Pragmatic Experience with Risk-based versus Universal Hepatitis C Screening in Pregnancy: Detection of Infection and Postpartum Linkage to Care

Abstract

Objective Despite the Centers for Disease Control and Prevention (CDC) and U.S. Preventive Services Task Force (USPSTF) recommending universal hepatitis C virus (HCV) screening in pregnancy Society for Maternal-Fetal Medicine (SMFM) and American College of Obstetricians and Gynecologists (ACOG) continue to endorse risk-based screening for HCV in pregnancy. We hypothesized that universal screening is associated with increased HCV diagnosis and postpartum linkage to HCV care compared with risk-based screening. Study Design This retrospective cohort study included pregnant women screened for HCV at a single tertiary-care center. We defined two cohorts: women managed with risk-based (January 2014–October 2016) or universal HCV screening (November 2016–December 2018). Screening was performed with ELISA antibody testing and viremia confirmed with HCV ribonucleic acid (RNA) polymerase chain reaction (PCR). Primary outcomes were the rate of HCV screen positivity and postpartum linkage to care. Results From 2014 to 2018, 16,489 women delivered at our institution, of whom 166 screened positive for HCV. A total of 7,039 pregnant women were screened for HCV: 266 with risk-based and 6,773 with universal screening; 29% (76/266) were positive HCV antibody screening (HCVAb + ) in the risk-based cohort and 1.3% (90/6,773) in the universal cohort. HCVAb+ women in the risk-based cohort were more likely to have a positive drug screen. Only 69% (62/90) of HCVAb+ women in the universal cohort met the criteria for risk-based testing. Of the remaining 28 women, 6 (21%) had active viremia (HCV RNA+). Of the 166 HCVAb+ women, 64% (103/166) were HCV RNA+—51 of 266 (19%) in the risk-based and 52 of 6,773 (0.8%) in the universal cohort. Of HCVAb+ women, 75% (125/166) were referred postpartum for HCV evaluation and 27% (34/125) were linked to care. Only 9% (10/103) of women with viremia initiated treatment within 1 year of delivery. Conclusion Universal HCV screening in pregnancy identified an additional 31% of HCVAb+ women compared with risk-based screening. Given low rates of HCV follow-up and treatment regardless of screening modality, further studies are needed to address barriers to postpartum linkage to care. Key Points

Trends in the Prevalence of Hepatitis C Infection During Pregnancy and Maternal-Infant Outcomes in the US, 1998 to 2018

“…Universal screening is undoubtedly more comprehensive than previous strategies of targeted screening . One cohort study reported that universal HCV screening during pregnancy identified 31% more expectant mothers with HCV seropositivity than a risk-based screening protocol . Yet, universal HCV screening of pregnant women also may remain cost-effective even when the disease prevalence is as low as 0.07% .…”

“…Given the health-related implications and vertical transmission risk, connecting to appropriate specialist care is paramount for both mother and child. However, previous data report that postpartum engagement with HCV care occurs in only about a quarter of the cases …”

“…However, previous data report that postpartum engagement with HCV care occurs in only about a quarter of the cases. 31,33 Our study findings suggest that multidisciplinary collaborations in caring for women with HCV may help enhance engagement with specialist care. In the cohort studied herein, alcohol, tobacco, and drug use and limited income were more common among HCV-positive women.…”

Hepatitis B and C in Pregnancy and Children: A Canadian Perspective

“…In the Canadian context we have shown that including missed follow-up RNA testing and referrals for positive individuals, that 56% of women missed an opportunity for linkage to care during pregnancy [ 57 ]. Other groups in the United States have shown that in single-centre studies, only 9% of women are treated postpartum (10/103) [ 71 ], with larger multi-state studies modelling a follow-up postpartum rate of 6% [ 72 ].…”

Defer no more: advances in the treatment and prevention of chronic hepatitis C virus infection in children

“…Recently, universal screening in pregnancy, rather than risk-based, has been widely advocated by several professional societies and adopted by the CDC and USPSTF [69,70,81–83]. This change was prompted by the continued opioid-related escalation in maternal HCV prevalence [6,7 ▪ ,84,85] and multiple demonstrations that universal screening policies uncover more HCV cases than risk-based strategies and are cost-effective [85–88].…”