What is the recommended screening and treatment approach for individuals at high risk of Hepatitis C (HCV) infection?

Hepatitis C Screening and Treatment for High-Risk Individuals

All adults aged 18-79 years should be screened for Hepatitis C virus (HCV) infection at least once in their lifetime, with more frequent screening for those with ongoing risk factors. 1

Screening Recommendations

Who to Screen

• Universal screening: All adults aged 18-79 years should receive one-time screening 1
• High-risk individuals who should receive more frequent screening:
  • Persons who have ever injected illicit drugs
  • Persons who received blood/blood products transfusions or organ transplants prior to 1992
  • Persons who have ever been on hemodialysis
  • Persons with HIV infection
  • Persons with hemophilia
  • Persons with current sexual contact with HCV-infected individuals
  • Children born to mothers infected with HCV
  • Healthcare providers after needle stick injury or mucosal exposure to HCV-positive blood 1
  • Pregnant women during each pregnancy 2

Screening Tests

1. Initial screening: Anti-HCV antibody testing 3
2. Confirmatory testing: If antibody test is positive, perform HCV RNA polymerase chain reaction (PCR) testing to confirm active infection 3

Screening Frequency

• One-time screening for general adult population
• Periodic screening for persons with continued risk factors (e.g., ongoing injection drug use) 1

Post-Screening Evaluation

For patients with confirmed HCV infection:

1. Initial assessment:

   • Complete blood count
   • Liver function tests (AST/ALT, alkaline phosphatase, bilirubin, albumin)
   • Prothrombin time
   • Creatinine
   • HCV genotype testing 3

2. Assessment of liver disease severity:

   • Noninvasive testing or liver biopsy to determine fibrosis stage 3
   • Abdominal ultrasound to assess for cirrhosis and screen for hepatocellular carcinoma in those with advanced fibrosis 3

Treatment Approach

Treatment Candidates

• All patients with chronic HCV infection should be considered for treatment, with priority given to those with:
  • Advanced fibrosis (stage ≥2)
  • Cirrhosis
  • Significant extrahepatic manifestations 1

Treatment Regimen

• Direct-acting antiviral (DAA) therapy is the standard of care
• Treatment selection based on:
  • HCV genotype
  • Presence/absence of cirrhosis
  • Prior treatment history
  • Comorbidities 3
• Typical treatment duration: 8-12 weeks 1

Treatment Goal

• Achieve sustained virological response (SVR), defined as undetectable HCV RNA 12 weeks after completion of therapy 3

Management of Chronic HCV Infection

1. Lifestyle modifications:

   • Abstain from alcohol or drink in moderation
   • Maintain suitable body weight through physical exercise and dietary control 1

2. Vaccinations:

   • Vaccinate against hepatitis A and B if not immune 1, 3

3. Monitoring:

   • Continuous surveillance for development of cirrhosis and hepatocellular carcinoma 1
   • For patients with cirrhosis: ultrasound surveillance every 6 months 3

Clinical Considerations and Pitfalls

Important Caveats

• Screening is voluntary and should be undertaken only with patient knowledge and consent 1
• False positives can occur with antibody testing, especially in low-prevalence populations, necessitating confirmatory RNA testing 1
• Comorbidities such as alcohol misuse, HIV infection, or other liver diseases accelerate disease progression 1
• HBV reactivation can occur during HCV treatment, so test for HBV before initiating therapy 3

Common Pitfalls to Avoid

1. Missing high-risk individuals who need more frequent screening
2. Failing to provide confirmatory testing after positive antibody results
3. Overlooking comorbidities that affect treatment decisions
4. Not assessing liver disease severity before treatment
5. Neglecting post-SVR monitoring in patients with cirrhosis

Outcomes and Benefits

Early detection and treatment of HCV infection significantly reduces:

• Progression to cirrhosis
• Development of hepatocellular carcinoma
• Overall mortality 1

The mortality rate is significantly higher in patients who do not achieve SVR (HR, 0.066; 95% CI, 0.001-0.484), highlighting the importance of effective treatment 1.