine to prevent it (False; 26%); spread by light kiss (False; 43%); diagnosed with x-ray (False; 50%); and spread by sneezing, coughing, and food (False; 50%; Table 3).

The HCV Knowledge scores did not differ significantly by level of education. Patients who stated they had HCV (mean, 17.6) had significantly higher knowledge scores than those that did not know or reported being negative (mean, 11.6; t [56] = 4.66; P < .001). 

This quality project explored HCV risk factors and self-reported screening, occurrence, and treatment of HCV in patients seeking wound care in an urban setting and their knowledge of HCV.  Patients’ self-report of screening in this clinic was high. Although two-thirds of patients (39/58) had been tested and most (31/39, 79.5%) were told they were HCV infected, few were sent to a clinic for HCV evaluation and treatment. Jemal and Fedewa²⁰ found self-report of HCV testing in baby boomers remains low (13.8%). Jayasekera et al¹ reported less than 50% of people with HCV in the United States are aware of their infection.

Hepatitis C virus is said to be an under-recognized and an under-diagnosed disease.³⁵ Sarkar et al¹³ reported that older male African-Americans with established risk factors and receiving care from urban centers of excellence were more likely to be tested. This could be why so many patients in this project had been tested since they matched the previous description. Another study reported 32% to 38% of patients with known HCV have received HCV care and less than 18% have been treated.¹ The HCV disease burden is expected to increase significantly with aging of the infected population.¹⁶ It is critically important that all providers, including those providing wound care, participate in identification of patients with HCV. 

This project’s sample had a high number of patients who injected drugs; persons who injected drugs represent the majority of HCV-infected persons. Only a small minority of persons who injected drugs have been evaluated and treated for HCV.^2,5 There are several reasons for this: (1) limited knowledge about HCV; (2) concerns about treatment-related side effects, thus lower perceived need and fear of treatment; (3) distrust of the health care community; (4) cost of treatment; (5) stigma of the disease; (6) lack of understanding of the seriousness of HCV; and (7) lack of access to HCV evaluation and treatment.²² Clinicians also have concerns about treating persons who injected drugs: concerns about poor adherence, psychiatric comorbidities, and potential for reinfection after treatment stops. Treatment of HCV is safe and effective in the majority of infected persons and would reduce the associated morbidity and mortality.² Treatment outcomes are comparable between patients with and without a history of drug use²; treatment is recommended for all patients with chronic HCV infection.¹⁵

The present surveyed patients tended to have low overall HCV knowledge. This may reflect the low educational level of participants, with about one-third having less than high school-level education. Some of the patients’ responses were similar to the literature and others dissimilar. Walley et al²² reported that 97% knew the modes of transmission, and patients in this project also knew this information. They²² reported that 34% knew there was a treatment, and the study authors herein found that 72% knew there was treatment available. Walley et al²² reported 38% stated most or all could become sick; in this study, 83% were reported as knowing they could develop liver damage, failure, and cancer. Other persons in methadone treatment who were infected with HCV or had prior education about it scored higher on knowledge tests than those not infected with HCV.⁵ Canfield et al²⁵ reported that the majority of HCV-infected patients had basic knowledge about the virus. In contrast, Carey et al³⁴ reported that only 49% knew it was transmitted by sharing needles; herein, it is reported that 86% of patients knew this. Chen et al²⁴ reported mean knowledge scores of >50% of total possible; the present mean knowledge score was only slightly higher (67%). 

Attitudes that reflected indifference and shame toward HCV were associated with lower knowledge scores. Allison et al⁷ administered a true-false-don’t know test to 427 baby boomers in an urban Emergency Department. Most knew the natural history, complications, and bloodborne risk for HCV. Less than one-third of participants identified the baby boom birth cohort as being at greater risk for HCV than other age groups. Many (52%) thought a vaccine was available to prevent it⁷; in this study, 74% of participants thought there was a vaccine. 

Implications for care. This project has implications for wound care. Wound care clinicians should ask their patients if he/she has ever been tested for HCV, the findings of that test, and if he/she was ever treated (if the test was positive). The clinician’s interest in the patient encourages the patient to undergo tests. Knowing risk factors for HCV will help to focus the depth of questions asked about the virus. Depending upon the location of the clinic and integration of health records across the system, clinicians may have varying access to HCV diagnostic information, such as laboratory studies or liver ultrasounds. Patients may ask questions about some of the diagnostic tests needed to assess HCV as well as medications used to treat HCV. Having an understanding of these diagnostic tests and being able to answer patients’ questions can positively affect patients’ level of care. In addition, being able to reinforce teaching about HCV medication is helpful for the long-term success in taking medication. Having access to a HCV knowledge test or other HCV handouts helps to focus the discussion about HCV with the patient. 

The limitations of this project include its small size from an inner-city clinic. It is not known what the findings would be like in a clinic that saw more economically and culturally diverse individuals. This was a one-time assessment; patients were not followed longitudinally to evaluate if they eventually went for HCV care. The investigators did not include questions about alcohol use. Alcohol can accelerate the progression of liver fibrosis and cirrhosis.^14,16 People infected with HCV need to be advised to decrease or abstain from alcohol. History of and current moderate alcohol use have been associated with a 2-fold increase in all-cause mortality for those infected with HCV.¹⁶ The authors did not include an educational intervention to improve knowledge; however, brief educational programs have been shown to increase knowledge.^23,29-30

This project explored patients’ self-reports of HCV risk factors, status, and knowledge in an urban wound care clinic. Hepatitis C virus is a worldwide health problem. Because of its long-term negative effects on the liver, HCV can adversely impact wound healing. Baby boomers are the highest risk adult group to have HCV, and this aging group also is at risk for wounds.  No reports about the occurrence of HCV in persons seeking wound care could be found. All clinicians should take an active role in encouraging HCV screening and treatment; it is critical to identify persons with HCV and link them to care.¹⁶

From the College of Nursing, Wayne State University, Detroit, MI

Address correspondence to:
Barbara Pieper, PhD, RN, CWOCN, ACNS-BC, FAAN
Professor/Nurse Practitioner
College of Nursing 
Wayne State University
Detroit, MI 48202
bapieper@comcast.net

Disclosure: The authors disclose no financial or other conflicts of interest.