Curing your Patients from Hepatitis C: Addressing Complex Needs with Simplified Treatment Approaches - Episode 3
Experts in Hepatitis care discuss simplified screening practices for HCV.
Anthony Martinez, MD: The screening guidelines have kind of varied over the years. I mean, we’re all familiar with this. Things have changed a lot. Nancy, where are we in terms of screening right now? What’s the current recommendation?
Nancy Reau, MD: We are as close to universal screening as we have ever been. So 17 to 79, you deserve a one -time screen. And if you have ongoing risk factors, you need to have ongoing screening. Now they leave that a little bit gray, but I think most of us would take a high-risk individual on the screen at least once a year. Then additionally, if there were abnormalities in the [lab work] or recent risk factors that they were forthcoming for, and then you would then again screen. Also very importantly, as Tipu [V. Khan, MD]was saying, and as we’re emphasizing, capturing these individuals at times when they have regular health care. So, it was a little controversial, but adding screening for each and every pregnancy is now in the screening guidelines. Not because pregnancy is a risk factor or not because we use hepatitis C therapy to decrease maternal childhood transmission, [but] because we recognize that this bimodal distribution, this young group of individuals, is now a near equal opportunity. Men and women are almost equally infected. It’s still a little male predominant, but time when you’re pregnant is a time when people are health-insured, invested in their health, and if you can identify them as having hepatitis C, and then linking them to someone who’s going to help eradicate their virus, post pregnancy, even, is a really important place.
Anthony Martinez, MD: I think this is really a key thing. We’ve seen a shift in the demographic of who has hepatitis C. It’s obviously skewing a little bit younger in terms of new cases or incident cases, and it’s also been a shift in terms of gender. In my own clinic, we’ve got the highest rates of women of child-bearing age with hepatitis C that I’ve ever seen. We have a significant proportion of pregnant women who have hepatitis C. So, basically, we’ve moved almost toward universal screening in the [aged] 17 and up group. We still see some adolescents, so a lot of us still see adolescents for addiction medicine or whatnot.Can you talk to us a little bit about risk factors? Because under that 17-year-old group, we’re still going to have to screen based on risk. So can you talk about some of those risk factors?
Nancy Reau, MD: Well, I think we’ve already established the fact that injection drug use is a risk factor. Tattooing used to be a risk factor, but most tattoos now are done in places where the needles and the ink are all clean. So I think that tattoos are universal, and they do not have the same highlight of link to hepatitis C. But I think it’s really important not just risk factors, but to think that maternal childhood transmission, pediatric hepatitis C, not necessarily adolescent, but pediatric hepatitis C is driven by maternal childhood transmission. This is not common. About 5% [are] mono-infected, 10% if you’re co-infected with HIV. But most children with hepatitis C will have acquired it from their mother. And when you look at your guidelines, our screening guidelines also say that if you are born to a hepatitis C–positive mother, you need to be screened. And that doesn’t mean infants, all infants. If your mom is 70 and you find out that she has hepatitis C and you happen to be 40, you should be screened. You’re still her child. So I think that when we’re talking about pediatric hepatitis C, [it’s about] identifying a mother who is positive and capturing not just the one child, but all the children. And how that extends beyond just the pediatric time point. That transition in adolescence is then again going to be risk-based. I think most of us have children. It’s really hard as a parent to be introspective and understand that your child might be doing anything other than studying for algebra. But when you go to the pediatrician, we don’t have clear guidelines yet on how to identify those risk factors. But I think pediatricians are getting a little bit better about asking the parent to step aside, talking about high-risk behaviors, and hopefully then generating appropriate screening.
Anthony Martinez, MD: Yeah, and some of the things that may be affected by noninjection drug use, sexual exposure, exposure, things like that. Nancy, the guidelines now have gotten pretty easy. It’s almost universal. Where the guidelines seem to kind of stop and don’t necessarily make clear is, what tests should we be using? For our audience, what tests do they have available to screen these patients?
Nancy Reau, MD: Our guidelines probably aren’t as clear as they should be. Part of that is driven by the number of tests that you need to get your medication approved in some states, and kind of archaic views of what you might have thought you needed. Our labs have simplified things so that often if you order the wrong test, you get the right answer anyway. But screening should be done with hepatitis C antibody. And if that’s positive, it will hopefully reflex automatically to a PCR [polymerase chain reaction test]. If you have had hepatitis C in the past and spontaneous clearance or you’ve been treated, you should be tested with a PCR. But if you get an antibody, it’s going to be positive, and it should then reflex to the PCR. So I think that when we look at our care cascade, one of the most important changes is that we move things to the lab so that even when clinicians didn’t ask for the correct test, the lab generally ordered the correct test anyway.
Anthony Martinez, MD: So, ideally, we’re using a reflex test. This may not be available everywhere. Best if we have to, we get the antibody test if that’s positive, we’re obviously then getting a viral load. So a 2-step process potentially, but it can be made a 1-step process.
Transcript was AI-generated and edited for clarity.