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USPSTF Updates HCV Screening Recommendations to Include All Adults

NEW YORK — The US Preventive Services Task Force (USPSTF) on Monday updated its guidance for hepatitis C virus (HCV) screening, recommending that all adults be tested for the disease in light of increasing cases of acute infection among younger people.

The agency specifically recommended one-time screening in asymptomatic individuals aged 18 to 79 years, with periodic screening for those at continued risk for HCV infection. The guidance, which appears in the Journal of the American Medical Association, updates guidelines issued in 2013 that called for screening adults born between 1945 and 1965 — a group that accounted for an estimated three-fourths of HCV infections at the time — and people at high risk.

Since 2013, however, there has been a significant increase in the incidence of acute HCV infection in younger people, particularly intravenous drug users aged 20 to 39 years, the USPSTF said. Cases of infection have grown approximately 3.8-fold between 2010 and 2017, with American Indian/Alaskan Native and non-Hispanic white populations experiencing particularly high rates.

Meanwhile, highly effective direct-acting antiviral (DAA) treatments have become available, offering higher rates of sustained virologic response with fewer serious side effects than previous interferon-containing therapies.

Against this backdrop, the USPSTF commissioned a systematic evidence review that focused on several areas such as whether HCV screening in adolescent and adults without abnormal liver enzyme levels reduces disease-related mortality; the effectiveness of different risk- or prevalence-based methods for screening on clinical outcomes; the yield of one-time versus alternative screening strategies for HCV infection; and the harms of screening and antiviral treatments.

Other areas of review included the effects of interventions during childbirth; the effectiveness of currently recommended antiviral treatments on improving patient outcomes and their ability to achieve a sustained virologic response; and the association between a sustained virologic response following antiviral treatment and a reduction in the risk of HCV-related adverse health outcomes.

Unlike the review that supported the USPSTF's 2013 screening recommendations, the current review includes adolescents.

According to the USPSTF, the review indicates that all-oral DAA regimens were associated with sustained virologic response rates greater than 95 percent with few short-term harms compared with older therapies, and that such a response was associated with improved clinical outcomes compared with no response.

Screening remains highly accurate, according to the review, and no differences in yield were observed between repeat versus one-time screening or alternative screening strategies such as ones based on risk.

Modeling studies, meanwhile, indicated that expanded screening strategies would be beneficial, with an analysis of one hypothetical cohort of the US population showing that screening all people 18 and older would identify an estimated 256,000 additional HCV cases and lead to an estimated 280,000 additional individuals who achieve sustained virologic responses.

Based on these and the other findings of the review, the USPSTF issued a B grade recommendation for HCV screening for all individuals 18 years and older. The grading indicates a high certainty of a moderate net benefit or a moderate certainty that the net benefit is moderate to substantial.

In an accompanying editorial in JAMA, the University at Albany School of Public Health's Eli Rosenberg and Boston University School of Medicine's Joshua Barocas called the new guidelines a "necessary step" that acknowledges "new infections are now largely driven by transmission via injection drug use and occur in younger adults.

"Although there remains no specific recommendation for screening intervals for persons with ongoing risks, one-time universal screening will likely identify substantially more HCV cases, leading to improved outcomes, including additional cures, fewer cases of hepatocellular carcinoma, and fewer liver-related deaths," they wrote.

Rosenberg and Barocas noted that the Affordable Care Act requires private insurers and Medicaid to cover preventive services recommended by the USPSTF with a grade of A or B with no cost sharing.