biopsy; 39% of those who were aware of their HCV infection status had been offered treatment, and 57% of these had received treatment.

Similarly, in the Collaborative Injection Drug User Study Drug User Intervention Trial (DUIT), which enrolled 3,004 young IDUs in five US cities, 72% of anti-HCV-positive and 46% of anti-HCV-negative IDUs were not aware of their HCV serologic status (Hagan et al., 2006). History of drug treatment or needle exchange was associated with increased awareness of HCV serologic status, so these programs may be key locations for provision of HCV screening in this population. In a questionnaire survey given to 150 patients who were seeking substance-abuse treatment at a Department of Veterans Affairs medical center, 90% of patients who were HCV-infected were not aware of their status, and 41% of the IDUs did not know or were unsure of how HCV is transmitted or about the complications of hepatitis C (Dhopesh et al., 2000)..

Stein et al. (2001) surveyed 306 former IDUs about their knowledge of HCV transmission, infection status, and risk of liver disease. They found that nearly all the participants knew that HCV is transmitted by sharing contaminated needles. Among people who had not been tested or did not know their test results, some 82% were HCV seropositive. One-third of the people reporting that they were seronegative were actually seropositive—a demonstration that, as in other surveys, self-reported infection status is unreliable. Of respondents, 81% estimated their risk of developing liver disease, specifically cirrhosis, in the next 10 years at 50% or greater.

The risk associated with the shared use of injection paraphernalia other than syringes is poorly understood (Rhodes et al., 2004). Among IDUs who have chronic HCV infection and are aware of their infection, the pattern is similar: the majority understand that they can transmit their infection by passing on their used syringes to others, but there is less certainty regarding the shared use of cookers, cottons, and rinse water (Rhodes and Treloar, 2008; Wright et al., 2005).

There is substantial confusion among IDUs regarding the interpretation of HCV screening tests. In an Australian study, 42% of IDUs believed that being antibody-positive meant that they were immune to HCV infection (O’Brien et al., 2008). Misunderstanding of the meaning of antibody-test results was also observed in a qualitative study of IDUs in London, England (Rhodes et al., 2004).

Stigma

A number of studies have examined the psychologic consequences of HCV infection and concluded that hepatitis C is a highly stigmatized disease, owing in large part to its association with injection-drug use (Conrad et al., 2006; Crofts et al., 1997; Dunne and Quayle, 2001; Grundy and



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