Hepatitis C Virus: Task Shifting and Screening

Hepatitis C virus (HCV)-related mortalities have decreased in recent years with the advent of highly eff ective antiviral therapies, but the incidence of new infections has continued to increase, particularly in younger individuals. As a result, it is crucial to identify those at high risk for HCV and to establish universal screening of adults, according to experts who participated in a recent Contagion® Peer Exchange panel titled, “Curing Your Patients From Hepatitis C: Addressing Complex Needs With Simplified Treatment Approaches,” moderated by Anthony Martinez, MD.

THE HEPATITIS C ELIMINATION GOAL
In 2015, the World Health Organization (WHO) stated a goal of reducing the incidence of viral hepatitis infections by 90% and mortality by 65% between 2016 and 2030, with the goal of eliminating viral hepatitis by 2030.^1,2 Although age-adjusted mortality attributed to hepatitis C decreased by 23% from 2017 to 2021 in the United States, certain populations of Americans are dying at a disproportionately high rate, said Mark Sulkowski, MD.³ Notably, the death rates among non-Hispanic American Indian/Alaska Native and non-Hispanic Black populations are ^3.4 and 1.7 times higher, respectively, than that of non-Hispanic White people in the United States.⁴ Sulkowski added that the WHO’s goal of reducing the incidence of HCV infection is not being met, with an increase in incidence of 60% from 2017 to 2021 and 7% from 2020 to 2021.³ The rate of newly reported cases is highest in those aged 30 to 39 years and 40 to 49 years, although Sulkowski noted that new cases continue to occur in people older than 60 years.³

Several barriers to HCV elimination exist, said Tipu V. Khan, MD. The current screening recommendation from the Centers for Disease Control and Prevention (CDC) states that all adults 18 years or older should be screened for HCV at least once, and multiple screenings should be performed in patients with ongoing risk factors, such as injectable drug use.⁵ However, identifying patients with HCV infection is often difficult, particularly younger patients who use injectable drugs because they are often otherwise healthy and do not frequently engage in the health care system, Khan said. “We need to, as a system, understand that whenever we capture them in the health care system—that could be at a medication-assisted treatment program or screening for incarceration— we should be able to identify them, screen them, and link them to care,” Khan said.

Khan added that with advances in treatment of HCV, primary care specialists and addiction medicine specialists should be at the forefront of treatment. “This is one of the few diseases [in primary care] that we can actually cure,” he said. “We can say, ‘I’ve got to [get a] cure for you. I’m going to shake your hand and get you cured, and we’ll be done with this.’ We, as prescribing providers, need to step up to the plate in screening and then understanding that algorithms are really simple for treatment.” Systemic barriers also have been preventing widespread treatment of HCV, Khan said. To access treatment in the past, patients have had to prove sobriety, a certain level of existing liver damage, and ability to adhere to treatment. Some states have eliminated the requirement of needing a specialist to prescribe HCV treatment; continued focus on eliminating these barriers is needed to improve access.

TASK SHIFTING IN HCV CARE
Currently, most patients with HCV infection are managed by advanced practice providers (APPs; eg, nurse practitioners or physician assistants); therefore, educating APPs about the disease state and the antiviral medications available for treatment is important for optimizing care of people with HCV, said Jordan Mayberry, PA-C. Khan added that with increasing incidence of HCV strongly driven by young, otherwise healthy patients who use injectable drugs, addiction medicine also is at the forefront of HCV treatment because these individuals are more likely to present to a methadone clinic, medication-assisted treatment provider, or primary care doctor to get medications for opioid use disorder than to another health care setting. “As a fellowship director, I train all my fellows [to recognize] that when you’re treating your patients for whatever substance use disorder they have, you need to be updated on the guidelines for screening, but you need to be comfortable with management because these patients may not go to the primary care doc[tor],” Khan said. “They may not go to a GI [gastrointestinal] doc[tor] or hepatologist or an infectious disease specialist. They may only come to you to get their buprenorphine prescription or their other MOUD [medications for opioid use disorder]… so when you [have] them, you’ve got to feel comfortable treating [them]. I do think that colocalization of treatment under the same roof by addiction medicine for hep[atitis] C is going to be important in eradication.” Khan’s practice has many patients who are screened for and found to have HCV when they come in to get medication for opioid use disorder, which provides the opportunity for him and his colleagues to provide HCV treatment and basic primary care. Patients may also be referred to primary care after being diagnosed with HCV in the emergency department or other facility, which opens the door for Khan and his colleagues to discuss and manage the patient’s opioid use disorder. Mayberry added that APPs tend to have more time with patients than most physicians, which allows them to discuss additional primary care issues and build a patient-provider relationship.

SCREENING FOR HEPATITIS C
The CDC recommendations for screening have shifted to a near-universal 1-time screening test for all adults aged 18 years or older, with additional screening needed for individuals with ongoing risk factors.5 Although frequency of screening for patients with ongoing risk factors is not specified in the guidelines, most clinicians recommend screening at least annually for high-risk individuals and as needed if abnormalities on the laboratory workup or recent risk factors come up, said Nancy Reau, MD. Screening during each pregnancy was recently added to the CDC guidelines, primarily because it is a time when individuals are likely to be engaged in the health care system, Reau said. “If you can identify them as having hepatitis C and then link them to someone who’s going to help eradicate their virus, post pregnancy, even, is a really important place,” she said.

Adolescents with risk factors (eg, injectable drug use) and infants and children of mothers with HCV also should be screened for HCV. Reau noted that more work is needed to establish clearer guidelines on how pediatricians can identify high-risk children and adolescents who should receive HCV screening. Screening for HCV begins with an HCV antibody test, followed by reflex testing with an HCV polymerase chain reaction (PCR) test if the antibody test is positive (individuals who have had HCV infection that has been treated or cleared on its own should be tested with PCR). Although the CDC guidelines are not specific on the screening tests needed (in part due to the differences among states in the number of tests needed to get approval for medication), Reau noted that her institution adjusted the care pathway so that the laboratory orders the correct test even if clinicians ask for the wrong one.

References

1. Hepatitis. World Health Organization. Accessed January 15, 2024. https://www.who.int/health-topics/hepatitis/elimination-of-hepatitis-by-2030#tab=tab_1

2. Hepatitis C. World Health Organization. Updated July 18, 2023. Accessed January 15, 2024. https://www.who.int/news-room/fact-sheets/detail/hepatitis-c

3. National profile of viral hepatitis. CDC. Updated August 7, 2023. Accessed January 15, 2024. https://www.cdc.gov/hepatitis/statistics/2021surveillance/introduction/national-profile.htm

4. 2021 viral hepatitis surveillance report. CDC. Updated August 7, 2023. Accessed January 15, 2024. https://www.cdc.gov/hepatitis/statistics/2021surveillance/index.htm

5. Schillie S, Wester C, Osborne M, Wesolowski L, Ryerson AB. CDC recommendations for Hepatitis C screening among adults — United States, 2020. MMWR Recomm Rep. 2020;69(2):1-17. doi:10.15585/mmwr.rr6902a1