Screening for Hepatitis C Virus Infection in Adolescents and Adults: US Preventive Services Task Force Recommendation Statement

Factors Associated With Perinatal Hepatitis C Screening Among Exposed Children: 2016-2020

BACKGROUND AND OBJECTIVES

Children perinatally exposed to hepatitis C virus (HCV) should be screened for infection, yet testing rates are low. Clinical perinatal HCV testing recommendations vary and may contribute to poor completion. This study examines pediatric care factors associated with perinatal HCV testing completion.

METHODS

A cohort of people living with HCV in Philadelphia, Pennsylvania, who delivered a live birth in 2016 to 2020 and their children were followed by the Philadelphia Department of Public Health. The association of completion of HCV screening with pregnant/postpartum person demographics, pediatric care factors, and testing policy were retrospectively explored. χ2 and multivariable logistic regressions were used.

RESULTS

HCV-positive pregnant people gave birth to 457 children of whom 307 (67.2%) were tested for HCV according to recommendations and 79 (17.2%) were inadequately tested. Children were more likely to be tested if born to a pregnant person with HIV coinfection (P = .007), if they were always on schedule for vaccinations (P < .001), and if they attended the 18-month well visit (P < .001). Completion rates varied significantly by pediatrician's testing policy: 90.9% tested if the policy was for 2 months, 79.6% if 2 to 12 months, 61.9% if 12 months, and 58.5% if 18 months of age (P < .001).

CONCLUSIONS

Timing of perinatal HCV testing policies was significantly associated with testing completion rates. Testing at 2 months was associated with far better HCV testing completion than other strategies, regardless of birthing person and pediatrician factors. These findings suggest routine HCV testing of children perinatally exposed to HCV is best achieved in the first year of life.

Review of the U.S. Air Force Academy Hepatitis C Virus Screening Program to Ensure High-Value Care

INTRODUCTION

Hepatitis C virus (HCV) is primarily transmitted through blood-to-blood contact. Leading health agencies have called for the elimination of HCV as a public health threat, with universal screening considered a part of the strategy. Hepatitis C virus screening among incoming cadets and cadet candidates at the United States Air Force Academy (USAFA) was implemented in 2023. The purpose of this quality improvement project was to determine the results of this screening and the associated fiscal costs, benefits, and harms to make a recommendation for future incoming classes.

MATERIALS AND METHODS

The prevalence of HCV antibody positivity and confirmed HCV infections were calculated among the incoming cadets and cadet candidates at USAFA in summer 2023. Screening was conducted with a highly sensitive HCV total antibody test, and those who screened positive were further tested with a quantitative HCV polymerase chain reaction. The screening and follow-up care costs were calculated, and the potential harm of receiving a false positive notification was considered.

RESULTS

Of the 1,360 persons screened at USAFA in 2023, no confirmed HCV infections were identified. There was one false positive on screening in the cadet population (n = 1,131) and one false positive in the cadet candidate population (n = 229). The fiscal cost of universal HCV screening upon accession of cadets and cadet candidates, including medical follow-up, was at least $5,279. The opportunity cost was minimal because blood was drawn for other mandatory programs, although screening may have caused social and psychological harm to those receiving a false positive notification.

CONCLUSIONS

The prevalence of chronic HCV infection among incoming USAFA cadets and cadet candidates was 0%, below the population screening threshold that warrants screening, according to the Centers for Disease Control and Prevention. The harms of screening, including fiscal costs and potential psychological harm to individuals with a false positive screen, likely outweigh the benefits. We recommend against universal HCV screening in 2024 upon accession of USAFA cadets and cadet candidates.

Envisioning how to advance the MASH field

Since 1980, the cumulative effort of scientists and health-care stakeholders has advanced the prerequisites to address metabolic dysfunction-associated steatotic liver disease (MASLD), a prevalent chronic non-communicable liver disease. This effort has led to, among others, the approval of the first drug specific for metabolic dysfunction-associated steatohepatitis (MASH; formerly known as nonalcoholic steatohepatitis). Despite substantial progress, MASLD is still a leading cause of advanced chronic liver disease, including primary liver cancer. This Perspective contextualizes the nomenclature change from nonalcoholic fatty liver disease to MASLD and proposes important considerations to accelerate further progress in the field, optimize patient-centric multidisciplinary care pathways, advance pharmacological, behavioural and diagnostic research, and address health disparities. Key regulatory and other steps necessary to optimize the approval and access to upcoming additional pharmacological therapeutic agents for MASH are also outlined. We conclude by calling for increased education and awareness, enhanced health system preparedness, and concerted action by policy-makers to further the public health and policy agenda to achieve at least parity with other non-communicable diseases and to aid in growing the community of practice to reduce the human and economic burden and end the public health threat of MASLD and MASH by 2030.

CDC's New Hepatitis C Virus Testing Recommendations for Perinatally Exposed Infants and Children: A Step Towards Hepatitis C Elimination

New U.S. Centers for Disease Control and Prevention (CDC) guidelines for hepatitis C virus (HCV) testing of perinatally exposed infants and children released in 2023 recommend a nucleic acid test (NAT) for detection of HCV ribonucleic acid (i.e., NAT for HCV RNA) at 2-6 months of age to facilitate early identification and linkage to care for children with perinatally acquired HCV infection. Untreated hepatitis C can lead to cirrhosis, liver cancer, and premature death and is caused by HCV, a blood-borne virus transmitted most often among adults through injection drug use in the United States. Perinatal exposure from a birth parent with HCV infection is the most frequent mode of HCV transmission among infants and children. New HCV infections have been increasing since 2010, with the highest rates of infection among people aged 20-39 years, leading to an increasing prevalence of HCV infection during pregnancy. In 2020, the CDC recommended one-time HCV screening for all adults aged 18 years and older and for all pregnant persons during each pregnancy. Detecting HCV infection during pregnancy is key for the identification of pregnant persons, linkage to care for postpartum treatment, and identification of infants with perinatal exposure for HCV testing. It was previously recommended that children who were exposed to HCV during pregnancy receive an antibody to HCV (anti-HCV) test at 18 months of age; however, most children were lost to follow-up before testing occurred, leaving children with perinatal infection undiagnosed. The new strategy of testing perinatally exposed children at age 2-6 months was found to be cost-effective in increasing the identification of infants who might develop chronic hepatitis C. This report describes the current perinatal HCV testing recommendations and how they advance national hepatitis C elimination efforts by improving the health of pregnant and postpartum people and their children.

Cancer in people who identify as lesbian, gay, bisexual, transgender, queer, or gender-nonconforming

BACKGROUND

Individuals who identify as lesbian, gay, bisexual, transgender, queer, intersex, or gender-nonconforming (LGBTQ+) experience discrimination and minority stress that may lead to elevated cancer risk.

METHODS

In the absence of population-based cancer occurrence information for this population, this article comprehensively examines contemporary, age-adjusted cancer risk factor and screening prevalence using data from the National Health Interview Survey, Behavioral Risk Factor Surveillance System, and National Youth Tobacco Survey, and provides a literature review of cancer incidence and barriers to care.

RESULTS

Lesbian, gay, and bisexual adults are more likely to smoke cigarettes than heterosexual adults (16% compared to 12% in 2021-2022), with the largest disparity among bisexual women. For example, 34% of bisexual women aged 40-49 years and 24% of those 50 and older smoke compared to 12% and 11%, respectively, of heterosexual women. Smoking is also elevated among youth who identify as lesbian, gay, or bisexual (4%) or transgender (5%) compared to heterosexual or cisgender (1%). Excess body weight is elevated among lesbian and bisexual women (68% vs. 61% among heterosexual women), largely due to higher obesity prevalence among bisexual women (43% vs. 38% among lesbian women and 33% among heterosexual women). Bisexual women also have a higher prevalence of no leisure-time physical activity (35% vs. 28% among heterosexual women), as do transgender individuals (30%-31% vs. 21%-25% among cisgender individuals). Heavier alcohol intake among lesbian, gay, and bisexual individuals is confined to bisexual women, with 14% consuming more than 7 drinks/week versus 6% of heterosexual women. In contrast, prevalence of cancer screening and risk reducing vaccinations in LGBTQ+ individuals is similar to or higher than their heterosexual/cisgender counterparts except for lower cervical and colorectal cancer screening among transgender men.

CONCLUSIONS

People within the LGBTQ+ population have a higher prevalence of smoking, obesity, and alcohol consumption compared to heterosexual and cisgender people, suggesting a higher cancer burden. Health systems have an opportunity to help inform these disparities through the routine collection of information on sexual orientation and gender identity to facilitate cancer surveillance and to mitigate them through education to increase awareness of LGBTQ+ health needs.

