90% of people who inject drugs in United States missed opportunities for HIV or hepatitis C tests

Keith Alcorn
27 February 2020
Image: ANURAKE SINGTO-ON/Shutterstock.com

Around 90% of people who inject drugs in the United States missed opportunities for HIV or hepatitis C virus testing between 2010 and 2017, a review of more than 840,000 healthcare visits shows. Men in rural America seeking care for skin infections or endocarditis were most likely to miss out on testing.

HIV testing for people at high risk of infection is recommended at least once a year in the United States and the Centers for Disease Control and Prevention also recommends that people who inject drugs should be tested for hepatitis C.

The study looked at commercial health insurance databases to identify people with probable markers of injecting drug use including overdose, endocarditis, skin infections or abscesses normally indicative of injecting drug use, substance use or prescription of opioid substitutes, naltrexone or naloxone. The researchers calculated the likelihood of testing for hepatitis C according to demographic factors.

The researchers estimated that 844,242 people who inject drugs attended healthcare facilities and were covered by an insurance claim. This population only covers people who were covered by employer or commercial insurance, not people covered by public insurance (Medicare), so it will underestimate the number of people who inject drugs who came into contact with health services in the United States during the study period.

Almost two-thirds of injecting drug users attended medical facilities for treatment of skin infections or endocarditis and 31% attended for drug dependence treatment. Women made up half the population and around 40% of the study population were under 30 years old.

Only 8% were tested for HIV and men were significantly less likely to have an HIV antibody test than women (adjusted odds ratio 0.50, 95% CI 0.49-0.50, p < 0.001). HIV testing was less likely to take place if a person visited a general medical practice than other forms of healthcare visit. People receiving treatment for skin infections associated with injecting drug use were less likely to be tested for HIV than people diagnosed with a substance use disorder.

Few people were tested for hepatitis C. Just under 8% had a test for hepatitis C and it was more likely to have taken place if the visit occurred more recently or if the person was diagnosed with a substance use disorder or overdose, or if they made frequent healthcare visits. People treated for skin infections indicative of injecting drug use were less likely to be tested for hepatitis C than those without (aOR 0.90, 95% CI 0.86–0.95, p < 0.001).

People in rural areas were less likely to be tested for HIV or hepatitis C, as were people outside the north-eastern United States. The study investigators note that 31% of acute hepatitis C infections are estimated to occur in rural counties of the United States.

In an accompanying editorial in the Journal of Infectious Diseases, Benjamin Linas of Boston University School of Medicine proposes that venue-based testing might be an effective way of increasing the proportion of people who inject drugs who are tested for hepatitis C and HIV.

Routine testing of everyone who attends an addiction treatment clinic, a needle and syringe programme or a residential drug detoxification clinic would increase the number of people tested and would be more effective than risk-based testing in the United States, he argues. “Risk-based targeted testing does not work. Many times, providers do not identify the risk behavior.” What’s more, routine one-time testing does not address the needs of people at ongoing risk of infection.

“One thing is clear—we cannot end any epidemic among PWID [people who inject drugs] unless we take concrete steps to address underperformance in identifying and treating new infections. It is time for a new approach to HIV and HCV [hepatitis C virus] testing among PWID,” Dr Linas concludes.


Bull-Otterson L et al. Human immunodeficiency virus and hepatitis C virus infection testing among commercially insured persons who inject drugs, United States, 2010–2017. Journal of Infectious Diseases, advance online publication, 30 January 2020.

DOI: 10.1093/infdis/jiaa017

Linas BP. Time for a new approach to guidance for Human Immunodeficiency Virus and hepatitis C virus testing among persons who inject drugs. Journal of Infectious Diseases, advance online publication, 30 January 2020.