Challenges of Diagnosing Hepatitis C Virus

In this podcast, Vincent Lo Re, MD, talks about the current knowledge gaps around hepatitis C virus screening, as well as how health care providers can implement better screening protocols in their practice. 

Additional Resources:

• Center for Clinical Epidemiology and Biostatistics. Perelman School of Medicine, University of Pennsylvania. Accessed November 6, 2020. https://www.cceb.med.upenn.edu
• Penn Center for AIDS Research. Perelman School of Medicine, University of Pennsylvania. Accessed November 6, 2020. https://www.med.upenn.edu/cfar

Vincent Lo Re, MD, is an associate professor of medicine (Infectious Diseases) and Epidemiology at the University of Pennsylvania, senior scholar in the Penn Center for Clinical Epidemiology and Biostatistics, and codirector of the Penn Center for AIDS Research Clinical Core.

TRANSCRIPT:

Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

Nearly 2.4 million individuals in the United States—1% of the adult population—were living with hepatitis C virus (or HCV) from 2013 through 2016, according to estimates from the Centers for Disease Control and Prevention. In 2016, the World Health Organization committed to eliminating viral hepatitis as a public health threat by setting goals of reducing mortality by 65% and reducing new infections by 80% by 2030, compared with 2015 rates.

With us today to talk more about HCV is Dr Vincent Lo Re, who is an associate professor of medicine (Infectious Diseases) and Epidemiology at the University of Pennsylvania, senior scholar in the Penn Center for Clinical Epidemiology and Biostatistics, and codirector of the Penn Center for AIDS Research Clinical Core.

Thank you so much for joining me today, Dr Lo Re.

What knowledge gaps currently exist around hepatitis C virus (HCV) screening?

Vincent Lo Re: If you look at the current hepatitis C cascade of care, you'll see that only approximately 50% of individuals who are chronic hepatitis C infected actually are diagnosed. So, that's a huge gap. There are knowledge gaps amongst patients, and there are knowledge gaps among providers.

Many patients are unaware of the risks of transmission for hepatitis C—things like injection or intranasal drug use most prominently, and so when they come to the health care provider, they may not necessarily feel compelled to admit to those prior behaviors, either because of concerns about being stigmatized or that's in their past and they just don't want to dredge up all those old sensations or feelings. And so providers who are operating under a risk-based approach to hepatitis C screening may miss those individuals.

Alternatively, providers are busy, and there are numerous tasks that need to be completed in a relatively short period of time—assessing issues, making sure laboratory studies may be done, vaccines may be given, may be attention to certain risk behaviors may be overlooked from a provider standpoint, and so they may not be tested.

One of the ways that these gaps may be overcome is in the most recent recommendations from the Centers for Disease Control Prevention for one-time screening for hepatitis C in all individuals aged 18 to 79 years of age.

It was apparent that in the solely risk-based approach—that was the traditional approach to hepatitis C screening since 2013—an approach that included both risk-based approaches to hepatitis C, where you have people who are assessing either based on prior exposures or specific subgroups that are at high-risk.

For example, people on haemodialysis in 2013. The CDC came out with data that showed that individuals were born between 1945 and 1965—“the baby boomer” subgroup had about a 6-fold higher prevalence of hepatitis C.

And so, there was a push over time from 2013 until just last year: “We're going to focus efforts on one-time screening of this birth cohort, those born between ‘45 and ’65.” Subsequently, over the past several years, studies that have shown that even with both risk-based and baby boomer birth cohort-based screening, we are still as a medical community missing huge numbers of individuals with chronic hepatitis C virus infection, either because many new and younger individuals in the 18 to 35 year demographic, since 2010, are using opioid drugs and are acquiring hepatitis C.

Or just from the standpoint that you have lack of contact with the health care system. And so, recognizing that we will missing many individuals, the push over the past 2 years was we needed to start considering one-time screening for all individuals in the 18- to 79-year period.

Ultimately, the CDC, the US Preventive Services Task Force, and I sit on the American Association for the Study of Liver Diseases (AASLD) and Infectious Disease Society of America (IDSA) Hepatitis C Guidance Panel, and all of these groups came together to really push the effort toward one-time screening for all individuals to enhance that gap in the hepatitis C care cascade from infection to diagnosis.

I think all of that has converged, and the hope now is that one-time screening will at least increase diagnosis. Of course, there are issues from the standpoint, still, for the fact that you can have patients who are diagnosed as hepatitis C antibody positive, but many of these patients may not necessarily return for confirmatory hepatitis C RNA testing. And that in itself is a challenge that at our hospital, the University of Pennsylvania, we have instituted reflective hepatitis C RNA testing for anybody who is antibody positive. That at least overcomes a limitation of requiring a patient to return after an antibody positive result is identified. It’s done automatically.

So I've tried to go over issues in awareness, both from the patient and provider side, the challenges in traditional risk-based, newer baby boomer birth cohort-based, and how hopefully this new approach of one-time screening will hopefully overcome this gap in hepatitis C diagnosis.

I'll tell you that there have been other interventions that have been instituted, such as electronic medical record alerts that our hospital is also involved in, particularly from the outpatient/inpatient setting to prompt health care providers to make sure you are screening for hepatitis C infection during an outpatient visit or during the hospitalization.

Amanda Balbi: HCV screening is recommended for all Baby Boomers, but recent data suggests that screening rates have been low since 2018. How can health care providers implement better screening protocols in their practice?

Vincent Lo Re: Recognizing that particularly primary care clinicians are often so overwhelmed already with more and more guidelines, having electronic alerts to prompt clinicians to order these tests are often really valuable. And I know some health systems have already incorporated this kind of approach to close that gap in diagnostic testing for hepatitis C by having this sort of protocol-based approach.

I think another alternative approach is setting up really solid systems for diagnosis and linkage into care. At our hospital, we have a hepatitis C diagnosis and linking linkage team, where each week as patients are coming into the hospital. They are being screened for hepatitis C. We have a specific hepatitis C health care provider and a nurse who will facilitate linkage of those individuals in our infectious disease practice to facilitate the review of these patients, modifying their risk factors, and getting them treated with new direct-acting antivirals.

Those kinds of approaches where you have either alerts in the electronic medical records or protocols for hospitalized patients to be tested and then linked into care will help to augment these screening protocols and get patients linked into hepatitis C care.

Amanda Balbi: Thank you so much for speaking with me today and answering all my questions.

Vincent Lo Re: Well, it was my pleasure. And I hope that some of the information that was gleaned in this conversation will help other health care providers to treat more patients with hepatitis C and get them through the hepatitis C care continuum, so that we can reduce the overall prevalence of hepatitis C and reduce the likelihood of end-stage liver disease and other liver complications.