Hepatitis C Virus Screening Recommendations

Universal one-time, opt-out HCV screening is recommended for all adults aged 18 years and older, regardless of risk factors. 1, 2, 3

Universal Screening Approach

The American Association for the Study of Liver Diseases (AASLD) and Infectious Diseases Society of America (IDSA) recommend one-time, routine, opt-out HCV screening for all individuals aged 18 years or older 1
The U.S. Preventive Services Task Force (USPSTF) recommends universal screening for all adults aged 18-79 years 1
The AASLD-IDSA guidance does not recommend an upper age limit for universal adult HCV screening due to excellent quality of life in many older adults and the association between advanced age and more rapid HCV disease progression 1
Universal screening aligns with the World Health Organization and National Academies of Sciences, Engineering, and Medicine goals of eliminating HCV as a public health threat by 2030 1
Universal screening bypasses barriers in obtaining accurate risk factor assessments 1, 4

One-time HCV testing should be performed for all persons younger than 18 years with behaviors, exposures, or conditions associated with increased risk of HCV infection 1
Periodic repeat HCV testing should be offered to all persons with ongoing risk behaviors or exposures 1, 4
Annual HCV testing is specifically recommended for:
- People who inject drugs 1, 4
- Men with HIV infection who have unprotected sex with men 1, 4
Clinicians may consider screening pregnant persons younger than 18 years due to increasing prevalence of HCV in women of childbearing age 1

HCV-antibody testing with reflex HCV RNA polymerase chain reaction testing is recommended for initial HCV screening 1, 2
For persons with negative HCV-antibody test who were exposed to HCV within the prior 6 months, HCV-RNA testing or follow-up HCV-antibody testing 6 months or longer after exposure is recommended 1, 2
For immunocompromised persons with negative antibody tests, HCV-RNA testing should be considered as antibody production may be delayed or inadequate 1, 2
For persons at risk for reinfection after previous viral clearance, HCV-RNA testing is recommended because a positive HCV-antibody test is expected 1, 2

A positive antibody test with positive RNA indicates current (active) HCV infection requiring evaluation for treatment 2
A positive antibody test with negative RNA suggests past resolved infection or false positive 1, 2
Persons found to have a positive HCV-antibody test and negative results for HCV RNA should be informed that they do not have evidence of current infection but are not protected from reinfection 1, 2

Relying solely on risk-based screening misses many cases of HCV infection due to clinician and patient barriers 1, 5
Failing to order reflex HCV RNA testing with antibody testing requires a return visit for confirmation, which may lead to loss to follow-up 2
Misinterpreting a positive HCV antibody with negative RNA as active infection, when it indicates resolved infection or false positive 2
In populations with low prevalence of HCV infection (e.g., 2%), approximately 59% of all positive tests using the third-generation EIA test would be false positive, highlighting the importance of confirmatory testing 1
Overlooking the need for HCV RNA testing in immunocompromised persons who may have false negative antibody tests 2

Early identification allows for timely treatment with direct-acting antiviral regimens that can achieve virologic cure in most persons within 8-12 weeks 3
Screening leads to appropriate evaluation and treatment of individuals chronically infected with HCV, preventing progression to cirrhosis, hepatocellular carcinoma, and associated morbidity and mortality 6
Identified individuals can be counseled to avoid alcohol consumption and receive hepatitis A and B vaccinations if appropriate 7, 8
Early detection enables education of family members about risk factors, increasing overall public awareness and improving prevention efforts 8