COMMENTARY

A Future Without Hepatitis C?

The Liver Meeting 2014: American Association for the Study of Liver Diseases (AASLD)

William F. Balistreri, MD

Disclosures

December 16, 2014

In This Article

Test-and-Treat Strategy

The Centers for Disease Control and Prevention (CDC) and the US Preventive Services Task Force recommended HCV testing for persons born between 1945 and 1965. The results of HCV screening efforts and the impact, including cost and access to care, especially in resource-constrained areas, were also presented at the meeting.

Birth Cohort Screening

Smith and colleagues[32] presented results from three independent trials designed to determine the relative probability of identifying HCV infections using birth cohort testing. HCV testing of persons in the 1945-1965 birth cohort without previous ascertainment of HCV risk was five times more effective in identifying persons with previous or current HCV infection compared with standard of care. This study provides data to support the effectiveness of the recommendations that baby boomers be screened for HCV infection.

In New York City, as many as 146,500 residents (2.4% of the adult population) have chronic HCV infection; it is estimated that one half of these people are unaware of their infection. Following the CDC recommendations, in 2013, New York State mandated that primary care providers offer HCV antibody testing to all persons born between 1945 and 1965. Therefore, a strategy called the Check Hep C campaign was designed to integrate HCV testing and linkage to care into community-based organizations to improve HCV testing rates.[33] The testing method involved targeted outreach and point-of-care rapid antibody testing; after a positive antibody test, an immediate blood draw was obtained to assess HCV RNA status. From May 2012 to April 2013, a total of 4751 individuals were tested; 19% were HCV antibody positive and 76% of these were documented by HCV RNA testing to have current infection. Of these, 85% attended their first medical appointment and 50% remained in care to receive treatment. The high overall prevalence (15%) of current infection among baby boomers supports the New York State Testing Law and CDC recommendations. Expanding this model to more settings with high-risk populations will aid in successfully identifying and linking HCV-positive individuals into care.

All-Oral Regimens Coupled With Birth Cohort Screening

At present, less than 10% of patients with chronic HCV have been treated successfully because of the failure of risk-based screening to identify all infected patients and the low efficacy and high rate of side effects from regimens based on IFN and RBV.

Younossi and colleagues[34] determined the health and economic impact of the recommended one-time birth cohort screening for HCV in the era of highly effective antiviral regimens. A decision-analytic Markov model that used computer-simulated patients compared four strategies for screening individuals born in 1945-1965 without known HCV infection:

Risk-based screening with treatment based on the stage of liver disease (RBS)

Risk-based screening and treat all without staging (RBA)

Birth cohort screening with treatment based on the stage of liver disease (BCSS)

Birth cohort screening and treat all without staging (BCSA)

Treatment based on staging implied treatment for fibrosis stages F2-F4, with subsequent staging every 5 years for F0-F2. Oral therapy was assumed to achieve a 98% SVR at a cost of $1000/day for 12 weeks, with no disutility of treatment, because quality of life is better on treatment. Effectiveness was measured in quality-adjusted life years (QALYs) and disease progression. The investigators estimated that about 100 million people would be screened and that 1.4 million would be found to have (unknown) HCV infection.

BCSA was the most cost-effective strategy ($32,263/QALY) compared with the RBS strategy. The BCSA strategy would cost an extra $123 billion but produce an additional 22.9 million QALYs. They concluded that the availability of highly efficacious all-oral regimens, with excellent tolerability, makes screening of baby boomers extremely cost-effective, with great health and economic benefits at the population level. The bottom line is to screen and then treat.

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