Time to Expand Age Base for HCV Screening?

Compared with currently recommended birth cohort screening, universal one-time screening for hepatitis C virus (HCV) for U.S. adults would be highly cost-effective, resulting in an expenditure of $11,378 per quality-adjusted life year (QALY) gained, researchers reported

The findings support broadening the current age cohort for one-time screening to all U.S. adults, concluded Mark H. Eckman, MD, of the University of Cincinnati, and colleagues. "A recommendation for HCV testing of all adults will support the national response to the epidemic of HCV infection among young persons in the United States."

As noted in the study online in Clinical Gastroenterology and Hepatology, the majority (81%) of U.S. residents with chronic HCV infection belong to the cohort born from 1945 through 1965, and testing is recommended for this age group by the Centers for Disease Control and Prevention, the U.S. Preventive Services Task Force, and the American Association of the Study of Liver Diseases/Infectious Diseases Society of America. "However, HCV incidence is increasing among younger persons in many parts of the country, and treatment is recommended for all adults with HCV infection," the researchers wrote.

Their study aimed to determine the prevalence of HCV antibody above which one-time HCV testing for all U.S. adults 18 years and older is cost effective. Using a Markov state transition model, the team found that a threshold prevalence of HCV antibody above 0.07% in the general adult population outside of the 1945-1965 cohort would cost less than $50,000/QALY compared with no screening. But compared with cohort testing, universal screening and treatment would cost $11,378 per QALY gained.

The analysis was based on healthcare system expenditures using 2017 U.S. dollars and factored in the toll taken by fibrosis, cirrhosis, hepatocellular carcinoma, and liver transplantation, as well as the impact of excess mortality, and also addressed patient quality of life and the cost of treatment with direct-acting antivirals. The researchers calculated a mean age of 40.85 for the expanded-base cohort versus the 61.85 years for referent birth cohort.

Asked for his perspective, Jagpreet Chhatwal, PhD, of Harvard Medical School, who was not involved in the study, said it "provides the compelling evidence needed to update HCV screening guidelines in the United States."

"The current screening guidelines predate the availability of all-oral direct-acting antivirals, now the current standard of care. This study shows that universal one-time screening will further reduce HCV-associated burden, will be cost-effective, and will bring us closer to the goal of HCV elimination by 2030."

Broader-based recommendations are needed, since the incidence of acute HCV infection rose almost three-fold in the period 2010-2015, an increase associated with more widespread injection drug use and was most pronounced in persons younger than 40. Furthermore, the new generation of potent, non-interferon-based, direct-acting oral regimens with fewer side effects and shorter treatment courses has altered the discussion around screening.

The authors noted that the estimated prevalence of HCV in the 1945-1965 cohort is 2.6% and 1.0% in the general population, while the calculated prevalence in adults outside the 1945-1965 cohort is 0.29%. "Our estimate for the prevalence of HCV antibody positivity in adults who are not part of the cohort of adults born between 1945 and 1965 is likely low, as it is based on estimates made prior to the steep rise in new cases of HCV infection associated with the opioid epidemic," they wrote.

Another recent analysis also found an age-expanded strategy of one-time testing of all adults ages 18 and older to be cost effective at $28,000/QALY versus birth cohort-based screening. Those authors noted that targeted screening is not cost effective in very low-risk subgroups, such as Caucasian women ages 20 to 59 with no or only one lifetime sexual partner and no history of drug use or other HCV risk factors, as well as Caucasians older than age 60 with no history of blood transfusions before 1992 and no other HCV risk factors.

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