HCV CARE

Hepatitis C Virus Infection Guideline Committee, July 2017

More than 50% of people with chronic hepatitis C virus (HCV) infection may not be aware of their infection [1]. Because approximately 75% of cases are among persons born between 1945 and 1965 [1-3], age-cohort screening of asymptomatic adults with no recognized risk factors is thought to increase identification and treatment for these patients. In addition to required HCV screening in the specific birth cohort, healthcare providers should screen patients with other risk factors for HCV infection (see the section on Risk-Based Screening in this guideline).

As part of HCV screening and diagnosis, a series of serologic and virologic tests are used, including laboratory-based antibody tests, point-of-care rapid HCV antibody tests for initial screening, and laboratory-based HCV RNA tests for HCV diagnosis.

KEY POINT: REPORTING
  • New York State (NYS) Public Health law mandates that clinicians report all suspected or confirmed cases of HCV infection, specifying acute or chronic, to the local health department of the area where the patient resides. See New York State Department of Health (NYSDOH): Communicable Disease Reporting 
 References
  1. Denniston MM, Klevens RM, McQuillan GM, et al. Awareness of infection, knowledge of hepatitis C, and medical follow-up among individuals testing positive for hepatitis C: National Health and Nutrition Examination Survey 2001-2008. Hepatology 2012;55(6):1652-61. [PMID: 22213025]
  2. Armstrong GL, Wasley A, Simard EP, et al. The prevalence of hepatitis C virus infection in the United States, 1999 through 2002. Ann Intern Med 2006;144(10):705-14. [PMID: 16702586]
  3. CDC. Testing for HCV infection: an update of guidance for clinicians and laboratorians. MMWR Morb Mortal Wkly Rep 2013;62(18):362-5. [PMID: 23657112]

Cohort-Based

Hepatitis C Virus Infection Guideline Committee, July 2017

NEW YORK STATE REQUIREMENT
  • New York State (NYS) Public Health Law mandates that primary care clinicians offer hepatitis C virus (HCV) screening to individuals born from 1945 to 1965 in a culturally and linguistically appropriate manner.

In NYS, physicians, physician assistants, and nurse practitioners delivering primary care must provide HCV screening, regardless of setting and without regard to certification. Care providers working in hospitals (inpatient units and outpatient clinics) and other healthcare settings where primary care services are being delivered are also required to offer HCV screening. Emergency departments are not required by law to offer HCV screening, but in NYS, they are encouraged to do so.

If the initial screening is reactive, clinicians must offer follow-up healthcare, including HCV diagnostic testing, or referral to an experienced HCV care provider. By requiring HCV antibody screening for this age cohort in traditional medical settings and supporting screening efforts in community-based locations, NYS is actively seeking to identify people with chronic HCV infection and link them to treatment before irreversible liver damage occurs.

In response to the law, hospitals, clinics, health centers, and other primary care medical facilities have established HCV screening programs. However, people with HCV infection may face significant barriers to accessing care in clinical settings, including lack of health insurance, physical disability, ongoing substance use, mental health disorders, and housing instability. Locating HCV screening sites in a variety of community-based organizations, such as syringe exchange programs, sexually transmitted disease (STI) clinics, and local health departments, is integral to the effort to provide HCV screening, treatment, and education in diverse settings.

Birth cohort screening is particularly important because patients may not be aware of or remember exposures or may not disclose prior behavioral risks for HCV infection (see the Risk-Based Screening section of this guideline). Patient education is needed to ensure that patients know about risk factors for transmitting or acquiring HCV infection. While birth cohort screening is important, screening for HCV beyond the required birth cohort is needed in areas where HCV prevalence is high.

KEY POINTS
  • Cohort and risk-based screening are both crucial to identifying adults with HCV infection.
  • In geographical areas with high HCV prevalence, screening should be performed in all people who may have been exposed to HCV through any means of transmission.