DNA-directed formation of plasmonic core-satellite nanostructures for quantification of hepatitis C viral RNA

Hepatitis C virus (HCV) continues to be a significant public health challenge, affecting an estimated 71 million people globally and posing risks of severe liver diseases. Despite advancements in treatments, diagnostic limitations hinder the global elimination efforts targeted by 2030. This study introduces an innovative diagnostic approach, integrating catalytic hairpin assembly (CHA) with plasmonic core-satellite gold nanoparticle (AuNP) assemblies, to enable sensitive and specific detection of HCV RNA. We optimized the stoichiometry of DNA hairpins to form highly stable three-way junctions (3WJs), minimizing non-specific reactions in an enzyme-free, isothermal amplification process. The resulting dual-transduction biosensor combines colorimetric and surface-enhanced Raman spectroscopy (SERS) techniques, utilizing the Raman reporter malachite green isothiocyanate (MGITC) for signal generation. Our system targets a conserved 23-nucleotide sequence within the HCV 5'-UTR, essential for RNA replication, facilitating pan-genotypic HCV detection that complements direct-acting antiviral strategies. We evaluated the biosensor's efficacy using fluorescence spectroscopy, native PAGE, AFM, and TEM. Findings indicate that the 60 nm core AuNPs surrounded by 20 nm satellite AuNPs achieved a ten-fold increase in sensitivity over the 10 nm satellites, detecting HCV RNA concentrations as low as 1.706 fM. This sensitivity is crucial, given the extremely low viral loads present during early infection stages. Our research demonstrates the promise of enzyme-free molecular biosensors for HCV, with the potential to provide cost-efficient, rapid, point-of-care testing, although further sensitivity enhancements are needed to address the challenges of early-stage detection.

Genetic screening of liver cancer: State of the art

Liver cancer, primarily hepatocellular carcinoma, remains a global health challenge with rising incidence and limited therapeutic options. Genetic factors play a pivotal role in the development and progression of liver cancer. This state-of-the-art paper provides a comprehensive review of the current landscape of genetic screening strategies for liver cancer. We discuss the genetic underpinnings of liver cancer, emphasizing the critical role of risk-associated genetic variants, somatic mutations, and epigenetic alterations. We also explore the intricate interplay between environmental factors and genetics, highlighting how genetic screening can aid in risk stratification and early detection via using liquid biopsy, and advancements in high-throughput sequencing technologies. By synthesizing the latest research findings, we aim to provide a comprehensive overview of the state-of-the-art genetic screening methods for liver cancer, shedding light on their potential to revolutionize early detection, risk assessment, and targeted therapies in the fight against this devastating disease.

Contemporary Insights into Hepatitis C Virus: A Comprehensive Review

Hepatitis C virus (HCV) remains a significant global health challenge. Approximately 50 million people were living with chronic hepatitis C based on the World Health Organization as of 2024, contributing extensively to global morbidity and mortality. The advent and approval of several direct-acting antiviral (DAA) regimens significantly improved HCV treatment, offering potentially high rates of cure for chronic hepatitis C. However, the promising aim of eventual HCV eradication remains challenging. Key challenges include the variability in DAA access across different regions, slightly variable response rates to DAAs across diverse patient populations and HCV genotypes/subtypes, and the emergence of resistance-associated substitutions (RASs), potentially conferring resistance to DAAs. Therefore, periodic reassessment of current HCV knowledge is needed. An up-to-date review on HCV is also necessitated based on the observed shifts in HCV epidemiological trends, continuous development and approval of therapeutic strategies, and changes in public health policies. Thus, the current comprehensive review aimed to integrate the latest knowledge on the epidemiology, pathophysiology, diagnostic approaches, treatment options and preventive strategies for HCV, with a particular focus on the current challenges associated with RASs and ongoing efforts in vaccine development. This review sought to provide healthcare professionals, researchers, and policymakers with the necessary insights to address the HCV burden more effectively. We aimed to highlight the progress made in managing and preventing HCV infection and to highlight the persistent barriers challenging the prevention of HCV infection. The overarching goal was to align with global health objectives towards reducing the burden of chronic hepatitis, aiming for its eventual elimination as a public health threat by 2030.

Evaluating the Impact of an Educational Intervention on Hepatitis C Screening in a Midwest Regional Psychiatric Unit

INTRODUCTION

Affecting more than 3.9 million Americans, the hepatitis C virus (HCV) attacks the liver by causing inflammation. Left untreated, HCV can lead to serious consequences. Targeting high-risk individuals in the inpatient psychiatric setting can lead to increased testing and referral.

AIMS

This quality improvement project determined whether an intervention-consisting of a pretest, educational session, posttest, and screening implementation-increased staff knowledge about HCV screening recommendations, identified at-risk individuals, and increased the number of patients screened and referred for treatment.

METHOD

An online HCV educational session was provided to 30 staff at a Midwest regional psychiatric unit. An online pre/posttest was conducted to determine staff knowledge and understanding prior to and after the educational session. An HCV screening tool checklist was incorporated into the electronic health record (EHR) system. A 3-month pre/post-intervention chart review was completed to determine the number of patients identified and screened for HCV.

RESULTS

A comparison of the 30 staff members' mean pre/posttest scores were calculated using an unpaired t test, showing a prescore mean of 55.15 ± 19.09 and a postscore mean of 85.75 ± 13.44, p < .001. A chi-square analysis indicated that there was a statistically significant post-intervention increase in the percentage of high-risk patients identified (5.6%-36.4%, p < .001) and screened (5.6%-31.4%, p < .001) for HCV compared with pre-intervention.

CONCLUSION

The study intervention increased staff knowledge of HCV guidelines and the number of at-risk patients identified and screened for the disease.

Esophageal Lichen Planus: A Descriptive Multicenter Report

GOALS

To better understand the characteristics, treatment approaches, and outcomes of patients with esophageal lichen planus (ELP).

BACKGROUND

ELP is a rare, often unrecognized and misdiagnosed disorder. Data on this unique patient population are currently limited to small, single-center series.

STUDY

A multicenter, retrospective descriptive study was conducted of adults diagnosed with ELP over a 5-year period, between January 1, 2015, and October 10, 2020, from 7 centers across the United States.

RESULTS

Seventy-eight patients (average age 65 y, 86% female, 90% Caucasian) were included. Over half had at least 1 extraesophageal manifestation. Esophageal strictures (54%) and abnormal mucosa (50%) were frequent endoscopic findings, with the proximal esophagus the most common site of stricture. Approximately 20% had normal endoscopic findings. Topical steroids (64%) and/or proton pump inhibitors (74%) dominated management; endoscopic response favored steroids (43% vs. 29% respectively). Almost half of the patients required switching treatment modalities during the study period. Adjunctive therapies varied significantly between centers.

CONCLUSIONS

Given its at times subtle clinical and endoscopic signs, a high index of suspicion and biopsy will improve ELP diagnosis, especially in those with extraesophageal manifestations. Effective therapies are lacking and vary significantly. Prospective investigations into optimal treatment regimens are necessary.

GRADE good practice statements: a time to say "good-bye"? A new typology for normative statements on interventions

BACKGROUND

Clinical and public health guidelines include a variety of types of normative statements concerning interventions. "Recommendations" are usually the central focus, and are based on one or more systematic reviews of research evidence. Guidelines may include other types of normative statements, however, including Grading of Recommendations, Assessment, Develoment, and Evaluation (GRADE) good (or best) practice statements (GPS), which represent recommendations that guideline panels feel are important but are not appropriate for formal ratings of quality of evidence because it is sufficiently obvious that desirable effects outweigh undesirable effects. These normative statements are typically supported by a great deal of high-certainty, indirect evidence, which the authors feel would be a waste of time to examine. There are a number of conceptual and methodological issues with GRADE GPS, however, and these are manifested in guidelines, including both inappropriate overuse and underuse, and unclear interpretation and impact among end-users. This situation has arisen in part from lack of clarity in, and misunderstandings of, GRADE guidance, the lumping of many different types of normative statements under one label ("GPS"), from limitations in GRADE's approach to linked bodies of evidence, and because the appropriate basis for many normative statements about interventions is not reviews of research evidence. A new typology is needed for normative statements on interventions and policies that are not optimally based on reviews of research evidence.

PROPOSED TYPOLOGY

This proposed typology differentiates normative statements about interventions by the type or nature of the most appropriate basis for the statement. The typology encompasses the range of statements encompassed by GPS, but provides a more nuanced categorization designed to assist both guideline developers and end-users. This typology encompasses two main types of normative statements about interventions (including policies): (1) statements that indicate when to use (or not) an intervention, which intervention to use, and if, when and how to use it and (2) the principles, practices, or norms that inform or underpin such interventions. These correspond to normative statements based on empirical evidence, and those based on human rights, ethics, or norms, respectively. Normative statements based on empirical evidence include: (1) recommendations based on systematic reviews of human or animal evidence on effectiveness and harms, including linked bodies of evidence; (2) normative statements based on scientific fundamentals (eg, physical/biological/chemical properties, theories, laws, or principles); and (3) implementation guidance based most commonly on experiential evidence such as case studies. Normative statements based on human rights, ethics, or norms include: (1) guiding principles, based on human rights standards and conventions and/or ethics principles; and (2) practice norms and standards, based on clinical and public health norms and/or professional standards.

CONCLUSION

There are conceptual and methodological problems with GRADE GPS, leading to their misapplication, with overuse and underuse. This paper presents a proposal for a new typology for normative statements on interventions, according to the basis for the statement. This typology encompasses and replaces GPS, providing a more nuanced set of statements. Testing of this proposed approach is needed among both guideline developers and end-users.

