Finding Best Approach to Detecting HCV Among Persons with HIV

A study comparing annual screening of HCV for all persons with HIV (PWH) or those at higher risk of contracting HCV found the risk-based approach produced a lower rate of screening, and involved a greater program burden to discern risk.The study could not distinguish between the approaches in detecting previously undiagnosed HCV.

"Although guidelines endorse the risk-based screening approach for PWH who have previously tested HCV negative, others have recommended a yearly annual screening approach as incident HCV cases may be missed if there is reliance on risk factor assessment," explained lead author Ritche Hao, MD, Yale University, New Haven, CT, and colleagues.

"Implementing either approach can be logistically challenging.The risk-based HCV annual screening strategy relies on active and periodic assessment of risk which can be difficult for busy providers," Hao and colleagues observed.

The investigators compared the approaches in a 7-month prospective, observational study between April 2019 and March 2020 in which they implemented an electronic medical records-derived risk-based HCV screening in two HIV clinics (which were also to follow existing guideline recommendations for annual HCV screening) and emphasizedconsistency in ordering annual HCV screening for all PWH in a third clinic. A longer study duration was planned, but was curtailed because of changes to clinic scheduling in the COVID-19 pandemic.

The risk factors for acquiring HCV from current guidelines were cisgender men or transgender women who have sex with men {ascertained with the Sexual Orientation Gender Identity [SOGI] assessment tool); and persons at risk for injection/intranasal illicit drug use (from current use of street or prescription opioids, methamphetamine or cocaine identified on the NIDA ASSIST screening tool from the National Institute on Drug Abuse).

The investigators excluded assessment of some guideline-recommended high-risk behaviors such as intercourse without condom, they indicated, "due to high level of misreporting of sexual risk activity."

Two Best Practice Advisories (BPAs) on identifying the risk factors were developed to "pop up" on the EMR at the initiation of visits at the two clinics providing the risk-based screening. A third BPA during the visit prompted the clinical provider to order the screening labs for HCV for the person identified at risk. At the third HIV clinic, which received reminders and encouragement to conduct annual HCV screens for all patients, screening depended on provider review and ordering the HCV test.

"Although this study intended to compare a risk-based vs expanded annual screening approach, the three clinics had a hybrid of both practices. HCV screening involving provider discretion occurred at all sites," Hao and colleagues acknowledged.

Within limitations of the study, the investigators reported that at the two risk-based program sites, HCV testing was triggered by the BPAs in 10.3% of patients (139 of 1343) and by provider discretion in 7.4% (100 patients). Screening was conducted in 54.6% of patients (237 of 434) in the clinic in which expanded annual HCV screening was encouraged. There were no undiagnosed HCV cases detected at any of the clinics.

The investigators noted serial-drop-offs in orders for the HCV tests in the risk-based programs, and that the SOGI and NIDA screening rates were only between 69% and 82%.They attributed this, in part, "due to inherent delays in clinic staff implementing the process."They suggest that this, in turn, may reflect a selection bias in perceiving those at "low risk."

"Although...estimates suggest that the risk factor-based annual screening approach might be less costly overall, the additional staff costs of designing and implementing the BPA have not been accounted for," Hao and colleagues indicate. "It is possible that clinician-based strategies—ie, diagnostic testing based on clinical concerns for hepatitis—may be more cost-effective."