July 8, 2011

Survey Finds Support for Universal Hep C Testing

Universal testing for hepatitis C virus (HCV) infection, as opposed to testing based on known risk factors, is the way to go, according to a survey of people attending general outpatient clinics in Seattle.

While most patients surveyed preferred to know that they were being tested and to be alerted of the results even when they were negative, the study findings, published in the June 6 issue of BMC Infectious Diseases, suggest that patients believed ensuring universal testing for HCV was more important than either soliciting patient consent for the test or providing negative test results.

The need for increased HCV testing is clear. According to U.S. Centers for Disease Control and Prevention (CDC) estimates, between 2.9 and 3.7 million people in the United States are living with HCV, yet 50 to 75 percent of them remain unaware of their status. This is problematic, given that the number of new cases of cirrhosis from HCV is expected to increase by more than 30 percent as of 2020 and subsequent liver failure, liver cancer and death will continue to increase into the 2030s--largely because of the fact that most people living with the disease do not know they are infected and, as a result, are not receiving the care and treatment they need.

With the approval of the HCV protease inhibitors--Incivek (telaprevir) and Victrelis (boceprevir)--today's HCV treatment regimens are expected to cure more than 70 percent of people living with chronic HCV infection. "Yet, despite the scale of the problem and the availability of increasingly effective treatment," write Phillip Coffin, MD, and his colleagues of the Division of Allergy and Infectious Diseases of the University of Washington in Seattle, "relatively little has been done to identify persons with HCV and ensure their treatment."

National guidelines recommend that testing for HCV be limited to people with identified risk factors, such as injection drug use, a blood transfusion before 1992, or elevated liver function tests. However, the authors suggest, "barriers to risk-based screening have resulted in inadequate detection of HCV. Most importantly, patients with a remote history of injection drug use, the primary risk factor for HCV, are often reluctant to admit that behavior to a clinician." The authors add: "In all but the most complex guidelines, risk factor--based screening also fails to account for suspected transmission routes, such as remote iatrogenic transmission [rare infections via medical procedures], intranasal drug use or even a fist fight."

But is the public ready for universal testing, which would involve testing virtually all people for HCV infection? Yes, according to the survey conducted by Coffin's group.

The survey was conducted at five outpatient clinics of a major public urban medical center in Seattle. Two hundred survey responses were received, involving a study group whose average age was 47 and more than half of which were women. Of the participants, 56.3 percent were white, roughly 33 percent were black, nearly 10 percent had tested positive for HCV and more than 2 percent had tested positive for HIV.

The survey included three options. The first, universal testing without being informed of the test or being told of negative results, was preferred by 48 percent of survey respondents. The second, testing with an opportunity to opt out and the requirement that negative results be provided, was preferred by 37 percent. The third option, which involves testing based on clinician judgment, which is most similar to current testing recommendations, was preferred by 15 percent.

"In summary," Coffin's team writes, "our findings demonstrate that patients support universal testing for HCV, as well as HIV, that an 'opt-out' program would be preferred if feasible, but that patients appear to place a higher priority on being tested than they do on the process of informed consent or the receipt of negative results. These findings should inform the priorities of clinicians, public health officials and clinical risk managers."

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