RACIAL DIFFERENCES IN HEPATITIS В AND HEPATITIS С: DISCUSSION part 2
Crack cocaine use has physical, social, and biological effects that may explain why it remained an independent risk factor for HCV in our study. Physically, when crack cocaine is smoked, individuals can suffer mucosal burns and ulcerations, which could enhance the likelihood of HCV viral transmission. Crack has neurochemical effects that make it uniquely addictive and, with chronic use, causes strong cocaine craving and a desire for frequent use. In addition to a desire to use crack frequently, crack’s neurochemical effects can result in increased sexual risk behaviors. Our multivariate analyses, however, showed that the analyzed sex-risk behaviors did not contribute independently to HCV infection. Thus, the social and contextual factors that underlie the enhanced use of crack cocaine among African Americans are complex, and the biological effects of this drug may also underlie other high-risk behaviors, including sex-risk behaviors.
In contrast, having multiple sex partners was related to HBV in the multivariate model. Although epidemiological evidence suggests that IDU—not sexual behavior—is the predominant mode of transmission for both these infections, our findings highlight that HBV can also be spread sexually and that it is transmitted more efficiently by sex than HCV is. HBV and HCV have unique aspects in both mode of and risk factors for transmission. Both viruses may be transmitted by percutaneous or permucosal exposure to infected body fluids. The HCV model is better characterized in this regard than that of HBV Nevertheless, there likely are routes of transmission of HBV besides the traditional drug and sex routes that need to be further examined and, as noted, may explain the racial difference we observed. revatio 20 mg
There are other limitations in this study that temper interpretation of the findings. Whereas IDU was the single most important risk factor predicting HBV and HCV seropositivity, the temporal relationship of risk behaviors to the acquisition of these infections is uncertain, as are the duration and frequency of these behaviors. In addition, as to specific high-risk behaviors queried on the risk interview, there may be respondent bias or a resistance to disclose socially stigmatized behaviors in a personal interview format. Of note, we did not query lifetime reports of multiple sexual partners but instead inquired about the six months prior to the study interview. This may decrease recall bias but limit a longitudinal assessment of sex-exposure risk. Another limitation is that blood transfusion and tattooing, which have been found to be related to a small percentage of HCV infections in veterans, were unavailable as risk factors in this data set. Prior to 1990, before the national blood supply was screened for HCV, the incidence of transfusion-associated HCV was relatively high, particularly in older persons. Although our study found that older age was related to both HBV and HCV infection, the association was not statistically significant. Finally, this study was conducted on veterans who were psychiatric inpatients and may not be generalizable to outpatient veterans with SMI. Overall, veterans with SMI warrant study because the VA is the largest integrated mental health delivery system in the country, providing services to over 700,000 veterans annually.
In summary, risk factors for HBV were African-American race, IDU, and having multiple sex partners in the past six months. Risk factors for HCV were IDU and crack cocaine use, but not race. The overall prevalence rates of HBV and HCV were very high for this cohort with SMI, but especially high for African-American veterans. Given that the incidence rates of HBV have not changed from 1976 to 1943 and that persons with HCV for the most part remain infective, screening for both viruses should be done in veterans with SMI. Our study suggests that there may be an enhanced vulnerability of individuals with mental illness to particular domains of risk behaviors, such as crack cocaine use for HCV and multiple sex partners for HBV Increased time spent by mental healthcare providers in assessing these risks may be warranted. avodart online
There are important clinical implications for the high rates of hepatitis among SMI persons—particularly African Americans. HCV has been associated with depression, cognitive impairment, emotional distress, and an adverse impact on psychiatric illness. These viruses—particularly chronic HCV— can impair hepatic function, which is relevant to the care of persons with mental disorders who are taking hepatically metabolized drugs. Disparities may exist in accessing newer effective HCV treatments for SMI persons—particularly those who are African American—as has been reported for newer antipsychotics. Further, the drugs used to treat hepatitis (e.g., alpha interferon) have been associated with depression, suicidality, and mania and psychosis. There is a suggestion in the literature that depression—including that induced by HCV treatment—may be prevented by the SSRI antidepressants. Further, newer drug therapies—such as peg interferon alpha-2a-plus ribovirin—may have a better side effect profile for patients with mental illnesses (e.g., less depression). Collectively, these are pressing issues that need to be assessed and fully appreciated by mental health providers who treat persons with SMI, particularly those who provide mental health services to African-American people.