Advancing Hepatitis C Elimination through Opt-Out Universal Screening and Treatment in Carceral Settings, United States

Incarcerated persons are infected with hepatitis C virus (HCV) at rates ≈10 times higher than that of the general population in the United States. To achieve national hepatitis C elimination goals, the diagnosis and treatment of hepatitis C in incarcerated persons must be prioritized. In 2022, the Centers for Disease Control and Prevention recommended that all persons receive opt-out HCV screening upon entry into a carceral setting. We review recommendations, treatments, and policy strategies used to promote HCV opt-out universal HCV screening and treatment in incarcerated populations in the United States. Treatment of hepatitis C in carceral settings has increased but varies by jurisdiction and is not sufficient to achieve HCV elimination. Strengthening universal HCV screening and treatment of HCV-infected incarcerated persons is necessary for HCV elimination nationwide.

Working with the Electronic Health Record and Laboratory Information System to Maximize Ordering and Reporting of Molecular Microbiology Results

Molecular microbiology assays have a higher cost of testing compared to traditional methods and need to be utilized appropriately. Results from these assays may also require interpretation and appropriate follow-up. Electronic tools available in the electronic health record and laboratory information system can be deployed both preanalytically and postanalytically to influence ordering behaviors and positively impact diagnostic stewardship. Next generation technologies, such as machine learning and artificial intelligence, have the potential to expand upon the capabilities currently available and warrant additional study and development but also require regulation around their use in health care.

Large-Scale, Primary Care-Based Hepatitis C Treatment in an Urban, Medically Underserved Patient Population

Hepatitis C virus (HCV) infection is a critical public health concern in the United States. HCV is highly curable, but access to care is limited for many patients. Primary care models can expand access to HCV care. The Grady Liver Clinic (GLC) is a primary care-based HCV clinic founded in 2002. During 20 years, using a multidisciplinary team, the GLC expanded its operations in response to advances in HCV screening and treatment. We describe the clinic model, patient population, and treatment outcomes of the clinic from 2015 through 2019. During this period, 2689 patients were seen in the GLC, and 77% (n = 2083) initiated treatment. Eighty-five percent (1779 of 2083) of patients who started treatment completed treatment and were tested for cure, and 1723 (83% of the total treated cohort, 97% of those tested for cure) were cured. Building on a successful primary care-based treatment model, the GLC dynamically responded to the changes in HCV screening and treatment guidelines, continually increasing access to HCV care. The GLC serves as a model of primary care-based HCV care that aims to achieve HCV microelimination in a safety-net health system. Our findings support the notion that for the United States to achieve elimination of HCV by 2030, generalists can and should provide HCV care, particularly in medically underserved patient populations.

Association of Medicaid expansion with health insurance, unmet need for medical care and substance use disorder treatment among people who inject drugs in 13 US states

BACKGROUND AND AIMS

Impoverished people who inject drugs (PWID) are at the epicenter of US drug-related epidemics. Medicaid expansion is designed to reduce cost-related barriers to care by expanding Medicaid coverage to all US adults living at or below 138% of the federal poverty line. This study aimed to measure whether Medicaid expansion is (1) positively associated with the probability that participants are currently insured; (2) inversely related to the probability of reporting unmet need for medical care due to cost in the past year; and (3) positively associated with the probability that they report receiving substance use disorder (SUD) treatment in the past year, among PWID subsisting at ≤ 138% of the federal poverty line.

DESIGN

A two-way fixed-effects model was used to analyze serial cross-sectional observational data.

SETTING

Seventeen metro areas in 13 US states took part in the study.

PARTICIPANTS

Participants were PWID who took part in any of the three waves (2012, 2015, 2018) of data gathered in the Center for Disease Control and Prevention's National HIV Behavioral Surveillance (NHBS), were aged ≤ 64 years and had incomes ≤ 138% of the federal poverty line. For SUD treatment analyses, the sample was further limited to PWID who used drugs daily, a proxy for SUD.

MEASUREMENTS

State-level Medicaid expansion was measured using Kaiser Family Foundation data. Individual-level self-report measures were drawn from the NHBS surveys (e.g. health insurance coverage, unmet need for medical care because of its cost, SUD treatment program participation).

FINDINGS

The sample for the insurance and unmet need analyses consisted of 19 946 impoverished PWID across 13 US states and 3 years. Approximately two-thirds were unhoused in the past year; 41.6% reported annual household incomes < $5000. In multivariable models, expansion was associated with a 19.0 [95% confidence interval (CI) = 9.0, 30.0] percentage-point increase in the probability of insurance coverage, and a 9.0 (95% CI = -15.0, -0.2) percentage-point reduction in the probability of unmet need. Expansion was unrelated to SUD treatment among PWID who used daily (n = 17 584).

CONCLUSIONS

US Medicaid expansion may curb drug-related epidemics among impoverished people who inject drugs by increasing health insurance coverage and reducing unmet need for care. Persisting non-financial barriers may undermine expansion's impact upon substance use disorder treatment in this sample.

Projected Incidence of Hepatobiliary Cancers and Trends Based on Age, Race, and Gender in the United States

BACKGROUND

Identifying the projected incidence of hepatobiliary cancers and recognizing patient cohorts at increased risk can help develop targeted interventions and resource allocation. The expected incidence of subtypes of hepatobiliary cancers in different age groups, races, and genders remains unknown.

METHODS

Historical epidemiological data from the Surveillance, Epidemiology, and End Results (SEER) database was used to project future incidence of hepatobiliary malignancies in the United States and identify trends by age, race, and gender. Patients ≥18 years of age diagnosed with a hepatobiliary malignancy between 2001 and 2017 were included. US Census Bureau 2017 National Population projects provided the projected population from 2017 to 2029. Age-Period-Cohort forecasting model was used to estimate future births cohort-specific incidence. All analyses were completed using R Statistical Software.

RESULTS

We included 110381 historical patients diagnosed with a hepatobiliary malignancy between 2001 and 2017 with the following subtypes: hepatocellular cancer (HCC) (68%), intrahepatic cholangiocarcinoma (iCCA) (11.5%), gallbladder cancer (GC) (8%), extrahepatic cholangiocarcinoma (eCCA) (7.6%), and ampullary cancer (AC) (4%). Our models predict the incidence of HCC to double (2001 to 2029) from 4.5 to 9.03 per 100,000, with the most significant increase anticipated in patients 70-79 years of age. In contrast, incidence is expected to continue to decline among the Asian population. Incidence of iCCA is projected to increase, especially in the white population, with rates in 2029 double those in 2001 (2.13 vs. 0.88 per 100,000, respectively; p < 0.001). The incidence of GC among the black population is expected to increase. The incidence of eCCA is expected to significantly increase, especially among the Hispanic population, while that of AC will remain stable.

DISCUSSION

The overall incidence of hepatobiliary malignancies is expected to increase in the coming years, with certain groups at increased risk. These findings may help with resource allocation when considering screening, treatment, and research in the coming years.

Evaluation of State-Mandated Third Trimester Repeat HIV Testing in a Large Tertiary Care Center

OBJECTIVE

 The Illinois Perinatal HIV Prevention Act was passed to ensure universal HIV testing once during pregnancy and was extended in 2018 to add third trimester repeat HIV screening. The objectives of this analysis were to describe uptake of, and patient factors associated with, third trimester repeat HIV testing at a high-volume birthing center.

STUDY DESIGN

 This is a retrospective cohort study of people who delivered at a single tertiary care hospital in Illinois during 2018. Women who delivered before 27 weeks, had an intrauterine fetal demise, a known diagnosis of HIV, or no HIV test during pregnancy were excluded. Repeat testing was defined as an HIV test at or after 27 weeks' gestation after an earlier negative HIV test during the same pregnancy. The primary outcome was the proportion of people who received repeat testing prior to delivery. Bivariable analyses were performed to identify patient characteristics associated with documentation of repeat HIV testing.

RESULTS

 Of 12,053 people eligible for inclusion, 3.4% (n = 414) presented without a documented third trimester repeat HIV test. The proportion of people with repeat testing improved from 80 to >99% in the first year. Patient factors were largely not associated with testing performance although multiparous people were more likely to have documented repeat testing.

CONCLUSION

 Rapid implementation of third trimester repeat HIV testing was achieved without disparity. Patient factors were largely not associated with testing performance which reinforces the goal of a universal screen to test all people equitably and effectively without bias.

KEY POINTS

· Little is known about adherence to repeat third trimester HIV testing in pregnancy.. · Universal third trimester HIV screening was implemented with high uptake and without disparity.. · Protocolization of repeat HIV testing in pregnancy may reduce bias compared to risk based-screening..

