What are the current hepatitis C screening recommendations for adults and pregnant women, including high‑risk groups?

Current Hepatitis C Screening Recommendations

All adults aged 18-79 years should receive universal, one-time hepatitis C screening, and all pregnant women should be screened during each pregnancy. 1

Universal Adult Screening

• Screen all adults aged 18-79 years once in their lifetime using anti-HCV antibody testing followed by confirmatory PCR testing for HCV RNA. 1

• The USPSTF issued this Grade B recommendation in 2020, expanding from the previous birth cohort (1945-1965) approach to universal screening due to the near-quadrupling of HCV incidence from 2010-2017, driven primarily by the opioid epidemic and injection drug use. 1

• The AASLD-IDSA guidelines recommend universal screening for all adults aged 18 years and older without an upper age limit, citing excellent quality of life in many octogenarians and more rapid HCV disease progression with advanced age. 1, 2

• This represents a critical shift because risk-based screening failed to identify the majority of infected individuals due to clinician and patient barriers, with most new infections now occurring in persons aged 20-39 years born after 1965. 1, 2

Pregnant Women Screening

• Screen all pregnant women during each pregnancy, regardless of age or risk factors. 1, 2, 3

• HCV prevalence doubled in women aged 15-44 years from 2006-2014, with 0.73% of pregnant women testing positive and a 68% increase in infants born to HCV-infected mothers. 1

• Approximately 1,700 infected infants are born annually to 29,000 infected mothers, making pregnancy a crucial screening opportunity. 1

• Consider screening pregnant persons younger than 18 years given the increasing prevalence in this age group. 1

High-Risk Groups Requiring Periodic Screening

Persons with ongoing risk factors should receive periodic screening, though optimal intervals remain undefined by evidence. 1, 2

Specific high-risk populations requiring periodic testing:

• People who inject drugs (current or past): This is the most important risk factor, with one-third of persons aged 18-30 who inject drugs infected and 70-90% of older persons who inject drugs infected. 1, 2

• Annual testing is specifically recommended for people who inject drugs and men with HIV who have unprotected sex with men. 2

• Persons younger than 18 years or older than 79 years with high-risk factors (particularly injection drug use history) should be considered for screening. 1, 2

Screening Implementation

Testing methodology:

• Use anti-HCV antibody testing with reflex HCV RNA PCR testing as the initial screening approach. 2

• Reflex testing requires only a single blood collection, eliminating the need for return visits and addressing a major barrier in the HCV care continuum. 2

• For recent exposure (within 6 months), perform HCV RNA testing or follow-up antibody testing ≥6 months after exposure if initial antibody test is negative. 2

Patient communication requirements:

• Screening must be voluntary and undertaken only with the patient's knowledge, using an opt-out approach. 1, 2, 4

• Inform patients about HCV infection transmission routes, the meaning of positive and negative results, and treatment benefits and harms before screening. 1, 2, 4

• Provide patients the opportunity to ask questions and decline screening. 1

Rationale for Universal Screening

The evidence supporting universal screening is compelling:

• Direct-acting antiviral regimens achieve sustained virologic response (cure) in >95% of adults with 8-12 weeks of oral therapy. 1, 4

• SVR is consistently associated with decreased risk of all-cause mortality, liver disease mortality, cirrhosis, and hepatocellular carcinoma. 1, 4

• Universal screening is cost-effective at <$30,000 per quality-adjusted life year compared to birth-cohort screening. 1, 2

• Many infected persons are unaware of their condition, and most new infections now occur outside the previously targeted 1945-1965 birth cohort. 1, 4

Critical Pitfalls to Avoid

• Do not rely solely on antibody testing without confirmatory RNA testing, as this misses the distinction between active and resolved infection. 2

• Do not fail to implement reflex RNA testing, as requiring separate visits leads to patients being lost to follow-up between antibody and confirmatory testing. 2

• Do not use only antibody testing in previously infected patients, as antibodies remain positive after clearance and will miss reinfection—use HCV RNA testing instead. 2

• Do not overlook immunocompromised patients, who may require direct HCV RNA testing due to delayed or inadequate antibody production. 2