Am Fam Physician. 2013;88(1):62-65
Guideline source: Centers for Disease Control and Prevention
Evidence rating system used? Yes
Literature search described? Yes
Guideline developed by participants without relevant financial ties to industry? Not reported
Published source: Morbidity and Mortality Weekly Report, August 17, 2012
Approximately 3 to 4 million persons in the United States have hepatitis C virus (HCV) infection, and persons born in 1945 through 1965 account for roughly 75% of all chronic HCV infections among adults. Many persons with HCV infection are asymptomatic and unaware they are infected, and therefore do not receive treatment. Identifying persons with HCV infection through testing is important to improve health outcomes in this population, which is at increased risk of liver cirrhosis, hepatocellular carcinoma, and extrahepatic complications. The HCV Birth Cohort Testing Work Group, including experts from the Centers for Disease Control and Prevention (CDC) and other medical and professional organizations, has released birth-year–based recommendations to augment the 1998 HCV testing guidelines from the CDC.
In addition to testing adults at risk of HCV infection, it is recommended that adults born in 1945 through 1965 receive one-time testing for HCV without previous determination of HCV risk. Also, persons with confirmed HCV infection should receive a brief alcohol screening and intervention as clinically indicated, which should be followed by referral for appropriate care and treatment. HCV testing can be discussed as part of a patient's preventive care. Appropriate care for those identified with HCV infection may include screening for alcohol use, hepatitis A and B vaccination, and medical monitoring of the disease. Patients and physicians should discuss treatment options after considering the patient's stage of disease, hepatitis C genotype, comorbidities, therapy-related adverse events, and benefits of treatment.
Public Health Testing Criteria
Testing for HCV infection in persons born in this birth-year cohort is consistent with established criteria for general public health screening based on the following: (1) HCV infection affects a large number of persons, causes health problems, and can be diagnosed before the appearance of symptoms; (2) testing is readily available, minimally invasive, and reliable; (3) testing limits the progression of disease and allows for earlier access to treatment; and (4) testing is cost-effective.
No new laboratory testing methods have been introduced with these recommendations. HCV testing should be performed using a U.S. Food and Drug Administration (FDA)-approved test for antibody to HCV (anti-HCV). An immunocompetent person without HCV risk factors who tests negative for anti-HCV requires no further testing. However, additional testing may be needed for persons with recent risks of exposure (e.g., injection drug use) or persons who are severely immunocompromised (e.g., those with human immunodeficiency virus [HIV]/AIDS or those on hemodialysis). A reactive anti-HCV test indicates current HCV infection or previous HCV infection that has cleared.
Identification of active infection requires an HCV nucleic acid test (NAT; also known as an HCV RNA test) after an initial positive anti-HCV test. FDA-approved tests include quantitative HCV NATs (for HCV viral load) and qualitative NATs (for presence or absence of viremia). Persons with a positive or indeterminate antibody test result and a positive HCV NAT result are considered to have active infection and require further evaluation and treatment. Those who test anti-HCV positive and HCV NAT negative do not have active infection.
COMMUNICATING TEST RESULTS TO PATIENTS
Persons with negative anti-HCV test results should be notified of the result and reassured that they are not infected unless they were recently at risk of infection, such as through current injection drug use. Repeat testing may be performed in persons engaging in at-risk behaviors. Persons with positive anti-HCV results and a negative HCV NAT result should be notified that they are not infected and do not need further testing.
Persons who test positive for anti-HCV and HCV NAT should be informed that they have HCV infection and need evaluation for liver disease, ongoing medical monitoring, and possible treatment. When physicians deliver test results, they should evaluate patients' level of alcohol use and provide alcohol intervention if needed. Physicians also should provide information about HCV infection, risk factors for disease progression, preventive self-care and treatment options, and strategies for preventing transmission. Resources for medical evaluation and social support may also be helpful.
POSTTEST COUNSELING MESSAGES
Persons with confirmed HCV infection should be counseled on the following:
Contacting a health care professional for evaluation of the presence or development of chronic liver disease, advice on treatment options, and advice on achieving optimal liver health, even if treatment is not recommended.
Protecting the liver from further harm by considering hepatitis A and B vaccination, reducing or discontinuing alcohol consumption, avoiding new medications without consulting a health care professional, and obtaining HIV risk assessment and testing.
Losing and managing weight, if patients are overweight (body mass index of 25 kg per m2 or greater) or obese (body mass index of 30 kg per m2 or greater), and following a healthy diet and exercise plan.
Preventing transmission of the virus; not donating blood, tissue, or semen; and not sharing items that may come into contact with blood, such as toothbrushes, razors, or nail clippers.
ALCOHOL USE REDUCTION
Alcohol screening and brief interventions for treatment referral may help patients consume fewer drinks per week and reduce episodes of binge drinking. This process involves screening for excessive drinking, brief counseling for persons who screen positive, and referral to specialized alcohol treatment if dependence is suspected. Brief interventions provide an opportunity for physicians to explain HCV-associated risks from alcohol and to encourage behavioral change. The U.S. Preventive Services Task Force recommends screening and counseling to reduce alcohol misuse by adults in the primary care setting. Effective screening tools include the Alcohol Use Disorders Identification Test, as well as other items available from the National Institute on Alcohol Abuse and Alcoholism (http://www.niaaa.nih.gov/guide) and the World Health Organization (http://www.who.int/substance_abuse/activities/sbi/en/index.html).