Differences in Provider Hepatitis C Virus Screening Recommendations by Patient Risk Status

Providers' recommendation is among the strongest predictors to patients engaging in preventive care. Therefore, the aim of this study was to compare providers' Hepatitis C Virus (HCV) screening recommendation quality between high-risk and average-risk patients to determine if providers are universally recommending HCV screening, regardless of risk behaviors. This cross-sectional survey of 284 Indiana providers in 2020 assessed provider characteristics, HCV screening recommendation practices (strength, presentation, frequency, timeliness), self-efficacy, and barriers to recommending HCV screening. T-test and Chi-square compared recommendation practices for high-risk and average-risk patients. Prevalence ratios were calculated for variables associated with HCV recommendation strength comparing high-risk and average-risk patients. Logistic regression analyses examined factors associated with HCV recommendation strength for high- and average-risk patients, with odds ratios. Compared to average-risk patients, high-risk patients received higher proportion of HCV recommendations that were strong (70.4 % v. 42.4 %), routine (61.9 % v. 55.6 %), frequent (37.7 % v. 28 %), and timely (74.2 % v. 54.9 %) (P-values < 0.001). Compared to average-risk patients, providers with high-risk patients had a lower percentage of giving a strong recommendation if they were nurse practitioner (PR = 0.49). For high-risk patients, providers with higher self-efficacy (aOR = 2.16;95 %CI = 0.99-4.69) had higher odds, while those with higher perceived barriers (aOR = 0.19;95 %CI = 0.09-0.39) and those with an internal medicine specialty compared to family medicine (aOR = 0.22;95 %CI = 0.08-0.57) had lower odds of giving a strong recommendation. These data suggest providers are not universally recommending HCV screening for all adults regardless of reported risk. Future research should translate these findings into multilevel interventions to improve HCV screening recommendations regardless of patient risk status.

Epidemiological Perspectives: A Four-Year Insight Into Hepatitis C Surveillance in the Kingdom of Saudi Arabia

Introduction Hepatitis C is a viral disease caused by the hepatitis C virus (HCV), a member of the Flaviviridae family. This compact, enveloped RNA virus possesses a positive single-stranded genome and can be transmitted through various means, including blood exposure, sexual contact, and vertical transmission. The disease is associated with significant morbidity and mortality, imposing substantial costs on the healthcare system. In Saudi Arabia, HCV is a notifiable disease; however, there is a scarcity of recent reports on HCV trends in the country. This study aims to provide updated insights into the infection patterns of HCV across demographics, regions, and genders in Saudi Arabia. Methods A retrospective analysis was conducted to investigate the epidemiological trends of HCV infection in Saudi Arabia. Data were obtained from the Saudi Ministry of Health (MOH), encompassing the timeframe from 2019 to 2022. A descriptive analysis of HCV infection, organized by year, age group, and gender, was conducted using the data reported to the MOH. Results Between 2019 and 2022, there was a significant decrease of 56.9% in the overall rate of hepatitis C cases in Saudi Arabia. The rate dropped from 9.94 to 4.29 cases per 100,000 people during this period. Males consistently had higher reported cases compared to females, although there was a notable decline in cases for both genders from 2019 to 2022. The highest incidence of HCV was found in individuals aged 45 years and above. However, there was a decline in cases among this age group, with the number dropping from 2,195 cases in 2019 to 946 cases in 2022. In terms of regional variations, Riyadh, Makkah, Jeddah, Alsharqiya, and Taif had the highest incidence of HCV cases. Some regions experienced an increase in cases between 2021 and 2022, particularly Jeddah, Taif, and Al-Ahsaa. Conclusion This study reveals a significant reduction in reported HCV cases in Saudi Arabia from 2019 to 2022. However, gender disparities persist, with males having a higher number of reported cases. There is also a notable decline in HCV cases among children and adolescents, which can be attributed to preventive measures. The findings emphasize the importance of region-specific strategies, as certain areas, such as Riyadh, Makkah, Jeddah, Alsharqiya, and Taif, continue to have a high number of reported cases. Proactive measures, surveillance, and public awareness campaigns remain crucial in addressing HCV as a significant public health challenge in the Kingdom.

Hepatitis C in Black Individuals in the US: A Review

Importance

In the US, the prevalence of hepatitis C virus (HCV) is 1.8% among people who are Black and 0.8% among people who are not Black. Mortality rates due to HCV are 5.01/100 000 among people who are Black and 2.98/100 000 among people who are White.

Observations

While people of all races and ethnicities experienced increased rates of incident HCV between 2015 and 2021, Black individuals experienced the largest percentage increase of 0.3 to 1.4/100 000 (367%) compared with 1.8 to 2.7/100 000 among American Indian/Alaska Native (50%), 0.3 to 0.9/100 000 among Hispanic (200%), and 0.9 to 1.6/100 000 among White (78%) populations. Among 47 687 persons diagnosed with HCV in 2019-2020, including 37 877 (79%) covered by Medicaid (7666 Black and 24 374 White individuals), 23.5% of Black people and 23.7% of White people with Medicaid insurance initiated HCV treatment. Strategies to increase HCV screening include electronic health record prompts for universal HCV screening, which increased screening tests from 2052/month to 4169/month in an outpatient setting. Awareness of HCV status can be increased through point-of-care testing in community-based settings, which was associated with increased likelihood of receiving HCV test results compared with referral for testing off-site (69% on-site vs 19% off-site, P < .001). Access to HCV care can be facilitated by patient navigation, in which an individual is assigned to work with a patient to help them access care and treatments; this was associated with greater likelihood of HCV care access (odds ratio, 3.7 [95% CI, 2.9-4.8]) and treatment initiation within 6 months (odds ratio, 3.2 [95% CI, 2.3-4.2]) in a public health system providing health care to individuals regardless of their insurance status or ability to pay compared with usual care. Eliminating Medicaid's HCV treatment restrictions, including removal of a requirement for advanced fibrosis or a specialist prescriber, was associated with increased treatment rates from 2.4 persons per month to 72.3 persons per month in a retrospective study of 10 336 adults with HCV with no significant difference by race (526/1388 [37.8%] for Black vs 2706/8277 [32.6%] for White patients; adjusted odds ratio, 1.02 [95% CI, 0.8-1.3]).

Conclusions and Relevance

In the US, the prevalence of HCV is higher in people who are Black than in people who are not Black. Point-of-care HCV tests, patient navigation, electronic health record prompts, and unrestricted access to HCV treatment in community-based settings have potential to increase diagnosis and treatment of HCV and improve outcomes in people who are Black.

Hepatitis C infection seroprevalence in pregnant women worldwide: a systematic review and meta-analysis

Background

Monitoring progress towards the WHO global target to eliminate hepatitis C virus (HCV) infection by 2030, entails reliable prevalence estimates for HCV infection in different populations. Little is known about the global burden of HCV infection in pregnant women. Here, for the first time to our knowledge, we estimated the global and regional seroprevalence of HCV antibody (Ab) and determinants in pregnant women.

Methods

In this systematic review and meta-analysis study, we searched PubMed/MEDLINE, Web of Science, Embase, Scopus, and SciELO databases for peer-reviewed observational studies between January 1, 2000 and April 1, 2023, without language or geographical restrictions. Pooled global seroprevalence (and 95% confidence interval, CI) were estimated using random-effects meta-analysis and seroprevalences were categorised according to World Health Organization regions and subregions, publishing year, countries' income and human development index (HDI) levels. We used sensitivity analysis to assess the effect of four large sample size studies on pooled global prevalence through the "leave-one-out" method. We also investigated the association of potential risk factors with HCV seropositivity in pregnant women by subgroup and meta-regression analyses. The Protocol was registered in PROSPERO CRD42023423259.

Findings

We included 192 eligible studies (208 datasets), with data for 148,509,760 pregnant women from 53 countries. The global seroprevalence of HCV Ab in pregnant women was 1.80% (95% CI, 1.72-1.89%) and 3.29% (3.01-3.57%) in overall and sensitivity analyses, respectively. The seroprevalence was highest in the Eastern Mediterranean region (6.21%, 4.39-8.29%) and lowest in the Western Pacific region (0.75%, 0.38-1.22%). Subgroup analysis indicated that the seroprevalence of HCV Ab among pregnant women was significantly higher for those with opioid use disorder (51.94%, 95% CI: 37.32-66.39) and HIV infection (4.34%, 95% CI: 2.21-7.06%) than for the general population of pregnant women (1.08%, 95% CI: 1.02-1.15%), as confirmed by multivariable meta-regression (p < 0.001). A significant decreasing trend was observed with increasing human development index levels. Other important risk factors for HCV seropositivity included older age, lower educational levels, poly sexual activity, history of blood transfusion, hospitalization, surgery, abortion and sexual transmitted diseases, having scarification/tattoo or piercing, and testing hepatitis B positive.

Interpretation

This meta-analysis showed relatively high burden of exposure to HCV infection (2.2-5.3 million) in pregnant women globally. However, due to substantial heterogeneity between studies, our estimates might be different than the true seroprevalence. Our findings highlighted the need to expand HCV screening for women of reproductive age or during pregnancy, particularly in countries with high prevalence; as well as for more studies that assess safety of existing therapeutic drugs during pregnancy or potentially support development of drugs for pregnant women.

Funding

There was no funding source for this study.

