What is the recommended frequency of hepatitis B and hepatitis C screening for adults, including universal screening, baby‑boomer cohort, high‑risk groups, and pregnant women?

Hepatitis C Screening Frequency

All adults aged 18 years and older should receive one-time universal hepatitis C screening, with pregnant individuals screened during each pregnancy, and those with ongoing risk factors—particularly people who inject drugs and HIV-positive men who have sex with men—screened at least annually. 1

Universal One-Time Screening

One-time, routine, opt-out HCV screening is recommended for all adults aged 18 years or older without an upper age limit. 1 This represents a major shift from previous birth-cohort (1945-1965) and risk-based strategies that failed to identify the majority of infected individuals. 2

• The AASLD-IDSA guidelines recommend no upper age limit, citing excellent quality of life in many octogenarians and the association between advanced age and more rapid HCV disease progression. 1
• The USPSTF recommends screening adults aged 18-79 years, though this differs slightly from AASLD-IDSA guidance. 2
• This universal approach is cost-effective at less than $30,000 per quality-adjusted life year compared to birth-cohort screening alone. 1, 2

The rationale for universal screening stems from the near-quadrupling of HCV incidence from 2010 to 2017, driven primarily by the opioid epidemic and injection drug use. 1 Most new infections now occur in persons aged 20-39 years born after 1965, outside the traditional birth cohort. 1, 2

Pregnancy Screening

All pregnant individuals should be screened during each pregnancy, regardless of age or risk factors. 2 This recommendation reflects:

• HCV prevalence among women aged 15-44 years doubled between 2006-2014. 2
• Approximately 0.7% of pregnant persons test positive, with a 68% rise in infants born to HCV-infected mothers. 2
• Annually, about 1,700 infants are born with HCV infection from an estimated 29,000 infected mothers. 2

Periodic Screening for High-Risk Groups

Annual HCV testing is specifically recommended for people who inject drugs and men with HIV infection who have unprotected sex with men. 1 These populations warrant more frequent screening due to:

• Approximately 33% of people who inject drugs aged 18-30 years are infected, rising to 70-90% in older injectors. 2
• High incidence and prevalence rates in these populations justify at least annual testing. 1

For other individuals with ongoing risk factors, periodic repeat HCV testing should be offered, with frequency determined by individual risk assessment. 1 While optimal intervals are not precisely defined for all risk groups, testing should continue as long as risk behaviors persist. 1

Risk factors warranting periodic screening include: 3

• Injection drug use (current or former)
• Intranasal illicit drug use
• Men who have sex with men
• Multiple sexual partners or history of sexually transmitted infections
• Long-term hemodialysis
• Percutaneous or parenteral exposures in unregulated settings
• Healthcare workers after needlestick or mucosal exposure to infected blood

Pediatric Screening

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 There is currently insufficient evidence to support universal HCV screening in the pediatric population. 1

Screening Implementation

Screening should use HCV-antibody testing with reflex HCV RNA polymerase chain reaction testing as the initial approach. 2 This reflex testing strategy:

• Requires only a single blood collection, eliminating the need for return visits. 2
• Addresses a major barrier in the HCV care continuum where patients are lost to follow-up between antibody and confirmatory testing. 2

Screening must be voluntary and conducted using an opt-out approach, where patients are informed orally or in writing that HCV testing will be performed unless they decline. 2, 4 Before screening, patients should receive an explanation of HCV infection, transmission routes, the meaning of test results, and the benefits and harms of treatment. 2, 4

Special Testing Considerations

For individuals with recent exposure (within 6 months), HCV RNA testing or follow-up HCV-antibody testing ≥6 months after exposure is recommended for those with negative antibody tests. 2 Antibodies may be negative during the first 6 weeks after exposure. 3

For immunocompromised patients, direct HCV RNA testing should be considered, as antibody production may be delayed or inadequate. 2, 3

For patients at risk for reinfection (those with prior clearance), HCV RNA testing is recommended since antibody tests will remain positive after prior clearance. 2, 3

Clinical Rationale

The recommendation for universal and periodic screening is supported by:

• Direct-acting antiviral regimens achieve sustained virologic response (cure) in >95% of adults after 8-12 weeks of oral therapy. 2, 4
• Achieving sustained virologic response is consistently linked to lower all-cause mortality, reduced liver-disease mortality, and decreased incidence of cirrhosis and hepatocellular carcinoma. 2, 4
• Many people with chronic HCV infection are unaware of their condition. 4

Common Pitfalls

Avoid relying solely on antibody testing without reflex RNA confirmation, which can miss active infection or incorrectly classify resolved infections as current. 2, 3

Do not fail to implement reflex RNA testing, as this leads to patients being lost to follow-up between antibody and confirmatory testing. 2, 3

Do not overlook reinfection by using only antibody testing in previously infected patients, as this will miss new infections. 2, 3

Do not miss the diagnosis in high-risk groups, especially people who inject drugs or immunocompromised patients, as this has significant consequences. 2

---

Hepatitis B Screening Frequency

Universal screening for hepatitis B is recommended for all adults aged 18 years and older by testing for HBV surface antigen, hepatitis B surface antibody, and total hepatitis B core antibody. 3 This represents a one-time screening recommendation for the general adult population, with periodic screening for those with ongoing risk factors similar to hepatitis C. 3