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A Step Toward Universal HCV Screening: Write a Letter
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Mark Mascolini
IDWeek 2022, October 19-23, 2022, Washington, DC
A mass mailing to US veterans in the Los Angeles area who did not have an HCV antibody result in the last 10 years got one third of recipients to come in for antibody screening [1]. Among the 4000 veterans who showed up for an antibody test (one third of those sent a letter), 4% tested positive, and 41% of the positive group had HCV viremia. Most viremic veterans started direct-acting antivirals (DAAs).
In the wake of high HCV cure rates with DAA regimens, US health authorities recommended universal screening for HCV. But no one knows for sure how to reach this goal. Researchers in the Veterans Affairs (VA) Greater Los Angeles Healthcare System and the University of California, Los Angeles (UCLA) decided to take a direct approach: Check VA records to see who in the 1945-1965 birth cohort did not have an HCV antibody result recorded in the past 10 years and send those with no antibody test a letter inviting them to visit a VA lab for a blood draw. Those positive for HCV antibody and also with HCV viremia got referred to appropriate clinics to start DAA therapy.
Of the 12,875 people sent letters from 2017 through 2020, 4011 (31%) came in for an antibody test. Of the 4011 veterans tested, 167 (4.2%) had a positive result, and 69 of those 167 (41.3%) had HCV viremia indicating active infection. Of all the letters mailed, 0.54% yielded a veteran with HCV viremia.
Of these 69 viremic people, 65 were men, median age stood at 63 years, 49.3% were white, 26.1% black, and the rest some other race or ethnicity. Forty-three people (62.3%) reported having stable housing, 12 (17.4%) had cirrhosis, 7 (10.1%) had opioid use disorder, and 20 (29%) had alcohol use disorder. Sixty-five of 69 viremic people (94.2%) had never taken an anti-HCV drug. These viremic people lived a median of 27.9 miles from a VA clinic, but 24% had to travel more than 90 miles to a clinic.
Fifty-five of the 69 viremic people (80%) attended a first HCV care visit. Forty-six of those who went to the HCV visit (84%) started a DAA regimen, 43 (93% of 46) completed the regimen, and 40 (93% of 43) had a sustained virologic response. Factors that favored making the first HCV visit were stable housing and having cirrhosis. Longer distance from a VA clinic tended to favor not making the first HCV visit.
The VA/UCLA team concluded that "automated letter screening may be an important implementation tool for universal HCV screening." They suggested refining methods to enable remote evaluation and therapy, such as telehealth and e-consults, for people with marginalized housing and other barriers to care.
Reference
1. Harjono L, Motwani Y, Mohtashemi N, et al. Analysis of an automated letter HCV screening program within a Veterans Affairs health system: implications for universal HCV screening. IDWeek 2022, October 19-23, 2022, Washington, DC. Abstract 1234.
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