Risk-Based

Hepatitis C Virus Infection Guideline Committee, July 2017

RECOMMENDATIONS
  • Clinicians should perform hepatitis C virus (HCV) screening at least once for patients of any age who are not known to have HCV infection and currently have, or have a history that includes, any of the following risk factors:
    • Injection drug use (AI)
    • Intranasal drug use (AII)
    • Sex partner(s) with HCV infection (AII)
    • Incarceration (AII)
    • Long-term hemodialysis (AI)
    • Receipt of blood transfusion or organs before 1992, or of clotting factor concentrates from human plasma before 1987 (AI)
    • A mother with a reactive HCV antibody test result (AI)
    • Tattoo, piercing, or acupuncture obtained in a nonsterile setting (AII)
    • HIV infection (AII)
    • Unexplained liver disease or abnormal transaminase levels (AI)
  • Clinicians should offer HCV screening at least annually to individuals who are not known to have HCV infection and:
    • Use injection drugs (AII)
    • Use intranasal drugs (AII)
    • Receive current long-term hemodialysis (AII)
  • Clinicians should offer HCV screening at least annually to men who have sex with men (MSM) and to others who are not known to have HCV infection and:
    • Engage in receptive anal sex and other behaviors that may tear mucous membranes (AII)
    • Have multiple sex partners (AII)
    • Engage in sex while using recreational mind-altering substances, particularly methamphetamine (AII)
    • Have been diagnosed with another sexually transmitted infection (STI) within the previous 12 months (AII)
  • Clinicians should perform HCV screening for individuals who are not known to have HCV infection and have a possible exposure in a healthcare setting, including those who:
    • Have a break in the skin caused by a sharp object that is contaminated with blood, visibly bloody fluid, or other potentially infectious material or that has been in the source patient’s blood vessel (AII)
    • Have been bitten by an individual with visible bleeding in the mouth that causes bleeding in the exposed worker (AII)
    • Have been splashed on a mucosal surface with blood, visibly bloody fluid, or other potentially infectious material (AIII)
    • Have non-intact skin (e.g., dermatitis, chapped skin, abrasion, or open wound) that has been exposed to blood, visibly bloody fluid, or other potentially infectious material (AIII)

In the United States, an estimated 60% of chronic HCV infections result from use of shared needles, syringes, or other drug-use paraphernalia [1]. Overall, sexual transmission accounts for approximately 5% of HCV infections, although transmission rates differ in select groups, as discussed below. Vertical transmission (transmission from mother to child) accounts for 5% to 6% of infection; receipt of contaminated organs or blood component transfusions before HCV testing of the blood supply began in 1992 accounts for approximately 5% of HCV infections [1]. The average incidence of anti-HCV seroconversion after unintentional needle sticks or sharps exposures from a source with confirmed HCV infection is estimated at 1.8% [1], and HCV infection has also resulted from unsterile skin piercing activities, such as tattoos in prisons (1%) [2]. There are a few case reports that might suggest transmission during trauma, including biting [3] and fist fighting [4], when there is potential for blood-to-blood transmission, but there are insufficient data to limit patients with HCV from participating in sports such as boxing or wrestling at this time.

Injection drug use: Sharing of injection drug use (IDU) equipment is an efficient method of transmitting HCV. In the U.S., a reduction in new HCV infections between 1992 and 2009 was attributed to expansions of syringe-access programs, safer injection practices among people who inject drugs (PWID), and increased enrollment in drug treatment programs [5]. However, HCV prevalence among PWID entering substance use treatment in New York City (n= 1,535) was 67% (95% confidence interval: 66% to 70%) during the 2006 to 2013 period and was not significantly different from that observed from 2000 to 2001 [6].

The demographics of IDU now include many young people living in suburban and rural regions [5]. Adolescents and young adults may advance to IDU after first becoming addicted to prescription oral opioids [7]. Reports from several states (including New York State), underscore the importance of awareness of HCV risk among adolescent and young adult patients and of offering HCV screening to this population [8-13].

KEY POINT: HCV SCREENING IN ADOLESCENTS AND YOUNG ADULTS
  • Epidemics of HCV infection that parallel opioid-use epidemics have been observed among young male and female injection drug users, primarily in suburban and rural areas [8-13].
  • HCV screening should be offered to at-risk adolescents and young adults.
  • In 2015, 2,309 (27.2%) of HCV cases reported in New York State (excluding New York City) were in people <30 years of age [14]. Among those <30 for whom risk information is available, 91% reported a history of IDU.

Intranasal drug use: In a systematic review of 28 studies on the prevalence of HCV in noninjecting drug users who smoked, sniffed, or snorted such drugs as heroin, powder or crack cocaine, or methamphetamine, investigators found HCV prevalence rates ranging from 2.3% to 35.3% [15,16]. Among noninjecting drug users, sharing of oral and nasal drug use equipment is associated with an increased risk of HCV infection [17-19]. In addition, blood and HCV RNA have been confirmed in the nasal secretions and drug-sniffing paraphernalia of HCV-infected intranasal drug users [20].