Outcomes of Pharmacist-Led Treatment of Hepatitis C in the Virginia Department of Corrections

A higher proportion of people in correctional settings have, or are at risk for, hepatitis C virus (HCV) due to socioeconomic factors, mental health concerns, substance use disorders, history of high-risk experiences, and more. Compared with the general population, the prevalence of HCV is 10 times higher among people who are incarcerated. The objective of this retrospective cohort study was to describe the HCV treatment cascade in a pharmacist-led clinic model, from referral through treatment completion and documentation of cure. Pharmacists in the Virginia Department of Corrections, in collaboration with Virginia Commonwealth University, established and led a telemedicine HCV clinic. A total of 1,040 incarcerated individuals with chronic HCV infection were treated between January 2020 and January 2022. In this study, the clinical endpoint was the number of patients achieving a 12-week sustained virological response (SVR12), which is considered cure of an HCV infection. The economic endpoint was total dollars spent per patient to achieve the SVR12. Participants were HCV treatment naïve, positive for HCV genotypes 1-6, not concurrently infected with HIV, and without decompensated liver disease. The overall cure rate was 97% with no discontinuation due to adverse effects. The cost-to-cure ratio was $23,223/person achieving SVR12.

Hepatitis C Prevalence on the Rise but Screening at Safety Net Institutions Lagging behind

Introduction

In the United States, the hepatitis C virus (HCV) is a leading contributor to liver-related illnesses and fatalities. Despite effective antiviral medications, acute infections have increased in recent years, likely due to IV drug use and the opioid epidemic. Previous guidelines recommended one-time screening for individuals born between 1945 and 1965. The CDC now recommends screening all adults over 18 unless there is a low prevalence in the area. Accurate measurement of HCV prevalence is essential for targeted prevention. In New York, over 100,000 individuals have HCV. We present data on HCV screening at a safety net hospital in Long Island, NY.

Objective

To identify screening rates for hepatitis C and the exposure prevalence and specific demographics of a community in Long Island, NY.

Methods

We performed a review of all patients seen in our hospital from 2012 to 2019. We identified patients born in the years 1945 to 1965 using our electronic medical record (EMR) system and subsequently analyzed those who were anti-HCV positive. We reviewed their demographics, including age, gender, and ethnicity, as well as their history of intravenous drug use and HIV coinfection status. Basic statistical analysis was used.

Results

Our study identified 21,722 patients born between 1945 and 1965 and found that only 8.5% or 1,858 individuals were screened for hepatitis C. Among them, we found that 5.9% (109) tested positive for HCV antibody, with 3.0% (56) having an active infection. Demographic characteristics of those with HCV antibodies included 70.6% male, 53.2% Caucasian, 33.9% Black, and 15.6% persons who inject drugs (PWID).

Conclusion

Our study findings suggest that a significant portion of patients in our community had missed opportunities for screening in our hospital. Our community had an estimated 5.9% prevalence, higher than the national and state averages. Caucasian men had higher prevalences. This study suggests the need for broader screening initiatives and more focused resource allocation, perhaps to safety net institutions, to decrease the burden of HCV.

CDC Recommendations for Hepatitis C Testing Among Perinatally Exposed Infants and Children - United States, 2023

The elimination of hepatitis C is a national priority (https://www.hhs.gov/sites/default/files/Viral-Hepatitis-National-Strategic-Plan-2021-2025.pdf). During 2010-2021, hepatitis C virus (HCV) acute and chronic infections (hereinafter referred to as HCV infections) increased in the United States, consequences of which include cirrhosis, liver cancer, and death. Rates of acute infections more than tripled among reproductive-aged persons during this time (from 0.8 to 2.5 per 100,000 population among persons aged 20-29 years and from 0.6 to 3.5 among persons aged 30-39 years). Because acute HCV infection can lead to chronic infection, this has resulted in increasing rates of HCV infections during pregnancy. Approximately 6%-7% of perinatally exposed (i.e., exposed during pregnancy or delivery) infants and children will acquire HCV infection. Curative direct-acting antiviral therapy is approved by the Food and Drug Administration for persons aged ≥3 years. However, many perinatally infected children are not tested or linked to care. In 2020, because of continued increases in HCV infections in the United States, CDC released universal screening recommendations for adults, which included recommendations for screening for pregnant persons during each pregnancy (Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC recommendations for hepatitis C screening among adults-United States, 2020. MMWR Recomm Rep 2020;69[No. RR-2]:1-17). This report introduces four new CDC recommendations: 1) HCV testing of all perinatally exposed infants with a nucleic acid test (NAT) for detection of HCV RNA at age 2-6 months; 2) consultation with a health care provider with expertise in pediatric hepatitis C management for all infants and children with detectable HCV RNA; 3) perinatally exposed infants and children with an undetectable HCV RNA result at or after age 2 months do not require further follow-up unless clinically warranted; and 4) a NAT for HCV RNA is recommended for perinatally exposed infants and children aged 7-17 months who previously have not been tested, and a hepatitis C virus antibody (anti-HCV) test followed by a reflex NAT for HCV RNA (when anti-HCV is reactive) is recommended for perinatally exposed children aged ≥18 months who previously have not been tested. Proper identification of perinatally infected children, referral to care, and curative treatment are critical to achieving the goal of hepatitis C elimination.

A Synopsis of Hepatitis C Virus Treatments and Future Perspectives

Hepatitis C virus (HCV) infection is a worldwide public health problem. Chronic infection with HCV can lead to liver cirrhosis or cancer. Although some immune-competent individuals can clear the virus, others develop chronic HCV disease due to viral mutations or an impaired immune response. IFNs type I and III and the signal transduction induced by them are essential for a proper antiviral effect. Research on the viral cycle and immune escape mechanisms has formed the basis of therapeutic strategies to achieve a sustained virological response (SVR). The first therapies were based on IFNα; then, IFNα plus ribavirin (IFN-RBV); and then, pegylated-IFNα-RBV (PEGIFNα-RIV) to improve cytokine pharmacokinetics. However, the maximum SVR was 60%, and several significant side effects were observed, decreasing patients' treatment adherence. The development of direct-acting antivirals (DAAs) significantly enhanced the SVR (>90%), and the compounds were able to inhibit HCV replication without significant side effects, even in paediatric populations. The management of coinfected HBV-HCV and HCV-HIV patients has also improved based on DAA and PEG-IFNα-RBV (HBV-HCV). CD4 cells are crucial for an effective antiviral response. The IFNλ3, IL28B, TNF-α, IL-10, TLR-3, and TLR-9 gene polymorphisms are involved in viral clearance, therapeutic responses, and hepatic pathologies. Future research should focus on searching for strategies to circumvent resistance-associated substitution (RAS) to DAAs, develop new therapeutic schemes for different medical conditions, including organ transplant, and develop vaccines for long-lasting cellular and humoral responses with cross-protection against different HCV genotypes. The goal is to minimise the probability of HCV infection, HCV chronicity and hepatic carcinoma.

Hepatitis C

Hepatitis C virus (HCV) is a hepatotropic RNA virus that can cause acute and chronic hepatitis, with progressive liver damage resulting in cirrhosis, decompensated liver disease, and hepatocellular carcinoma. In 2016, WHO called for the elimination of HCV infection as a public health threat by 2030. Despite some progress, an estimated 57 million people were living with HCV infection in 2020, and 300 000 HCV-related deaths occur per year. The development of direct-acting antiviral therapy has revolutionised clinical care and generated impetus for elimination, but simplified and broadened HCV screening, enhanced linkage to care, and higher coverage of treatment and primary prevention strategies are urgently required.

Viral Hepatitis in Pregnancy: ACOG Clinical Practice Guideline No. 6

PURPOSE

The purpose of this document is to describe the specific types of viral hepatitis, their implications during pregnancy, the risk of perinatal transmission, and issues related to both treatment and prevention of infection.

TARGET POPULATION

Pregnant or postpartum women and individuals who screen positive for viral hepatitis infection. The onset of these conditions may have predated the perinatal period or may have occurred for the first time in pregnancy or the first year postpartum.

METHODS

This guideline was developed using an a priori protocol in conjunction with a writing team consisting of one specialist in obstetrics and gynecology appointed by the ACOG Committee on Clinical Practice Guidelines-Obstetrics and one external subject matter expert. ACOG medical librarians completed a comprehensive literature search for primary literature within Cochrane Library, Cochrane Collaboration Registry of Controlled Trials, EMBASE, PubMed, and MEDLINE. Studies that moved forward to the full-text screening stage were assessed by two authors from the writing team based on standardized inclusion and exclusion criteria. Included studies underwent quality assessment, and a modified GRADE (Grading of Recommendations Assessment, Development, and Evaluation) evidence-to-decision framework was applied to interpret and translate the evidence into recommendation statements.

RECOMMENDATIONS

This Clinical Practice Guideline includes recommendations on hepatitis B virus and hepatitis C virus screening in pregnancy; prepregnancy, antepartum, intrapartum, and postpartum management for patients with hepatitis B virus infection or hepatitis C virus infection; management of accidental and occupational exposure to hepatitis B virus or hepatitis C virus in pregnant health care workers; and hepatitis A virus and hepatitis B virus vaccination in pregnancy. Recommendations are classified by strength and evidence quality. Ungraded Good Practice Points are included to provide guidance when a formal recommendation could not be made because of inadequate or nonexistent evidence.

