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HCV Screening in HIV is Poorly Implemented, MSM don't get screened adequately, only 55% get screened again after initial screen
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Download the PDF here
Download the PDF here
Acute hepatitis C virus infection in HIV+ MSM: Should
we change our screening practice?
(Clinical Infectious Diseases Advance Access published September 3, 2014)
"there is often a gap between the recommendations by guidelines and the actual clinical practice. This is clearly demonstrated by the study of Dr. Freiman et al.7 published in this issue of CID. While the majority of patients (85%) were screened by anti-HCV antibody testing within 3 months after first presentation at HIV primary care clinics, the follow-up HCV screening modalities did not follow the guidelines in a substantial proportion of patients, with only 55.6% receiving additional HCV tests after initial screening.7 Most interestingly, even patients with elevated transaminases (ALT>100IU/L) did not receive additional HCV screening tests in the majority of cases (only 26.7% of those patients were tested for HCV infection).7 As that the study population was enrolled between 2000 and 2011, it has to be emphasized, that in the first years of the study period the guidelines on when, how, and which HIV+ persons should be tested for HCV had not been as clear as today. Over the last decade the important clinical impact of HCV co-infections in HIV+ individuals attracted more attention among clinicians, and especially now - when novel directly acting antiviral agents (DAAs) can achieve impressive cure rates8-10 - HCV screening represents an even more critical issue........there is still need for improvement11 of HCV screening - especially in the setting of AHC[acute], as anti-HCV testing is recommended as the primary screening test for AHC in HIV+ MSM. In this issue, Vanhommerig et al.12 provide important data on the dynamics of anti-HCV development (HCV seroconversion) and loss of anti-HCV (sero-reversion) following AHC in the "at-risk" population of HIV-infected MSM. In brief, the main finding was an average duration of 2.5
months (74 days) for seroconversion and a rate of up to 51% of zero-reversion following spontaneous clearance or successful HCV-treatment.......It seems that anti-HCV testing is a reliable screening tool for diagnosis of AHC in MSM, since - at least in this cohort of HIV+ MSM - there was not a single case of "occult" AHC infection. However, since the average time to HCV seroconversion was 74 days (around 11 weeks) - which implies that "early" diagnosis of AHC is often missed when only anti-HCV testing is performed HIV+ MSM........These novel data on anti-HCV dynamics in HIV+ MSM are highly relevant, since they support a broader use of a sensitive quantitative PCR-based HCV-RNA testing in this high-risk population to prevent potential transmission during the early phase of AHC (as the patient is otherwise unaware of the HCV co-infection) and to allow early administration of antiviral therapy (that is likely associated with improved response rates). Indeed, the authors conclude that screening for AHC is ideally performed using HCV-RNA testing."
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Current Practices of Screening for Incident Hepatitis C Virus Infection among HIV- Infected, HCV-Uninfected Individuals in Primary Care......"Only 55.6% ever received additional HCV screening following"
"Only 55.6% ever received additional HCV screening following .....HCV screening increased over time, but not uniformly at all sites. Only 26.7% of first-time ALT elevations to >100 IU/L were followed-up within 12 months by HCV Ab or RNA testing......Those who reported MSM or heterosexual as their risk factor for HIV transmission were less likely than IDU to ever receive surveillance HCV screening (OR= 0.59......Guidelines are needed to help HIV providers know who to screen, how frequently to screen, and which screening test to use"
Clinical Infectious Diseases Advance Access published September 3, 2014
Freiman, J. Morgan1, Huang, Wei1, White, Laura2, Geng, Elvin H.4, Hurt, Christopher B.5, Taylor, Lynn E.6, Overton, E. Turner7, Cachay, Edward R.8, Kitahata, Mari M.9, Moore, Richard D.10, Rodriguez, Benigno11, Mayer, Kenneth H.12, Linas, Benjamin P.1,3
BRIEF SUMMARY
We examined HCV screening among HIV infected patients enrolled in care at seven U.S. sites between 2000-2011. We identified a trend toward more frequent screening in recent years, but screening remains variable among sites and high-risk MSM are screened infrequently.
In summary, this analysis demonstrates that although most HIV-infected patients are screened once for prevalent HCV infection at entry into HIV care, significant practice variations remain in rates of screening for incident HCV. These differences are not well explained by patient demographics or risk behaviors, though patients who report IDU remain more likely to be screened than MSM or heterosexual. Additionally, those with new ALT elevations to >100 IU/L are unlikely to have diagnostic testing for HCV. Therefore, opportunities exist to improve outcomes. U.S.-based national guidelines informing whom to screen, how frequently to screen them, and what screening test to use are an important first step in this direction.
ABSTRACT
Background: HIV-infected, HCV-uninfected patients are at risk for incident HCV infection, but little is known about screening practices for incident HCV among HIV-infected individuals in HIV primary care clinics.
Methods: We used data from the CFAR Network of Integrated Clinical Systems (CNICS) to investigate historical trends in screening for incident HCV infection among HIV-infected patients who were HCV-uninfected at enrollment in care. We used descriptive measures and Poisson regression to identify factors associated with screening for HCV infection (using HCV antibody or RNA), performed temporal analyses to assess changes in screening over time, and investigated the frequency with which elevated alanine aminotransferase (ALT) levels were followed by diagnostic HCV testing.
Results: Among 17,090 patients registered at CNICS sites between 2000-2011, 14,534 (85%) received HCV Ab screening within 3-months of enrolling in care, and 9,077 met all of the inclusion criteria. Only 55.6% ever received additional HCV screening following. HCV screening increased over time, but not uniformly at all sites. Only 26.7% of first-time ALT elevations to >100 IU/L were followed-up within 12 months by HCV Ab or RNA testing.
Conclusion: Though most HIV-infected patients were screened for prevalent HCV infection at enrollment in care, only half who were HCV-uninfected were screened again. Screening varied between sites, even when controlling for demographics and risk behaviors. Patients with new ALT elevations to >100 IU/L were seldom assessed for incident HCV infection. Guidelines are needed to help HIV providers know who to screen, how frequently to screen, and which screening test to use.
Those who reported MSM or heterosexual as their risk factor for HIV transmission were less likely than IDU to ever receive surveillance HCV screening (OR= 0.59, 95% CI = 0.42-0.84, and OR= 0.513, 95% CI = 0.36-0.73 respectively).
The odds of ever receiving HCV surveillance at site 3 were 9.6 times greater than those at site 1 (95% CI 7.88-11.61) (Table 1).
Across the follow-up period, the rate of surveillance HCV Ab and RNA screening varied significantly by site, ranging from 0.14-0.52 screens per person-year (PY). Surveillance screening increased over time, but the rate of increase differed between sites (Table 1 and Figures 1a and b). In the most recent calendar period (2008-2011), the screening rates ranged from 0.24 at site 1 to 0.63 at site 3. In multivariate analysis that controlled for patient demographics, risk factors for HIV transmission, clinical characteristics, drug use and sexual risk behaviors, clinical site, and calendar time, the surveillance screening rate varied significantly between sites (Table 1).
Participants who seroconverted were more likely to report past or current amphetamine use (OR = 1.86 95% CI =1.12-3.08 for past use; OR = 3.59 95% CI = 2.07-6.21 for current use). Inconsistent condom use (anal or vaginal sex) was associated with seroconversion, but the finding did not meet the level of statistical significance. Seropositivity was also higher among MSM/IDU than MSM or heterosexual risk categories (OR = 0.82, 95% CI = 0.45-1.51) (Table 2).
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