COMMENTARY

Testing, Care, and Cure of Hepatitis C Can Be Done in Primary Care

Alexander Millman, MD

Disclosures

May 05, 2017

Editorial Collaboration

Medscape &

Hi. I'm Alexander Millman, a physician in the Division of Viral Hepatitis at the Centers for Disease Control and Prevention in Atlanta, Georgia. I appreciate the chance to speak with you as part of the CDC Expert Video Commentary Series on Medscape.

Today I will discuss opportunities for improving the testing, care, and cure of hepatitis C virus (HCV) infection. An estimated 2.7-3.9 million persons in the United States are chronically infected with HCV.[1] Due to a historically high incidence of HCV infection before the discovery of the virus in 1989, persons born from 1945 through1965 are estimated to have a prevalence of 3.25%, accounting for approximately 75% of all HCV infections in the United States.[2]

Although all persons in the 1945-1965 birth cohort should be tested at least once for HCV, the burden of the disease varies among different groups within this cohort. For example, prevalence is twice as high in males as in females, and the highest prevalence within the birth cohort (8.12%) was found among non-Hispanic black males.[2] Although the majority of the chronic HCV disease burden is among persons born from 1945 to1965, from 2010 to 2014 there was a 2.6-fold increase in the number of reported cases of acute HCV infection, primarily among young persons who inject drugs.[3] Fortunately, there have been significant advances in HCV treatments, and we are now in an era of all-oral, well-tolerated, highly efficacious direct-acting antiviral medications.

As we consider opportunities for improving testing, care, and cure of HCV in the United States, it can be useful to visualize a person progressing along a care cascade from HCV diagnosis to cure. In essence, it starts with a person being tested for HCV with an HCV antibody test. If the test is positive, then the diagnosis must be confirmed with an HCV RNA test.

Persons who test positive for HCV RNA should have their genotype checked and an assessment of the severity of liver disease. Their healthcare provider can then implement an HCV treatment plan appropriate to the person's specific needs. Sustained virologic response or cure is determined by testing for the presence of HCV RNA 12 weeks after the completion of treatment.

Testing for HCV and confirming a diagnosis of chronic HCV infection is the first and most important step in the care cascade. In fact, it is estimated that 50% of those with chronic HCV infection have not been tested for HCV and are unaware of their infection.[4] Testing guidelines for HCV are available from the US Preventive Services Task Force, CDC, and the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America (AASLD-IDSA).[2,5,6,7] Although there are variations in the recommendations from the different groups, all recommend one-time HCV testing for individuals born from 1945 to 1965, regardless of other risks for HCV infection, because of the historically high prevalence in that population.

Additionally, all organizations recommend testing persons of any age with the following HCV-related risk factors: current or past injection drug use, receipt of blood transfusions prior to 1992, receipt of long-term hemodialysis, and children born to HCV-infected mothers. In practice, interventions to improve HCV antibody and RNA confirmatory testing have included the use of prompts in electronic medical records for identifying eligible patients, immediate phlebotomy and expedited HCV RNA testing for anti-HCV-positive patients, and use of laboratory services that perform reflex testing on anti-HCV-positive specimens.

The next step in the cascade is linking the HCV-infected person to a healthcare provider capable of providing HCV-directed care and treatment. One potential reason for persons not progressing to care and treatment is that they may not follow through with the referral to a specialist who can provide such care.[8] Interventions such as case management programs and patient navigators have been shown to be particularly effective for retaining vulnerable patients in care and could be considered if there is a concern that a patient may be at risk for being lost to follow-up.[8] Additionally, in the era of direct-acting antivirals, there are increasing opportunities for primary care providers (PCPs) to provide HCV-directed care and treatment. For example, videoconferencing to train PCPs in the management of HCV-infected persons has been used to successfully scale up HCV treatment in underserved settings.[9]

Obtaining and completing treatment for patients is the final critical step. The treatments are well tolerated with cure rates in excess of 90% for most patients. The AASLD-IDSA has prepared a guidance document which is updated frequently and is an excellent reference for healthcare providers. While treatment is relatively uncomplicated, several third-party payers require preauthorization to obtain approval for HCV treatments. This process can be complicated and variable depending on the patient's health plan or payer, and it can be burdensome for busy healthcare providers.[10] Organizations such as the National Viral Hepatitis Roundtable have created resources for healthcare providers to help navigate this process, including templates for appealing denials. Despite these challenges, an increasing number of HCV-infected patients are being treated and cured.

Thank you for listening, and I wish you well as you take your patients from HCV diagnosis to cure.

Web Resources

CDC Viral Hepatitis Professional Resources

AASLD, ISDSA HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C

National Viral Hepatitis Roundtable. Resources For Patients and Providers

Alexander Millman, MD, is a medical epidemiologist with the CDC's Division of Viral Hepatitis, Prevention Branch, Clinical Interventions Team. He is a graduate of the Mount Sinai School of Medicine of New York University and completed internal medicine residency at the University of California, San Francisco. He previously served as an EIS officer in the CDC's Influenza Division. His professional interests include hepatitis C epidemiology and treatment as well as clinical and public health informatics.

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