Risk Factors for Perinatal Transmission of Hepatitis C Virus

OBJECTIVE

To estimate the rate of perinatal transmission of hepatitis C virus (HCV) infection, to identify risk factors for perinatal transmission of HCV infection, and to determine the viremic threshold for perinatal transmission.

METHODS

This was a prospective, multicenter, observational study of pregnant individuals at less than 24 weeks of gestation screened for HCV infection from 2012 to 2018 in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Maternal-Fetal Medicine Units Network. Individuals found to be HCV antibody-positive were followed throughout pregnancy. Children were followed for evidence of perinatal transmission at 2-6 months (HCV RNA testing) and at 18-24 months (HCV RNA and antibody testing) of life. The primary outcome was perinatal transmission, defined as positive test results at either follow-up time point.

RESULTS

A total of 109,379 individuals were screened for HCV infection. Of the 1,224 participants who screened positive, 772 (63.1%) enrolled and 432 of those 772 (56.0%) had data available to assess primary outcome. The overall rate of perinatal transmission was 6.0% (26/432, 95% CI 4.0-8.7%). All children with HCV infection were born to individuals with demonstrable viremia. In viremic participants (n=314), the perinatal transmission rate was 8.0% (95% CI 5.2-11.5%). Risk factors for perinatal transmission included HCV RNA greater than 106 international units/mL (adjusted odds ratio [aOR] 8.22, 95% CI 3.16-21.4) and vaginal bleeding reported at any time before delivery (aOR 3.26, 95% CI 1.32-8.03). A viremic threshold for perinatal transmission could not be established.

CONCLUSION

Perinatal transmission of HCV infection was limited to viremic individuals. High viral loads and antepartum bleeding were associated with perinatal transmission.

Hepatitis C Screening in Post-Baby Boomer Generation Americans: One Size Does Not Fit All

OBJECTIVES

To analyze the impact of access to routine health care, as estimated by health insurance coverage, on hepatitis C virus (HCV) infection prevalence in US adults born after 1965 (post-baby boomer birth cohort [post-BBBC]) and to use the data to formulate strategies to optimize population screening for HCV.

PATIENTS AND METHODS

Adult examinees in the National Health and Nutrition Examination Survey with available anti-HCV data were divided into era 1 (1999-2008) and era 2 (2009-2016). The prevalence of HCV infection, as defined by detectable serum HCV RNA, was determined in post-BBBC adults. In low prevalence groups, prescreening modalities were considered to increase the pretest probability.

RESULTS

Of 16,966 eligible post-BBBC examinees, 0.5% had HCV infection. In both eras, more than 50% had no insurance. In era 2, HCV prevalence was 0.26% and 0.83% in those with and without insurance, respectively (P<.01). As a prescreening test, low alanine aminotransferase level (<23 U/L in women and 32 U/L in men) would identify 54% of post-BBBC adults with an extremely low (0.02%) HCV prevalence. Based on these data, a tiered approach that tests all uninsured directly for HCV and prescreens the insured with alanine aminotransferase would reduce the number to test by 56.5 million while missing less than 1% infections.

CONCLUSION

For HCV elimination, passive "universal" screening in routine health care settings is insufficient, although the efficiency of screening may be improved with alanine aminotransferase prescreening. Importantly, for individuals with limited access to health care, proactive outreach programs for HCV screening are still needed.

Preexposure Prophylaxis to Prevent Acquisition of HIV: US Preventive Services Task Force Recommendation Statement

Importance

An estimated 1.2 million persons in the US currently have HIV, and more than 760 000 persons have died of complications related to HIV since the first cases were reported in 1981. Although treatable, HIV is not curable and has significant health consequences. Therefore, effective strategies to prevent HIV are an important public health and clinical priority.

Objective

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of preexposure prophylaxis with antiretroviral therapy for the prevention of HIV acquisition, and the diagnostic accuracy of risk assessment tools to identify persons at increased risk of HIV acquisition.

Population

Adolescents and adults who do not have HIV and are at increased risk of HIV.

Evidence Assessment

The USPSTF concludes with high certainty that there is a substantial net benefit from the use of effective antiretroviral therapy to reduce the risk of acquisition of HIV in persons at increased risk of acquiring HIV.

Recommendation

The USPSTF recommends that clinicians prescribe preexposure prophylaxis using effective antiretroviral therapy to persons at increased risk of HIV acquisition to decrease the risk of acquiring HIV. (A recommendation).

Expanding hepatitis C virus test uptake using self-testing among men who have sex with men in China: two parallel randomized controlled trials

BACKGROUND

HCV self-testing (HCVST) may be an effective strategy to address low rates of HCV test uptake among men who have sex with men (MSM). We evaluated the effectiveness and cost of providing HCVST to increase HCV test uptake among MSM in China.

METHODS

Two parallel, unmasked, individual-level randomized controlled trials were conducted. HIV-negative MSM and MSM living with HIV were enrolled from 22 cities in China. Men in both trials were randomly assigned (1:1) into standard-of-care (SOC) or HCVST arms. The primary outcome was the proportion of participants who tested for HCV during the trial period. Intervention effects were estimated using multiply imputed data in the main analysis. Costs were measured using a micro-costing approach.

RESULTS

A total of 84 men who were HIV-negative (trial 1) and 84 men living with HIV were enrolled (trial 2). Overall, the proportion of individuals who underwent HCV testing during the trial period was higher in the HCVST arm compared to SOC in trial 1 (estimated risk difference (RD): 71.1%, 95% CI: 54.6 to 87.7%) and trial 2 (estimated RD: 62.9%, 95% CI: 45.7 to 80.1%). Over half (58.6%, 34/58) of HCV self-testers reported the self-test was their first HCV test. The cost per person tested in trial 1 was $654.52 for SOC and $49.83 for HCVST, and in trial 2 was $438.67 for SOC and $53.33 for HCVST.

CONCLUSIONS

Compared to the standard of care, providing HCVST significantly increased the proportion of MSM testing for HCV in China, and was cheaper per person tested.

TRIAL REGISTRATION

Chinese Clinical Trial Registry.

REGISTRATION NUMBER

ChiCTR2100048379.

Hepatitis C screening in a community pharmacy setting: Patient perspective

BACKGROUND

Hepatitis C virus (HCV) is an infection of the liver, which contributes to over 15,000 deaths in the United States annually. When treated, HCV has a 90% or greater cure rate, however testing for HCV remains low.

OBJECTIVES

To assess patient perspectives on HCV screenings in the community pharmacy setting including awareness of screening, willingness to be screened, barriers to screening, and willingness to pay for HCV screening.

METHODS

This study used a cross-sectional survey design. The surveys were distributed by staff at an independent community pharmacy participating in an HCV screening initiative through the state department of public health. Eligible patients were born between 1945 and 1965. Descriptive statistics were calculated for survey variables. Open-ended responses were analyzed for additional context.

RESULTS

Fifty-seven surveys were returned and analyzed. The majority of the respondents were White (94%), female (56%), and had some college education (26%). Only 7% were aware that a finger-stick point-of-care test was available and 67% were unaware of the Centers for Disease Control and Prevention (CDC) recommendation for testing. The most frequently reported barrier or hesitation to screening was the patient not thinking they were at risk (29%) followed by uncertainty about cost (14%). Over half of respondents (63%) were either somewhat interested or very interested in testing in a community pharmacy, however, the majority (71%) were not willing to pay or only willing to pay less than $20.

CONCLUSIONS

Survey respondents were largely unaware of the recommendations and availability of finger-stick HCV screenings at community pharmacies but many were willing to be tested if low-cost. Providing patient education on the importance of HCV screenings and CDC recommendations may bolster interest in screening.

Impacts of the Egyptian national screening and treatment programme for viral hepatitis C: A cost-effectiveness model

BACKGROUND & AIMS

Egypt used to have one of the highest prevalences of HCV infection worldwide. The Egyptian Ministry of Health launched a national campaign for the detection and management of HCV to reduce its burden. This study aims to carry out a cost-effectiveness analysis to evaluate the costs and benefits of the Egyptian national screening and treatment programme.

METHODS

A disease burden and economic impact model was populated with the Egyptian national screening and treatment programme data to assess direct medical costs, health effects measured in disability-adjusted life years and the incremental cost-effectiveness ratio. The scenario was compared to a historical base case, which assumed that no programme had been conducted.

RESULTS

Total number of viremic cases is expected to decrease in 2030 by 86% under the national screening and treatment programme, versus by 41% under the historical base case. Annual discounted direct medical costs are expected to decrease from $178 million in 2018 to $81 million by 2030 under the historical base case, while annual direct medical costs are estimated to have peaked in 2019 at $312 million before declining to $55 million by 2030 under the national screening and treatment programme. Under the programme, annual disability-adjusted life years are expected to decline to 127 647 by 2030, leading to 883 333 cumulative disability-adjusted life years averted over 2018-2030.

