Screening and Treatment-Adherence for Hepatitis C

May is Hepatitis Awareness Month. We would like to take this time to spotlight the Hepatitis C virus (HCV) infection, which remains a significant public health challenge, largely because many infected patients are asymptomatic.  According to the Centers for Disease Control and Prevention (CDC), nearly one in three individuals with HCV are unaware of their infection, with 75-85% exhibiting no symptoms. As you know, early detection is crucial for timely treatment with highly effective direct-acting antivirals (DAAs), leading to improved patient outcomes and reduced transmission.

For our Highmark Wholecare members who may be facing additional risk factors or barriers to care, comprehensive screening and treatment for HCV are imperative to ensure overall well-being. Providers should test anyone who requests an HCV test, regardless of stated risk factors. Many patients may be reluctant to disclose potentially stigmatizing behaviors, so fostering a safe environment is important during the screening process.

Additionally, Highmark Wholecare encourages care coordination between all doctors providing care to a patient. By keeping these lines of communication open, we can track risk factors, screening results, and create treatment plans that best serve our members.

CDC-Recommended Universal Screening

The CDC recommends universal HCV screening for the following populations, except in settings where the prevalence of HCV RNA-positivity is under 0.1%:

• All adults ages 18 and older: A single lifetime screening is recommended for this age group.
• All pregnant women: Screening should occur during each pregnancy.
• Targeted Screening for High-Risk Individuals

Beyond universal screening, the CDC recommends one-time HCV testing for High-Risk Individuals with known risk factors or exposures:

• Injection Drug Use: Current or past injection drug users, particularly those who shared needles, syringes, or other drug preparation equipment.
• HIV Infection: Individuals with HIV are at increased risk of HCV co-infection.
• Selected Medical Conditions: This includes individuals who have ever received maintenance hemodialysis and those with persistently abnormal alanine aminotransferase (ALT) levels.
• Transfusion/Transplant Recipients: Prior recipients of blood transfusions or organ transplants before July 1992, those who received clotting factor concentrates produced before 1987, and individuals notified of receiving blood from a later HCV-positive donor.
• Occupational Exposure: Health care, emergency medical, and public safety personnel with needle sticks, sharps, or mucosal exposures to HCV-positive blood.
• Infants Born to HCV-Positive Mothers: Infants born to mothers with known HCV infection require testing.

Routine Periodic Testing for Ongoing Risk Factors

The CDC also recommends routine periodic testing for patients with persistent risk factors, regardless of setting prevalence:

• Current Injection Drug Users: Individuals who continue to inject drugs and share equipment require ongoing monitoring.
• Maintenance Hemodialysis Patients: Regular screening is crucial for this population.

Adherence to Treatment and Follow-Up Testing

Once a patient tests positive for HCV and is prescribed direct-acting antiviral (DAA) therapy, adherence to the complete treatment course is paramount for achieving sustained virologic response (SVR), which is considered a cure. Providers should emphasize the importance of taking medication as prescribed, without missing doses. Strategies to improve adherence include:

• Comprehensive Patient Education: Clearly explain the treatment regimen, its duration, potential side effects, and the importance of completing the full course, even if symptoms improve.
• Addressing Barriers to Adherence: Proactively identify and address potential barriers such as financial constraints, complex dosing schedules, pill burden, lack of social support, or substance use disorders. Connecting patients with resources like medication assistance programs, support groups, or case managers can be beneficial.
• Simplifying the Regimen: When possible, opt for simpler DAA regimens with fewer pills or less frequent dosing.
• Regular Follow-Up: Schedule regular office or telehealth appointments to monitor progress, address any concerns, and reinforce the importance of adherence.
• Post-Treatment Follow-Up: Ensuring Sustained Virologic Response (SVR).

Following completion of DAA therapy, a virologic cure, indicated by a sustained virologic response (SVR), should be assessed at least 12 weeks after the end of treatment (SVR12). This test confirms the elimination of the virus.

• SVR12 Testing: Perform an HCV RNA test at least 12 weeks after the last dose of DAA therapy. A negative result indicates SVR12.
• Monitoring for Reinfection: While SVR12 is generally considered a cure, patients with ongoing risk factors should be monitored periodically for possible reinfection.
• Liver Cancer Screening: Although DAAs dramatically reduce the risk of liver cancer, patients with cirrhosis should continue to undergo regular liver cancer screening.
• Documenting Results: Thoroughly document outcomes and SVR12 results in the patient's medical record to promote coordination of care between providers.

By utilizing both universal and targeted screening approaches and emphasizing adherence to treatment and proper follow-up testing, providers can maximize the effectiveness of DAA therapy, improve patient outcomes, and ultimately contribute to the elimination of HCV. Staying up-to-date on guidelines and recommendations is essential for ensuring optimal patient care.