Ending hepatitis C in the United States: the role of screening

Abstract

The US faces at least two distinct epidemics of hepatitis C virus infection (HCV), and due largely to revised screening recommendations and novel therapeutic agents, corresponding opportunities. As only 49%–75% of HCV-infected persons in the US are aware of their infection, any chance of addressing HCV in the US is dependent upon screening to identify undiagnosed infections. Most HCV in the US consists of longstanding infections among persons born during 1945–1965 who are suffering escalating rates of liver-related morbidity and mortality. Mathematical modeling supports aggressive action to reach and treat these persons to minimize the subsequent burden of advanced liver disease on patients and the health care system. Incident infection is primarily among persons who inject drugs, less than 10% of whom have been treated for HCV. Expanded screening and treatment of active persons who inject drugs raises the prospect of utilizing “treatment as prevention” to stem the tide of incident HCV infections in this population. HIV-positive men who have sex with men (MSM) represent a population at risk for sexually transmitted HCV who may also benefit from adjusted screening guidelines to identify both acute and chronic infections. Prisoners also represent a critical population for aggressive screening and treatment. Finally, the two-stage testing algorithm for HCV diagnosis is problematic and difficult for patients and providers to navigate. While emerging therapeutics raise the prospect of reducing HCV-related morbidity and mortality, as well as eliminating new infections, major barriers remain with regard to identifying infections, improving access to treatment, and ensuring payer coverage of costly new therapeutic regimens.

In an era of highly effective treatment, hepatitis C screening of the United States general population should be considered

“…Although the initial interferon‐based regimens were plagued with side effects and low efficacy the new all oral regimens have led to sustained viral eradication in almost all HCV patients with an excellent tolerability profile . There is substantial evidence that sustained viral eradication is durable and can be associated with improvement of clinical outcomes (lower rate of cirrhosis, HCC and mortality) and patient‐reported outcomes . Although expensive, these new regimens have been proven to be cost‐effective from a societal perspective in the USA …”

Epidemiology of Chronic Hepatitis C Infections at a Tertiary Care Centre in Oman

“…3,4 Screening programmes to enhance the early detection of infected patients and improve prevention strategies have been proven to reduce HCV-associated morbidity and mortality. 5 Most patients with acute HCV infections remain asymptomatic; as such, progression to a chronic subclinical infection is very common. Usually, liver cirrhosis and other HCV-related complications occur approximately 20-30 years following HCV exposure.…”

“…6 In the absence of proper HCV screening, infected patients frequently present at a late stage with multiple complications. [5][6][7] The presence of comorbidities like alcoholic liver disease, viral coinfection with HIV or hepatitis B and the presence of insulin resistance can further accelerate disease progression. [8][9][10][11] In Oman, there are currently no national programmes in effect to promote public awareness, enhance early diagnosis or enable prompt management of CHC cases.…”

Utility of electronic medical recordbased fibrosis scores in predicting advanced cirrhosis in patients with hepatitic C virus infection

“…It identifies patients with advanced disease stages who require screening for complications such as hepatocellular cancer or varices, while also being used to prioritize patients for treatment with direct-acting antiviral drugs. [1][2][3] The conventional staging process typically involves multiple steps, including laboratory testing, liver imaging, elastography or liver biopsy. In turn, this process requires numerous, dedicated patient visits, and is therefore not easily applicable to large patient populations.…”