CONCLUSIONS

The national screening and treatment programme is highly cost-effective by the year 2021, cost-saving by 2029 and expected to save about $35 million in direct costs and $4705 million in indirect costs by 2030.

Implementation of a Best Practice Advisory to Improve Infection Screening Prior to New Prescriptions of Biologics and Targeted Synthetic Drugs

OBJECTIVE

Use of biologic and targeted synthetic disease-modifying antirheumatic drugs (b/tsDMARDs) in patients with preexisting tuberculosis (TB), hepatitis B virus (HBV), or hepatitis C virus (HCV) infection can have serious consequences. Although various society guidelines recommend routine screening for these infections before initiating certain b/tsDMARDs, adherence to these recommendations varies widely. This quality improvement initiative evaluated local compliance with screening and assessed whether an automated computerized decision support system in the form of a best practice advisory (BPA) in the electronic health record could improve patient screening.

METHODS

Established patients with autoimmune rheumatic disease (ARD) aged 18 years or older with at least one visit to our rheumatology practice between October 1, 2017, and March 3, 2022, were included. When prescribing a new b/tsDMARD, clinicians were alerted via a BPA that showed the most recent results for TB, HBV, and HCV. Screening proportions for TB, HBV, and HCV before BPA initiation were compared with those of eligible patients after the BPA implementation.

RESULTS

A total of 711 patients pre-BPA and 257 patients post-BPA implementation were included in the study. The BPA implementation was associated with statistically significant improvement in screening for TB from 66% to 82% (P ≤ 0.001), HCV from 60% to 79% (P ≤ 0.001), hepatitis B core antibody 32% to 51% (P ≤ 0.001), and hepatitis B surface antigen from 51% to 70% (P ≤ 0.001).

CONCLUSION

Implementation of a BPA can improve infectious disease screening for patients with ARD who are started on b/tsDMARDs and has potential to improve patient safety.

Accessing hepatitis C direct acting antivirals among people living with hepatitis C: a qualitative study

BACKGROUND

Hepatitis C is curable with direct-acting antivirals (DAAs). However, treatment uptake remains low among marginalized populations such as people who inject drugs. We sought to understand challenges to treatment uptake with DAAs among people living with hepatitis C and compare treatment experiences between people who do and do not inject prescription and/or unregulated drugs.

METHODS

We conducted a qualitative study using focus groups with 23 adults aged 18 years and over who completed DAA treatment or were about to begin such treatment at the time of the study. Participants were recruited from hepatitis C treatment clinics across Toronto, Ontario. We drew upon stigma theory to interpret participants' accounts.

RESULTS

Following analysis and interpretation, we generated five theoretically-informed themes characterizing the experiences of individuals accessing DAAs: "being 'worthy' of the cure", "spatially enacted stigma", "countering social and structural vulnerability: the importance of peers", "identity disruption and contagion: attaining a 'social cure'" and "challenging stigma with population-based screening". Overall, our findings suggest that structural stigma generated and reproduced through healthcare encounters limits access to DAAs among people who inject drugs. Peer-based programs and population-based screening were proposed by participants as mechanisms for countering stigma within health care settings and 'normalizing' hepatitis C among the general population.

CONCLUSIONS

Despite the availability of curative therapies, access to such treatment for people who inject drugs is limited by stigma enacted in and structured within healthcare encounters. Developing novel, low-threshold delivery programs that remove power differentials and attend to the social and structural determinants of health and reinfection are needed to facilitate further scale up of DAAs and support the goal of eradicating hepatitis C as a public health threat.

The impact of immigration on hepatitis B burden in the United States: a modelling study

Background

The 2016 World Health Assembly endorsed the elimination of hepatitis B virus (HBV) infections by 2030. However, the HBV prevalence in Western countries, where the historical prevalence is low and highly impacted by immigration trends, remains uncertain making planning difficult. We aimed to develop a more accurate estimate of HBV prevalence and identify key immigrant populations that need to be screened, vaccinated, and treated to achieve the elimination targets.

Methods

US immigration data from 1900 forward and country-specific modeled prevalence by age and sex were used to estimate immigrated HBV infections entering the US, new infections in the US, mortality (all-cause and liver-related), and disease burden through 2030.

Findings

Using a dynamic Markov model, we estimated 1.8 million (95% uncertainty interval: 1.3-2.6 million) HBV infections in 2020 in all ages, higher than the NHANES national serosurvey. Infections between ages 30-74 accounted for 82% of all cases. Furthermore, HBV infections were concentrated among immigrants. New decompensated cirrhosis, hepatocellular carcinoma, and liver related deaths are expected to increase by 20%, 31% and 25% respectively from 2019 to 2030 at current diagnosis and treatment rate.

Interpretation

National serosurveys can underestimate total infections due to under-sampling in immigrant populations. To meet the WHO elimination targets, culturally appropriate screening and linkage to care programs in the immigrant populations are needed in the US. In their absence, there will be significant increases in the burden of HBV and the US will fail to meet the elimination targets by 2030.

Funding

This analysis was funded by a research grant from Gilead Sciences (IN-US-988-5786) and made possible by grants from John C Martin Foundation (2019-G024), ZeShan Foundation (2021-0101-1-CDA-HEP-10), and EndHep2030 who supported country analyses.

Hepatitis C Virus in Pregnancy: An Opportunity to Test and Treat

With the advent of safe and well-tolerated direct-acting antiviral (DAA) medications for hepatitis C virus (HCV), disease eradication is on the horizon. However, as the rate of HCV infection among women of childbearing potential continues to rise due to the ongoing opioid epidemic in the United States, perinatal transmission of HCV presents an increasingly difficult barrier. Without the ability to treat HCV during pregnancy, complete eradication is unlikely. In this review, we discuss the current epidemiology of HCV in the United States, the current management strategy for HCV in pregnancy, as well as the potential for future use of DAAs in pregnancy.

Development of a Patient Activation Toolkit for Hepatitis C Virus Testing

We evaluated the acceptability of a patient activation toolkit for hepatitis C virus (HCV) testing amidst universal adult guidelines. We developed a patient-facing toolkit that included a letter to the patient from their healthcare provider, HCV factsheet, and question prompt list, which contained questions for their provider about HCV infection and testing. We conducted qualitative interviews with patients ages 18-78 (n = 17), using a semi-structured interview guide based on learner verification. We assessed attraction, comprehension, cultural-linguistic acceptability, self-efficacy, and persuasiveness of toolkit materials using direct content analysis. Participants reported materials were attractive, offering suggestions to improve readability. They reported some understanding of materials but requested use of less medical jargon, particularly for the factsheet. Participants discussed cultural acceptability and suggested ways to improve language inclusiveness and comfort with content, given stigma surrounding HCV risk factors. Participants reported that including a letter, factsheet, and QPL improved the persuasiveness of materials, and they conveyed their motivation to be tested for HCV. Results indicate preliminary acceptability for use of the patient activation toolkit, which will be refined based on participants' recommendations. Overall, this patient activation toolkit holds promise for increasing HCV testing rates.

Hepatitis C Guidance 2023 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection

The Infectious Diseases Society of America and the American Association for the Study of Liver Diseases have collaboratively developed evidence-based guidance regarding the diagnosis, management, and treatment of hepatitis C virus (HCV) infection since 2013. A panel of clinicians and investigators with extensive infectious diseases or hepatology expertise specific to HCV infection periodically review evidence from the field and update existing recommendations or introduce new recommendations as evidence warrants. This update focuses on changes to the guidance since the previous 2020 published update, including ongoing emphasis on recommended universal screening; management recommendations for incomplete treatment adherence; expanded eligibility for simplified chronic HCV infection treatment in adults with minimal monitoring; updated treatment and retreatment recommendations for children as young as 3 years old; management and treatment recommendations in the transplantation setting; and screening, treatment, and management recommendations for unique and key populations.

Opportunities to address gaps in early detection and improve outcomes of liver cancer

Death rates from primary liver cancer (hepatocellular carcinoma [HCC]) have continued to rise in the United States over the recent decades despite the availability of an increasing range of treatment modalities, including new systemic therapies. Prognosis is strongly associated with tumor stage at diagnosis; however, most cases of HCC are diagnosed beyond an early stage. This lack of early detection has contributed to low survival rates. Professional society guidelines recommend semiannual ultrasound-based HCC screening for at-risk populations, yet HCC surveillance continues to be underused in clinical practice. On April 28, 2022, the Hepatitis B Foundation convened a workshop to discuss the most pressing challenges and barriers to early HCC detection and the need to better leverage existing and emerging tools and technologies that could improve HCC screening and early detection. In this commentary, we summarize technical, patient-level, provider-level, and system-level challenges and opportunities to improve processes and outcomes across the HCC screening continuum. We highlight promising approaches to HCC risk stratification and screening, including new biomarkers, advanced imaging incorporating artificial intelligence, and algorithms for risk stratification. Workshop participants emphasized that action to improve early detection and reduce HCC mortality is urgently needed, noting concern that many of the challenges we face today are the same or similar to those faced a decade ago and that HCC mortality rates have not meaningfully improved. Increasing the uptake of HCC screening was identified as a short-term priority while developing and validating better screening tests and risk-appropriate surveillance strategies.

