USPSTF Recommends HCV Screening for All US Adults Ages 18-79

Marcia Frellick

March 02, 2020

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

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