Sexual transmission: Because many with HCV infection have a history of drug use, estimation of sexual transmission is a challenge (as reviewed in [21]). Sexual transmission of HCV among monogamous heterosexual couples is infrequent. The estimated maximum prevalence of HCV infection among sex partners of individuals with chronic HCV infection was only 1.2%, and the maximum incidence of HCV transmission through sex contact was 0.07% per year or approximately 1 per 190,000 sexual contacts [22]. Sexual transmission risk increases in the setting of multiple partners, STIs, HIV, and exposure to blood [21]. Several reports have demonstrated isolated outbreaks of sexual HCV transmission among MSM with HIV infection who engage in receptive anal intercourse [12,23-25]. In a report from New York City on sexual transmission among HIV-infected MSM with no previous history of injection drug use, new HCV infections were highly correlated with receptive anal intercourse, engaging in sex while using methamphetamine, or participating in group sex [12].

History of incarceration: Incarcerated populations are a significant but declining portion of the HCV epidemic in the United States [26-28]. A study from 2009 to 2013 at two maximum-security prisons in New York State estimated an HCV prevalence of 10.1%; injection drug use, being the partner of a PWID, and HIV diagnosis were most strongly associated with HCV infection [28]. In New York City, the rate of newly reported chronic HCV infection in 2015 was 86.3 per 100,000. In the incarcerated population of the city, the rate was 964.3 per 100,000 for the same year [29].

Exposure to blood in a healthcare setting: The average incidence of anti-HCV seroconversion after unintentional needle sticks or sharps exposures from a source with HCV infection is 1.8% [1]. Healthcare-related transmission of HCV is documented infrequently in the United States [30,31]. In 2014, among reported acute HCV cases that included information on exposure type, 1% was considered to be occupationally acquired [32].

Hemodialysis: The estimated 8% prevalence of anti-HCV antibodies among chronic hemodialysis patients is significantly higher than the estimated 1.6% prevalence in the general U.S. population [1]. Nationally, 36 cases of acute HCV infection in 19 different hemodialysis clinics in 8 states were reported between 2014 and 2015, with epidemiologic and viral sequencing confirming transmission between patients [33]. The Centers for Disease Control and Prevention (CDC) recommend HCV antibody screening upon admission for chronic hemodialysis patients, followed by screening every 6 months thereafter [33,34]. The National Kidney Foundation stratifies by prevalence and recommends antibody screening upon admission to facilities with a low HCV prevalence and consideration of HCV RNA testing upon admission to facilities with high HCV prevalence [35].

Receipt of blood transfusion or organ transplant before 1992 or clotting factor concentrates from human plasma before 1987: Donor screening for HCV infection and inactivation procedures for pooled plasma and plasma derivative products have virtually eliminated the risk of HCV transmission through blood products in the U.S. [1,36].

Vertical transmission: A 2011 meta-analysis estimated that the risk of vertical HCV infection to children of HCV antibody-reactive and HCV RNA detectable women was 5.8% for children of HIV-uninfected women and 10.8% for children of women with HIV infection [37]. From 2011 to 2014, the national rate of HCV infection among women of childbearing age (15-44 years old) increased by 22% (from 139 to 169 per 100,000), and the national rate of infants born to women diagnosed with HCV infection increased by 68% (from 0.19% to 0.32%) [38]. Factors associated with an increased risk of perinatal transmission include HIV coinfection and higher maternal HCV viral loads [37,39]. Neither delivery by cesarean-section nor refraining from breastfeeding has been demonstrated to reduce vertical transmission [39].

Tattoos, piercings, or acupuncture obtained in nonsterile settings: Tattoos or piercings obtained in nonsterile settings, and especially those obtained during incarceration, have been associated with HCV infection, even after controlling for injection drug use and transfusion before 1992 [40,41]. Low levels of HCV RNA have been detected on acupuncture needles from individuals known to have HCV infection [42], although acupuncture has not been established as a confirmed route of transmission.

HIV infection: HCV infection is common among persons with HIV infection because the routes of acquisition are similar. For decades, injection drug use has been recognized as the main risk factor for HIV/HCV coinfection, but an increasing number of sexually transmitted HCV infections have been documented in MSM with HIV [43-45]. In a recent study among MSM with HIV in Europe, Australia, and Canada, HCV incidence significantly increased from 1990 to 2014 [24]. In this population, sexual acts that may tear mucous membranes, sex while using methamphetamines, and having other STIs have been associated with HCV infection [43,44].

Unexplained liver disease or abnormal transaminase levels: In primary care patients with an alanine transaminase (ALT) level 50 to 100 IU/L, HCV prevalence is 10-fold higher than in the general population, whereas hepatitis B (HBV) prevalence was not increased [46].

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