A National Hepatitis C Elimination Program in the United States: A Historic Opportunity

This Viewpoint introduces a proposed 5-year program from the Biden-Harris administration that would use direct-acting antivirals to eliminate hepatitis C in the United States.

Development and Feasibility Testing of a Multilevel Intervention to Increase Hepatitis C Virus Screening Among Baby Boomers in Primary Care

Chronic infection with hepatitis C virus (HCV) results in an increased risk of cirrhosis and hepatocellular carcinoma (HCC). Only 15% of baby boomers (born 1945-1965) have ever been screened. We aimed to develop a multilevel intervention to increase HCV screening for baby boomers in a primary care setting. This study included two phases: intervention development (phase 1) and feasibility testing (phase 2). In phase 1, we partnered with a Community Advisory Board and a Provider Advisory Board to develop a multilevel intervention to increase HCV screening to be delivered to both providers and patients in primary care. Phase 2 assessed intervention feasibility, acceptability, and usability by conducting Concurrent Think Aloud (CTA) interviews and surveys using previously validated scales with patients (n = 8) and providers (n = 7). Phase 1 results: The patient-level intervention included a mailed reminder letter and CDC pamphlet and a 7-min in-clinic educational video. The provider-level intervention included a 30-min educational session and monthly performance feedback e-mails. Phase 2 results: Qualitatively, both the patient and provider-level intervention were feasible, acceptable, and usable by the target audiences. Quantitatively, on a 1-4 scale, the range of patient-level scores was 3.00-4.00 and provider level was 3.50-4.00 for feasibility, acceptability, and usability. This intervention could improve HCV screening among a high-risk population and therefore reduce HCV-related morbidity and mortality. This project developed a feasible, acceptable, and usable multilevel intervention aimed at increasing HCV screening in primary care.

HCV universal EHR prompt successfully increases screening, highlights potential disparities

BACKGROUND & OBJECTIVES

Screening for hepatitis C virus is the first critical decision point for preventing morbidity and mortality from HCV cirrhosis and hepatocellular carcinoma and will ultimately contribute to global elimination of a curable disease. This study aims to portray the changes over time in HCV screening rates and the screened population characteristics following the 2020 implementation of an electronic health record (EHR) alert for universal screening in the outpatient setting in a large healthcare system in the US mid-Atlantic region.

METHODS

Data was abstracted from the EHR on all outpatients from 1/1/2017 through 10/31/2021, including individual demographics and their HCV antibody (Ab) screening dates. For a limited period centered on the implementation of the HCV alert, mixed effects multivariable regression analyses were performed to compare the timeline and characteristics of those screened and un-screened. The final models included socio-demographic covariates of interest, time period (pre/post) and an interaction term between time period and sex. We also examined a model with time as a monthly variable to look at the potential impact of COVID-19 on screening for HCV.

RESULTS

Absolute number of screens and screening rate increased by 103% and 62%, respectively, after adopting the universal EHR alert. Patients with Medicaid were more likely to be screened than private insurance (ORadj 1.10, 95% CI: 1.05, 1.15), while those with Medicare were less likely (ORadj 0.62, 95% CI: 0.62, 0.65); and Black (ORadj 1.59, 95% CI: 1.53, 1.64) race more than White.

CONCLUSIONS

Implementation of universal EHR alerts could prove to be a critical next step in HCV elimination. Those with Medicare and Medicaid insurance were not screened proportionately to the national prevalence of HCV in these populations. Our findings support increased screening and re-testing efforts for those at high risk of HCV.

Estimating the lifetime risk of a false positive screening test result

False positive results in screening tests have potentially severe psychological, medical, and financial consequences for the recipient. However, there have been few efforts to quantify how the risk of a false positive accumulates over time. We seek to fill this gap by estimating the probability that an individual who adheres to the U.S. Preventive Services Task Force (USPSTF) screening guidelines will receive at least one false positive in a lifetime. To do so, we assembled a data set of 116 studies cited by the USPSTF that report the number of true positives, false negatives, true negatives, and false positives for the primary screening procedure for one of five cancers or six sexually transmitted diseases. We use these data to estimate the probability that an individual in one of 14 demographic subpopulations will receive at least one false positive for one of these eleven diseases in a lifetime. We specify a suitable statistical model to account for the hierarchical structure of the data, and we use the parametric bootstrap to quantify the uncertainty surrounding our estimates. The estimated probability of receiving at least one false positive in a lifetime is 85.5% (±0.9%) and 38.9% (±3.6%) for baseline groups of women and men, respectively. It is higher for subpopulations recommended to screen more frequently than the baseline, including more vulnerable groups such as pregnant women and men who have sex with men. Since screening technology is imperfect, false positives remain inevitable. The high lifetime risk of a false positive reveals the importance of educating patients about this phenomenon.

Quality Assurance for Hepatitis C Virus Point-of-Care Diagnostics in Sub-Saharan Africa

As part of a multinational study to evaluate the Bioline Hepatitis C virus (HCV) point-of-care (POC) testing in sub-Saharan Africa (SSA), this narrative review summarises regulatory standards and quality indicators for validating and approving HCV clinical diagnostics. In addition, this review also provides a summary of their diagnostic evaluations using the REASSURED criteria as the benchmark and its implications on the WHO HCV elimination goals 2030.

A Microsimulation Study of the Cost-Effectiveness of Hepatitis C Virus Screening Frequencies in Hemodialysis Centers

BACKGROUND

National guidelines recommend twice-yearly hepatitis C virus (HCV) screening for patients receiving in-center hemodialysis. However, studies examining the cost-effectiveness of HCV screening methods or frequencies are lacking.

METHODS

We populated an HCV screening, treatment, and disease microsimulation model with a cohort representative of the US in-center hemodialysis population. Clinical outcomes, costs, and cost-effectiveness of the Kidney Disease Improving Global Outcomes (KDIGO) 2018 guidelines-endorsed HCV screening frequency (every 6 months) were compared with less frequent periodic screening (yearly, every 2 years), screening only at hemodialysis initiation, and no screening. We estimated expected quality-adjusted life-years (QALYs) and incremental cost-effectiveness ratios (ICERs) between each screening strategy and the next less expensive alternative strategy, from a health care sector perspective, in 2019 US dollars. For each strategy, we modeled an HCV outbreak occurring in 1% of centers. In sensitivity analyses, we varied mortality, linkage to HCV cure, screening method (ribonucleic acid versus antibody testing), test sensitivity, HCV infection rates, and outbreak frequencies.

RESULTS

Screening only at hemodialysis initiation yielded HCV cure rates of 79%, with an ICER of $82,739 per QALY saved compared with no testing. Compared with screening at hemodialysis entry only, screening every 2 years increased cure rates to 88% and decreased liver-related deaths by 52%, with an ICER of $140,193. Screening every 6 months had an ICER of $934,757; in sensitivity analyses using a willingness-to-pay threshold of $150,000 per QALY gained, screening every 6 months was never cost-effective.

CONCLUSIONS

The KDIGO-recommended HCV screening interval (every 6 months) does not seem to be a cost-effective use of health care resources, suggesting that re-evaluation of less-frequent screening strategies should be considered.

Hepatitis C viral load and mother-to-child transmission: A systematic review and meta-analysis

BACKGROUND AND AIM

We aim to assess the association between maternal hepatitis C virus (HCV) viral load and human immunodeficiency virus (HIV) coinfection and the risk for mother-to-child transmission (MTCT) among pregnant women infected with HCV.

METHODS

A literature search of the Medline, Embase, Central, Science Citation Index Expanded (SCIE), Conference Proceedings Citation Index-Science (CPCIS), Scopus, Literature Latino-Americana e do Caribe em Ciências da Saúde (LILACS), and WHO Global Index Medicus databases, from inception to June 21, 2022, was performed. Studies that reported the incidence HCV-MTCT were included. Pooled effect estimates were calculated using the random-effects model, and Holm-Bonferroni correction was performed for multiple pooled associations.

RESULTS

The present meta-analysis included 26 studies involving 4934 newborns with maternal HCV infection. Pregnant women with HCV viremia exhibited increased risk for MTCT (odds ratio [OR] 8.25 [95% confidence interval (CI) 4.65-14.63]) compared with those negative for HCV-RNA. Multiple subgroup analysis revealed that the HCV viremia/HIV-positive group demonstrated the highest risk for HCV MTCT, followed by the HCV viremia mono-infected group, while HCV-RNA-negative women demonstrated the lowest risk for HCV MTCT. Among females with HCV viremia, elevated risk for MTCT was found among subjects with a viral load ≥ 6 log₁₀ copies/mL compared with those with viral load < 6 log₁₀ copies/mL (OR 4.58 [95% CI: 2.52-8.34]).

CONCLUSION

The incidence of HCV MTCT was increased among pregnant women with detectable HCV viremia and was even higher in those with a viral load ≥ 6 log₁₀ copies/mL. HIV coinfection further increased the risk for HCV MTCT.