Health Record Prompts Can Improve Hepatitis Diagnosis

Heather Boerner

November 09, 2018

DENVER — One in five people with HIV have never been tested for hepatitis C and two-thirds of gay and bisexual men with HIV have not been tested for hepatitis C in the past 12 months, new survey results from the Centers for Disease Control and Prevention (CDC) Medical Monitoring Project show.

"One of the truly good-news stories is that hepatitis C treatment works," said John Weiser, MD, from the Centers for Disease Control and Prevention (CDC) and Grady Medical Center in Atlanta. "But to benefit from treatment, patients first need to be diagnosed — that is, tested."

Guidelines for the treatment of hepatitis C recommend that all people with HIV be screened for hepatitis C, and that gay and bisexual men and people who inject drugs be tested annually.

But providers need more support to help them adhere to guidelines for viral hepatitis, said Weiser here at the Association of Nurses in AIDS Care 2018.

In addition to the survey results on hepatitis C, a recent study that Weiser was involved in showed that more than one in three people living with HIV have not been vaccinated for hepatitis B (Ann Intern Med. 2018;168:245-254).

"We all have too many things to remember and too little time to stay on top of things. We need to make it more automatic," he explained. Programming hepatitis C testing reminders and hepatitis B vaccine reminders "could transform things."

"The capability is totally there" in electronic medical records, he said. It could be as easy as a pop-up screen on a computer.

Updated Hep B Vaccination Guidance

Guidelines for the prevention of hepatitis B were recently updated by the Advisory Committee on Immunization Practices (MMWR Recomm Rep. 2018;67:1-31). They recommend vaccination for people with autoimmune disorders, people with hepatitis C, gay and bisexual men, people living with HIV, and people who inject drugs. And they recommend that infants and pregnant women be tested for hepatitis B surface antigen.

The first dose of a hepatitis B vaccine could be administered at a person's first HIV care visit, even before lab work confirms infection or immunity, Weiser suggested. That would be more effective protection against hepatitis B than waiting to vaccinate until the HIV has stabilized.

"If someone misses this opportunity and then has a gap in care, it's just that much longer that they remain at risk," he explained.

A patient's CD4 count should not change this recommendation. If patients with advanced HIV do not respond, they can be revaccinated. But if the first opportunity to vaccinate is not taken, "people will surely remain at risk," he added.

And even though lamivudine, tenofovir, and emtricitabine taken for HIV can prevent hepatitis B infection, the guidelines recommend vaccination. "Some day those treatment options are going to change to something that maybe doesn't have action against hepatitis B," Weiser said.

Optimizing Patient Care

The recommendation to begin hepatitis B vaccination at the first HIV care visit, regardless of CD4 count, resonated with Zyra Gordon-Smith, APN, from the Mile Square Health Center in Chicago, who provides primary care to people with HIV and viral hepatitis.

There has been a question of whether the vaccine would actually work when the immune system is compromised. "Getting the information about the first visit — just give them the first shot and then follow through" — will likely be practice-changing for her, she said.

Weiser has disclosed no relevant financial relationships. Gordon-Smith has received speaker fees from Gilead Sciences.

Association of Nurses in AIDS Care (ANAC) 2018. Presented November 8, 2018.

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