Year of Publication


Degree Name

Doctor of Philosophy (PhD)

Document Type

Doctoral Dissertation




Behavioral Science

First Advisor

Dr. Jennifer R. Havens


Hepatitis C virus (HCV) remains a major cause of morbidity and mortality worldwide, with 3% of the global population chronically infected. Clinical impacts in the United States are projected to increase for two decades, and mortality attributed to HCV now exceeds HIV. Injection drug use (IDU) is the most common route of transmission in the developed world. Advances in treatment offer hope of mitigating HCV impacts, but substantial barriers obstruct people who inject drugs (PWID) from receiving care, particularly in medically underserved regions including Central Appalachia. This study assessed IDU paraphernalia sharing longitudinally over 24 months in a sample of 283 rural PWID recruited by respondent‐driven sampling. Medical follow‐up among 254 seropositive participants was also assessed using discrete‐time survival analysis.

HCV‐positive screening was associated with reduced IDU sharing frequency 18 months after testing compared to seronegative participants (adjusted OR [aOR]=1.4, 95% confidence interval [CI]: 1.0‐1.9), but this effect was not sustained. HCV‐positive participants were less likely to cease IDU 6 months after testing (aOR=0.4, 95% CI: 0.2‐0.7). Predictors negatively associated with decreased IDU sharing included recent unprotected sex, sedative use, and frequency of prescription opioid IDU; protective associations included female gender and religious affiliation. IDU cessation was negatively associated with ever being incarcerated, recent unprotected sex with PWID, heavy alcohol use, lifetime use of OxyContin®, and baseline frequency of prescription opioid IDU; protective associations included number of dependents, receiving disability payments, and substance abuse treatment. Drug‐specific associations decreasing IDU cessation included recent illicit use of OxyContin®, other oxycodone, and cocaine.

150 of 254 (59%) seropositive participants saw a clinician after HCV‐positive screening and counseling, 35 (14%) sought treatment, and 21 (8%) received treatment. Positive predictors of following up with a clinician following testing and counseling included health insurance, internet access, past substance abuse treatment, generalized anxiety disorder, and recent marijuana use. Factors decreasing odds of follow‐up included major depression, lifetime illicit methadone use, and recent legal methadone. These analyses shed valuable light on determinants of behavior impacting primary and secondary HCV prevention. Integrated, multidisciplinary approaches are recommended to meaningfully impact epidemic levels of HCV among rural PWID in Eastern Kentucky.