Supporting Universal HCV Screening Over Risk-Based Testing

Eyasu Teshale, MD

Credit: Eyasu Teshale on LinkedIn

This article first appeared on our sister site, HCPLive.

Testing for hepatitis C virus (HCV) has been an ongoing public health discussion about who should be tested, especially for a disease that has been referred to as the “silent killer,” which can, in many cases, not demonstrate symptomatic disease, so many people may not be aware they have it.

Findings from a recent study are calling attention to a notable HCV burden among people without traditional risk factors like injection drug use, supporting the concept of universal HCV testing rather than risk-based screening.¹

Leveraging 2013-March 2020 National Health and Nutrition Examination Survey (NHANES) data, the study estimated that 1.4 million people 12-59 years of age have current HCV infection, with more than 500,000 people in this population reporting no history of injection drug use. Of note, disparities were observed among people born between 1954-1965 and people with lower educational attainment, emphasizing the need for equitable access to HCV testing, treatment, and preventive services among disproportionately impacted populations and beyond those with traditionally recognized risk factors like injection drug use.¹

According to the World Health Organization, globally, an estimated 50 million people have chronic HCV infection, with about 1 million new infections occurring each year. Most infections occur through exposure to blood from unsafe injection practices, unsafe health care, unscreened blood transfusions, injection drug use, and sexual practices leading to exposure to blood. Early diagnosis can prevent health problems that may result from infection and prevent transmission of the virus, but risk-based testing may miss vulnerable patient populations who do not meet high-risk criteria or do not report their high-risk behaviors.²

“While steady declines in the national HCV-associated mortality rate were observed in more recent years, disparities have existed differentially across certain sociodemographic groups, with rates consistently at least two times the national average,” Eyasu Teshale, MD, a team lead for the epidemiology and research team in the division of viral hepatitis at the Centers for Disease Control and Prevention, and colleagues wrote.¹

To examine HCV prevalence and disparities among US residents with no injection drug use history, investigators analyzed NHANES data from January 2013 to March 2020. This study period was chosen because of a change in the hepatitis C laboratory testing sequence in 2013 to include the detection of HCV ribonucleic acid (RNA) to identify people with current HCV infection due to the availability of curative treatment and because of the early suspension of NHANES data collection field operations in March 2020 due to the COVID-19 pandemic.¹

The primary outcomes were laboratory evidence of HCV infection and self-reported drug use history. A current HCV infection was defined as having detectable HCV RNA in a blood specimen drawn during the examination, while cleared HCV infection was defined as having no detectable HCV RNA and a reactive Inno-Lia test result to confirm the presence of anti-HCV. Additionally, participants who reported ever having used a needle to inject drugs not prescribed by a doctor were categorized as having an injection drug use history.¹

Of note, the study population was limited to individuals aged 12–59 years because investigators pointed out the drug use questions were consistently available for this group during the study period.¹

Investigators stratified HCV infection prevalence estimates by self-reported sociodemographic characteristics, including age group, gender, year of birth, race and ethnicity, education level, and health insurance status. Citing the intersectionality of infection risks, investigators examined laboratory-based hepatitis A and hepatitis B status.¹

In total, 15,899 people aged 12-59 years had sufficient laboratory testing information to determine HCV infection status and were thus used to calculate HCV infection prevalence estimates. Of these, 14,542 people had information on both HCV infection and drug use status and constituted the group used to calculate HCV infection prevalence among those with information on drug use status. Among 188 people who tested positive for HCV RNA or confirmatory anti-HCV test, 106 were HCV RNA-positive and 82 were HCV RNA-negative.¹

Among the study cohort, 1.5% (95% CI, 1.1%–1.9%) of participants had past or present HCV infection. This figure was greatest among those with injection drug use history (40.1%; 95% CI, 29.8%–51.0%), followed by those with no history of injection drug use (1.7%; 95% CI, 1.0%–2.7%) and those with no history of drug use (.4%; 95% CI, .2%–.7%).¹

The prevalence of current HCV infection was .7% (95% CI, .5%–.9%) overall. Again, this figure was greatest among those with injection drug use history (17.2%; 95% CI, 11.4%–24.4%), followed by those with no history of injection drug use (.9%; 95% CI, .4%–1.7%) and those with no history of drug use (.2%; 95% CI, .1%–.4%). These rates represented 1.4 (95% CI, 1.0–1.8) million people with current HCV infection overall and specifically 262,000 (95% CI, 116,000–495,000) people with no history of injection drug use and 309,000 (95% CI, 154,000–617,000) people with no history of drug use, compared to 730,000 (95% CI, 484,000–1.0 million) with an injection drug use history.¹

Among people aged 12–59 years without a history of injection drug use, groups that had a higher prevalence of past or present HCV infection included people born between 1954-1965 compared to those born after 1965 (Prevalence ratio [PR], 5.3; 95% CI, 2.2–12.9) and people who completed high school or less compared to those who completed at least some college (PR, 2.9; 95% CI, 1.2–7.2). Investigators also pointed out a greater past or present HCV infection among people with past or present hepatitis B compared to those vaccinated for hepatitis B.¹

They acknowledged multiple limitations to these findings, including the potential for social desirability, non-response, and recall bias related to self-reported drug use; the lack of generalizability to all people with HCV infection; the lack of data for people older than 59 years of age; and the inability to explore socio-determinants of health factors that are community-based and could have contributed to disparities in HCV infection.¹

“This study supports universal HCV screening as a strategy that will help close the gap in identifying individuals who do not disclose risk factors. Utilizing quality surveillance and supplementary data sources can more effectively guide and monitor the progress of outreach efforts,” investigators concluded.¹ “To address disparities, efforts at the federal, state, and local should focus on tailored approaches to improve equitable access to HCV testing, treatment, and preventive services among disproportionately impacted populations.”

References

1. Ly KN, Barker LK, Kilmer G, et al. Disparities in hepatitis C among people aged 12–59 with no history of injection drug use, United States, January 2013–March 2020. Liver International. https://doi.org/10.1111/liv.16108

2. World Health Organization. Hepatitis C. Newsroom. April 9, 2024. Accessed October 7, 2024. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c