HBV, HCV Screening Disparities Among Low-Income US Veterans

Findings from a recent study are calling attention to disparities in hepatitis B virus (HBV) and hepatitis C virus (HCV) screening rates among low-income US veterans based on demographic, socioeconomic, and clinical characteristics.¹

Using nationally representative, cross-sectional data for more than 900 low-income US veterans from the National Veteran Homeless and Other Poverty Experiences (NV-HOPE) study, the present analysis found notably lower rates of lifetime HBV and HCV screening compared to those estimated among the general population of US veterans.¹

“Understanding screening behaviors aimed at the prevention of hepatitis B and C infections can help in the design, implementation, and evaluation of future interventions that can promote viral hepatitis screening provided by the VA and other organizations serving US veterans while informing the need for future vaccine development,” Hind Beydoun, PhD, a research health science specialist at the US Department of Veterans Affairs, and colleagues wrote, calling attention to a lack of research specifically focused on low-income US veterans who may be more susceptible for viral hepatitis exposure with fewer resources to access screening and care.¹

Estimates from the World Health Organization (WHO) suggest 354 million people worldwide are living with hepatitis B or C, with the WHO’s global hepatitis strategy aiming to reduce new hepatitis infections by 90% and deaths by 65% between 2016 and 2030. In the absence of safe and effective vaccines for preventing HCV, screening for viral hepatitis is important for preventing associated health problems and transmission, and understanding screening behaviors in different populations can help inform future interventions.²

To examine HBV and HCV screening behaviors among low-income US veterans and factors potentially influencing screening rates, investigators used cross-sectional data from the 2021-2022 NV-HOPE study, a series of nationally representative surveys designed to examine the health and psychosocial well-being of low-income US veterans. For inclusion in NV-HOPE, patients were required to be ≥ 18 years of age with a history of active-duty service in the US Armed Forces and be living in households <300% of the US federal poverty level in 2021. After excluding study participants with missing data on demographic and clinical characteristics or out-of-range values for body mass index (BMI), the final analytic sample consisted of 933 NV-HOPE participants.¹

Lifetime use of preventive services for multiple infectious and chronic diseases was assessed based on questionnaire items from NV-HOPE, and other variables of interest were collected through self-administered study questionnaire items. Investigators also leveraged electronic health record data from the VA Corporate Data Warehouse, a national repository of electronic health records comprising data on all inpatient and outpatient encounters from the VHA administrative and clinical systems, to estimate hepatitis B and C screening rates among US veterans seeking VA healthcare services. Data were extracted for 6,767,517 veterans ≥ 18 years of age at their initial visit between January 1, 2021, and December 31, 2022.¹

Results showed 15.9% (95% CI, 13.0%-18.8%) of low-income US veteran participants reported lifetime experience with screening for HBV and 20.6% (95% CI, 17.4%-23.8%) reported lifetime experience with screening for HCV. Investigators noted these rates are lower than HBV (47.3%) and HCV (92.9%) screening rates documented among contemporaneous veterans in VHA electronic health records during the same time period.¹

Compared to veterans ≥ 80 years of age, those 50–79 years of age were 3 times more likely to report ever screening for HBV (50–64 years: OR, 3.5; 95% CI, 1.3-9.3; 65–79 years: OR, 3.6; 95% CI, 1.5-8.7) or HCV (50–64years: OR, 2.5; 95% CI, 1.1-5.5; 65–79years: OR, 2.7; 95% CI, 1.4-5.1). Compared to non-Hispanic white veterans, those who identified as non-Hispanic other were more likely to screen for HBV (OR, 2.4; 95% CI, 1.2-4.6), and veterans reporting other types of employment were more likely than those reporting full-time or part-time employment to have ever screened for HBV (OR, 14.0; 95% CI, 3.4-57.7) or HCV (OR, 6.6; 95% CI, 1.6-26.6).¹

Additionally, investigators pointed out veterans living in households with ≥ 5 members were 3 times more likely than those living alone (OR, 3.1; 95% CI, 1.5-6.5) to report screening for HCV. An inverse relationship was observed between household income and lifetime HBV or HCV screening, where housing instability (OR, 1.7; 95% CI, 1.1-2.6) and Medicaid insurance (OR, 1.8; 95% CI, 1.0-3.1) were correlated with lifetime screening for HBV only.¹

Further analysis revealed lifetime HBV screening was more likely among veterans with histories of drug use (OR, 3.4; 95% CI, 1.6-7.1) and cognitive (OR, 13.3; 95% CI, 2.8-64.4) disorders. Similarly, investigators noted lifetime HCV screening was more likely in veterans with histories of alcohol use (OR, 3.1; 95% CI, 1.3-7.4), cancer (OR, 2.5; 95% CI, 1.4-4.2), and liver (OR, 7.2; 95% CI, 1.8-29.6) disorders. They also pointed out a history of HIV/AIDS was associated with a greater likelihood of screening for both HBV (OR, 3.4; 95% CI, 1.6-7.1) and HCV (OR, 2.5; 95% CI, 1.2-5.2).¹

Investigators acknowledged multiple limitations to these findings, including inherent limitations to NV-HOPE data on lifetime use of screening services and screening service location; the potential for selection and misclassification biases due to missing data and self-report; and the inability to generalize NV-HOPE findings to higher-income veterans and/or other adults in the US.¹

“Fewer than one-third of low-income US veterans ever-screened for HBV and/or HCV, reinforcing the idea of barriers for screening, diagnosis, and linkage-to-care, with lower screening rates among those less likely to be exposed to viral hepatitis, thereby informing interventions aimed at promoting available screening, treatment, and vaccinations for HBV/HCV,” investigators concluded.¹

References

1. ^{Beydoun HA, Tsai J. Screening rates for hepatitis B and C among low-income US veterans: Data from the National Veteran Homeless and Other Poverty Experiences Study. J Viral Hepat. doi:10.1111/jvh.13981}
2. ^{World Health Organization. Elimination of hepatitis by 2030. Health Topics. Accessed July 15, 2024. https://www.who.int/health-topics/hepatitis/elimination-of-hepatitis-by-2030}