What are the guidelines for screening and treatment of hepatitis C?

Hepatitis C Screening Guidelines

Universal Screening Recommendation

All adults aged 18 years and older should receive one-time, routine, opt-out hepatitis C screening, regardless of risk factors or age. 1, 2 This represents a shift from previous birth cohort-based screening (1945-1965) to universal screening, driven by the near-quadrupling of HCV incidence from 2010 to 2017, primarily among younger adults aged 20-39 years due to the opioid epidemic and injection drug use. 1

Key Points on Universal Screening:

• No upper age limit is recommended by AASLD-IDSA, despite USPSTF recommending screening only through age 79 years. 1, 2 The rationale for no age cap is that many octogenarians have excellent quality of life and advanced age is associated with more rapid HCV disease progression. 1
• All pregnant women should be screened during each pregnancy, as HCV prevalence has doubled in women aged 15-44 years from 2006 to 2014. 2
• Universal screening is cost-effective (<$30,000/quality-adjusted life years) compared with targeted approaches. 1

Screening Test Methodology

Use HCV antibody testing with reflex HCV RNA PCR testing as the initial screening approach. 2 This two-step reflex testing strategy requires only a single blood draw and automatically proceeds to RNA confirmation if antibody-positive, eliminating the need for return visits and addressing a major barrier in the HCV care continuum. 2

Test Interpretation:

• Positive antibody + positive RNA = current active infection requiring treatment evaluation 2
• Positive antibody + negative RNA = past resolved infection or false positive; patient does not have current infection but is not protected from reinfection 2
• Negative antibody = no evidence of current or past infection (unless recent exposure or immunocompromised) 2

Risk-Based and Periodic Screening

High-Risk Groups Requiring Periodic Testing:

• Annual testing is specifically recommended for:

  • People who inject drugs 1, 2
  • HIV-positive men who have unprotected sex with men 1, 3

• Periodic testing (frequency based on individual risk assessment) for those with ongoing risk factors including: 1, 2

  • Injection drug use history
  • Intranasal illicit drug use
  • Men who have sex with men
  • Multiple sexual partners or history of sexually transmitted infections
  • Long-term hemodialysis
  • Healthcare workers after needlestick exposure

Pediatric Screening:

• One-time screening for persons younger than 18 years with risk factors, particularly injection drug use history 1
• There is insufficient evidence to support universal screening in the pediatric population 1

Special Testing Considerations

Recent Exposure:

For individuals with recent exposure (within 6 months), HCV RNA testing or follow-up HCV antibody testing ≥6 months after exposure is required if initial antibody test is negative, as antibody production may be delayed. 2, 3

Immunocompromised Patients:

Consider direct HCV RNA testing for immunocompromised patients, as antibody production may be delayed or inadequate. 2

Previously Infected Patients:

Use HCV RNA testing (not antibody testing) for patients at risk for reinfection, since antibody tests will remain positive after prior clearance. 2, 4

Difficult-to-Access Populations:

Dried blood spot collection can be used for sequential antibody and reflex RNA testing in rural or difficult-to-access populations, requiring only a fingerstick rather than venipuncture. 2

Implementation Approach

Screening should be voluntary using an opt-out approach where patients are informed orally or in writing that HCV testing will be performed unless they decline. 2 Before screening, patients should receive an explanation of HCV infection, transmission routes, meaning of test results, and benefits/harms of treatment. 2

Critical Testing Before Treatment Initiation

Test all patients for hepatitis B virus (HBV) infection by measuring HBsAg and anti-HBc before initiating HCV treatment, as HBV reactivation has been reported during HCV treatment, sometimes resulting in fulminant hepatitis, hepatic failure, and death. 5, 6

Common Pitfalls to Avoid

• Relying solely on antibody testing without reflex RNA testing will miss the distinction between active and resolved infections, requiring patients to return for confirmatory testing and increasing loss to follow-up. 2, 4
• Missing the window period: Both HCV antibody and RNA testing are needed for suspected acute infection, as antibodies may be negative during the first 6 weeks after exposure. 4
• Using antibody testing for reinfection monitoring in previously infected patients will miss reinfection since antibodies remain positive after clearance. 2, 4
• Failing to screen immunocompromised patients with RNA testing may yield false negative antibody results. 2, 4
• Not implementing annual screening for people who inject drugs and HIV-positive MSM, despite clear guideline recommendations. 1