Based on an updated evidence report and systematic review1, the United States Preventive Services Task Force (USPSTF) now recommends screening for hepatitis C virus (HCV) infection in all asymptomatic adults, including pregnant persons, and those aged 18 to 79 years without known liver disease.2 The updated evidence report and recommendation statement were both published in JAMA.
The USPSTF has replaced its 2013 recommendation and broadened the age for HCV screening to account for the increased prevalence of HCV infection in younger persons (aged 20 to 39 years), which is likely driven by the opioid epidemic. The screening should occur once for the majority of adults. Persons with continued risk for HCV infection, such as people who inject illicit drugs, should be screened periodically, but additional information is needed to determine regarding how often to screen persons at increased risk.
In addition, “research is needed to identify labor management practices (eg, prolonged rupture of membranes or use of internal fetal monitoring) and treatment of HCV infection prior to pregnancy to reduce the risk of mother-to-child transmission,” noted the USPSTF.2 The task force also stated that clinicians should consider screening adolescents aged <18 years with past or current injection drug use.
This grade B recommendation is nearly identical to those of the American Association for the Study of Liver Diseases and Infectious Diseases Society of America, including a draft screening guideline by the Centers for Disease Control and Prevention.
In regards to treatment, the USPSTF focused on the currently recommended direct-acting antiviral (DAA) regimens; recommendations were, however, expanded to include adolescents, because “in the last 3 years, the HCV regimens commonly used in adults were also approved for use in adolescents 12 years and older,” stated Camilla S Graham, MD, MPH, from the division of infectious disease, Beth Israel Deaconess Medical Center at Harvard Medical School, in Boston, Massachusetts and Stacey Trooskin, MD, PhD, from the Perelman School of Medicine at the University of Pennsylvania in Philadelphia, in an editorial commentary.3 The update included 83 new studies and 9 were carried forward from the previous USPSTF review.1
Findings showed that DAA regimens were associated with sustained virologic response rates >95% and fewer harms compared with older interferon-based therapies. Similarly, the sustained virologic response rate ranged from 97% to 100% across all intervention studies of DAA in adolescents.
The USPSTF review evaluated the link between demonstrating sustained virologic response after antiviral therapy vs nonresponse. After adjusting for potential confounders, sustained response was associated with significantly decreased risk for all-cause mortality (13 studies; n=36,986; pooled hazard ratio [HR], 0.40; 95% CI, 0.28-0.56). Sustained virologic response was also associated with decreased risk for hepatocellular carcinoma (20 studies; n=84,491; pooled HR, 0.29; 95% CI, 0.23-0.38), liver-related mortality (4 studies; n=5953; pooled HR, 0.11; 95%CI, 0.04-0.27), and cirrhosis (4 cohorts reported in 3 studies; n=16,735; pooled HR, 0.36; 95% CI, 0.33-0.40).
Although the updated USPSTF screening recommendation are necessary, it is not sufficient for further progress, noted Jennifer C Price, MD, PhD, and Danielle Brandman, MD, from the division of gastroenterology, department of medicine, at the School of Medicine at the University of California, San Francisco in an editorial commentary.4 This was echoed in another editorial commentary published by the JAMA Network Open.5 The United States is not on track to achieve the World Health Organization’s goal of eliminating viral hepatitis as a major public health threat by 2030.3,4
“Implementation of HCV screening and linkage to treatment requires large-scale coordinated efforts, innovation, and resources,” highlighted Drs. Price and Brandman.4 Simplifying treatment regimens, localizing treatment in settings more easily accessible to marginalized populations, such as syringe service programs and opioid substitution programs, as well as increasing treatment capacity can bridge the gap between diagnosis and treatment. A coordinated and funded effort will be needed to control HCV infection in the United States. “There should be expanded access to clinicians, including primary care physicians, who can treat patients with HCV, as well as continued attention to preventing transmission through programs that offer patient education and harm reduction,” added Drs. Price and Brandman.
1. Chou R, Dana T, Fu R, et al. Screening for hepatitis C virus infection in adolescents and adults: updated evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2020;323(10):976-992.
2. US Preventive Services Task Force. Screening for hepatitis C virus infection in adolescents and adults: US Preventive Services Task Force recommendation statement. JAMA. 2020;323(10):970-975.
3. Graham CS, Trooskin S. Universal screening for hepatitis C virus infection: a step toward elimination. JAMA. 2020;323(10):936-937.
4. Price JC, Brandman D. Updated hepatitis C virus screening recommendation – a step forward [published online March 2, 2020]. JAMA Intern Med. doi:10.1001/jamainternmed.2019.7334
5. Rosenberg ES, Barocas JA. USPSTF’s hepatitis C screening recommendation – a necessary step to tackling an evolving epidemic. JAMA Netw Open. 2020;3(3):e200538.