The US Preventive Services Task Force (USPSTF) today expanded its recommendation for one-time
hepatitis C virus
(HCV) screening to include all asymptomatic US adults ages 18-79 years,
including pregnant women, who do not have known liver disease.
It is a B-level recommendation, indicating that the USPSTF “concludes
with moderate certainty” that screening for HCV will have a substantial
net benefit. The B level is also important because the Affordable Care
Act requires that private insurers and Medicaid cover preventive
services recommended at an A or B level by the USPSTF with no
deductibles or copayments.
Guidance Expands 2013 Recommendation
The recommendation updates and expands the Task Force’s 2013
guidance, which stated that one-time screening should include adults
born between 1945 and 1965, with periodic screening of those at
continued risk.
“HCV is associated with more deaths than the top 60 other reportable infectious diseases combined, including
HIV,” the group, led by Douglas K. Owens, MD, Stanford University, California, stated.
Among reasons for the change, authors cite the almost 3.8-fold increase in cases in the last decade, largely because of more
injection drug use and better monitoring.
The recommendation was
published online March 2 in
JAMA.
Owens and colleagues note that research indicates the most important risk factor for HCV is injection drug use.
“In the United States, recent increases in HCV incidence have
predominantly been among young persons who inject drugs (PWID).
Approximately one third of PWID aged 18 to 30 years are infected with
HCV, and 70% to 90% of older PWID are infected,” they write.
Patients Should Know Test Is Voluntary
The authors point out it is important for clinicians to let patients
know that screening is voluntary and to communicate what HCV is, how it
is acquired, what a positive or negative test means, and potential harms
and benefits of treatment.
The USPSTF also suggests that clinicians consider screening patients
considered high risk (past or current injection drug users even if they
fall outside the recommended age range).
The recommendations come in light of several developments over the past decade.
One is the convincing evidence that the newer direct-acting antiviral
(DAA) regimens result in cure rates above 95% for adults ages 18-79
years, and the “adequate evidence of sustained virologic response in
adolescents.”
In addition, the duration of treatment has declined. Whereas older,
interferon-based regimens required as long as 48 weeks of treatment,
DAA-based regimens require just 8 to 12 weeks of therapy.
Additionally, screening and treatment rates have varied widely.
Screening rates have been high in healthcare systems serving insured
people, some academic medical centers, and Veterans Health
Administration centers.
However, the authors write, “national HCV screening rates in
community health centers and from the National Health Interview Study
were 8.3% and 17.3%, respectively; one study of four safety-net primary
care practices serving low-income and uninsured or underserved
populations found that only 0.8% of persons born in 1945 through 1965
were screened over a 1-year period.”
The USPSTF did not find evidence of harm in screening in any new studies.
Test Can Give Results Quickly
Kalyan R. Bhamidimarri, MD, MPH, chief of the division of hepatology at the University of Miami in Florida, told
Medscape Medical News
that although much of the testing will fall on primary care physicians,
rapid testing with a swab or finger stick can mean results are quickly
available.
At their facility, they give patients a fingerstick test in the
waiting room so results are ready to discuss during appointments, he
said.
Even if rapid testing is not available and the blood sample needs to
be sent out, he said, testing is able to capture “more than 98% of HCV
infection” and false-positives are “very, very low.”
He pointed out that primary care offices are already on alert to watch for signs of
fatty liver disease, which has become an epidemic.
Bhamidimarri said the USPSTF move was important because while
hepatitis
C infections have decreased in the baby boomer group covered by the
previous recommendations, they have increased in other groups as opioid
use has increased, particularly in young people.
“The biggest challenge with hepatitis C is underscreening and
undiagnosis,” said
Bhamidimarri, an associate professor of clinical medicine at the university.
He said acute infections have risen sharply in recent years and warns
that without screening and treatment they will become chronic.
“So we are going to see another peak where individuals will have
cirrhosis and will need a
liver transplant
sometime in the future,” he said. “If this goes untreated we will see a
major public health burden later on. In all these years they are
untreated, they are going to horizontally spread the infection to
others.”
The broad screening that the USPSTF recommends is also important
because it gets around possible stigma. Just asking people if they have
risk factors won’t work because people may come to appointments with a
significant other and don’t want to admit behaviors or talk about them
with physicians, Bhamidimarri said.
Consistent With Other Recommendations
The USPSTF recommendation is very similar to the draft update of
guidelines by the Centers for Disease Control and Prevention (CDC),
which recommends screening for HCV at least once in a lifetime for all
adults 18 years old and over, “except in settings where the prevalence
is less than 0.1%.”
The CDC’s draft guidelines continue, “All persons with risk factors
(eg, persons with HIV, prior recipients of blood transfusions, persons
who ever injected drugs and shared needles, and persons who are born to
an HCV-infected mother) should be tested for HCV, with periodic testing
while risk factors persist.”
The American Association for the Study of Liver Diseases and the
Infectious Diseases Society of America recommends one-time, opt-out HCV
screening for everyone at least 18 years old and one-time testing for
all people younger than 18 years at increased risk of exposure. They
also recommend periodic screening for people with increased risk of
exposure as well as yearly HCV tests for all people who inject drugs and
HIV-infected men who have unprotected sex with men.
All members of the USPSTF receive travel reimbursement and an
honorarium for participating in USPSTF meetings. A coauthor has reported
receiving grants and personal fees from Healthwise. The US Congress
mandates that the Agency for Healthcare Research and Quality support the
operations of the USPSTF. Bhamidimarri has declared no relevant
financial relationships.
JAMA. Published online March 2, 2020.
Full text
https://www.medscape.com/viewarticle/926057#vp_1
