Spotlight on HCV screening

New guidance from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommended universal hepatitis C virus (HCV) screening for all adults, and two recent studies reported on interventions that improved HCV screening and care in baby boomers.

New guidance recommended universal hepatitis C virus (HCV) screening, while recent research focused on improving HCV screening and treatment in primary care, with or without a face-to-face clinical encounter.

First, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) updated their HCV guidance, published on Dec. 9 by Hepatology and online at the AASLD and IDSA HCV guidance website. The update highlighted key new or amended recommendations since the previous October 2018 print publication. Among other recommendations, the new guidance recommends one-time, routine, opt-out HCV screening for all individuals ages 18 years and older.

The new universal screening recommendation is intended to enhance HCV case finding among adults not included in the baby boomer cohort, the guidance said. “This is particularly important for men and women aged 20-39 years due to the disproportionate overlapping impact of the opioid epidemic and associated injection drug use and the rising rate of incident HCV infections in this age group,” the authors wrote.

Along with the universal screening recommendation, the guidance recommended universal antiviral treatment for all adults with acute or chronic HCV infection, except those with a short life expectancy that cannot be remediated by HCV therapy, liver transplantation, or another directed therapy. “The HCV guidance panel urges healthcare providers caring for adults to encourage hepatitis C screening and treatment (if positive) because DAA [direct-acting antiviral] therapy is safe and cures HCV infection in most people,” the guidance said.

Second, an HCV intervention increased the number of patients screened and treated in low-income, diverse communities, one study found. Researchers assessed outcomes of Screen, Treat, Or Prevent Hepatocellular Carcinoma (STOP HCC) at safety-net primary care practices. The study included patients at five federally qualified health centers and one family medicine residency program who were born from 1945 through 1965 (baby boomers) and were never tested for HCV. All practices tested patients for anti-HCV antibody and HCV RNA. Implementation of the intervention was promoted by multilevel practice engagement, patient navigation, and anti-HCV-antibody screening with reflex HCV RNA testing. Test costs were covered for uninsured patients. Results were published online on Dec. 3 by Annals of Internal Medicine.

While anti-HCV-antibody screening was virtually nonexistent before STOP HCC, it increased to 13,334 (48.1%) of 27,700 baby boomers over a period of 29 to 43 months, varying by practice from 19.8% to 71.3%. Of 695 anti-HCV-positive patients, HCV RNA was tested in 520 (74.8%; 48.9% to 92.9% by practice), and 349 patients (2.6% of those screened) were diagnosed with chronic HCV. In four federally qualified health centers, 174 (84.9%) of 205 uninsured patients with chronic HCV had disease staging, 145 (70.7%) had teleconsultation review, 119 (58.0%) were recommended to start DAA treatment, 82 (40.0%) initiated free DAA therapy, 74 (36.1%) completed therapy (27.8% to 60.0% by practice), and 70 (94.6% of DAA completers) achieved sustained virologic response.

Among other limitations, the study did not include control practices, practices had varying funding and implementation time frames, and data were missing for some variables, the authors noted. “The population targeted by STOP HCC represents a priority for HCC prevention because most of the undiagnosed HCV population in the United States comprises low-income and uninsured or underinsured persons,” they concluded.

Third, a nonrandomized controlled trial of 1,024 adults found that bulk ordering and electronic messaging to patients improved completion of HCV screening. Researchers enrolled patients due for HCV screening with at least one primary care office visit in one of three primary care clinics enrolled in the health care system's tethered personal health record (PHR). Control patients received normal care for HCV screening (i.e., passive HCV reminders to clinicians during face-to-face visits and passive notification through the PHR). Intervention patients received normal care and also had HCV antibody tests ordered for them and customized messages sent through their PHR inviting them to go directly to the lab for HCV screening over a 12-week period. Results were published online on Dec. 2 by the Journal of General Internal Medicine.

In the intervention group, 168 (33%) of 514 patients completed HCV testing, compared with 97 (19%) of 510 patients in the control group (odds ratio, 1.7; 95% CI, 1.2 to 2.1). Bulk lab ordering appeared to have a large impact, whereas bulk messaging appeared to play a less significant role. However, one limitation of the study was the fact that it was difficult to determine the separate effects of bulk ordering versus bulk messaging, the authors noted. “These [EHR-based] tools and techniques can be used to automate screening programs for bloodwork (and other testing) and demonstrates that EHR-based population health tools can be used to screen for HCV infection in accordance with national guidelines, independent of a face-to-face patient-provider encounter,” they concluded.