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Q&A: How to identify patients with HCV

Hepatitis Awareness Month and Hepatitis Testing Day are observed annually in May to raise awareness of the disease and encourage clinicians to test priority populations.

Hepatitis C virus (HCV) affects approximately 2.7 to 3.9 million people in the United States, and many are unaware that they are infected, according to the CDC. In addition, new data from the CDC revealed that the number of new HCV infections has recently reached a 15-year high, nearly tripling over the past 5 years.

For Hepatitis Testing Day today, May 19, ACP and the American Academy of HIV Medicine (AAHIVM)’s Institute for Hepatitis C released the new Guide to Hepatitis C Testing, which is designed to aid clinicians in screening patients for HCV, according to a press release.

“We know there is widespread uncertainty out there among providers about whom to test and with what labs, and how to get reimbursed,” Margaret Hoffman-Terry, MD, chair of the AAHIVM Board of Directors and director of the AAHIVM Institute for Hepatitis C, said in the release. “We hope this new resource will give clinicians the information they need to ramp up testing for Hepatitis C. It is imperative that clinicians are testing indicated patient cohorts, and this guide will help them to do that.”

In recognition of Hepatitis Awareness Month and Hepatitis Testing Day, Healio Internal Medicine spoke with Steven Flamm, MD, medical director of the Liver Transplant Program at Northwestern Memorial Hospital, about the risk factors and comorbidities of HCV that PCPs need to be aware of to identify patients who should be tested for the disease.

Steven Flamm

Question: What is the clinical role of PCPs in identifying HCV?

Answer: PCPs have a critical role in identifying patients with HCV because even though the diagnostic test for HCV has been available for almost 30 years, we think that at least 50% of the patients with HCV in the United States are undiagnosed. Now that we have curative therapies for it, it is even more important to identify the patients with HCV so that we can actually treat them. The identification of HCV patients is by primary care practitioners. Primary care doctors need to be aware that patients with HCV frequently have absolutely no symptoms of the disease and yet can have very advanced liver disease. Patients could have acquired HCV decades and decades ago and be evolving into cirrhosis and still feel well. In addition, liver blood tests may not look abnormal or be minimally abnormal but patients still can have advanced liver disease. Lastly, PCPs have to be aware of the screening recommendations — who exactly should be given the diagnostic test.

Q: What are the risk factors associated with HCV that PCPs need to be aware of?

A: HCV is primarily a bloodborne pathogen — primarily, not universally. The most common means of transmission of HCV is history of IV drug use with needle sharing, even when it was only one time, and it often was acquired decades ago. However, many patients aren’t often forthcoming with that history.

Anyone who has received a blood transfusion of any kind in the United States before the year 1990 to 1992 is also at risk because the diagnostic test for HCV did not come out until approximately 1990, which is when we first started screening blood and all other blood products for HCV. Therefore, anyone who received a blood transfusion prior to 1990 to 1992 could have received blood contaminated with HCV. People on dialysis also have a slightly increased risk because there is potential blood exposure in dialysis centers.

Sexual transmission is extremely uncommon. We do see HCV transmission not infrequently in people who have anal receptive intercourse. Whereas anal receptive intercourse is a risk factor for HCV, transmission of HCV through vaginal intercourse is thought to be rare. HCV is not spread by hugging, kissing, sharing food or coughing. Individuals cannot get HCV from living with a person unless there’s a blood exposure.

The screening recommendations for primary care that have not gained good traction yet are two-fold. First, PCPs are supposed to screen anyone in their practice that have any of the afore mentioned risk factors. Second, the CDC made an additional recommendation a couple of years ago: Anybody born between the years 1945 and 1965 — the so-called “baby boomers” — should have a one-time screening test for HCV. The reason for this recommendation is that we think approximately three-quarters or more of all patients with HCV in the United States are in that age group. IV drug use was popular in the 60s, 70s and 80s when these individuals would have been the age that is most likely to engage in such activity. The CDC and most key opinion leaders agree that if clinicians were to screen this birth cohort one time as recommended, most patients with HCV would be identified. Unfortunately, few PCPs are currently following these recommendations.

Q: What comorbidities are associated with HCV?

A: There are medical comorbidities, aside from the liver disease complications of cirrhosis and liver cancer that are associated with HCV. Patients with HCV can have kidney problems, including cryoglobulinemia and glomerulonephritis that affect the kidneys. There are some skin disorders that can occur with HCV, including porphyria cutanea tarda and lichen planus. There are some very common medical problems that we also think are linked to HCV, such as diabetes, lymphoma and thyroid disease, among others. PCPs should test their patients who exhibit such comorbidities for HCV because they may be linked.

Q: Who should PCPs encourage to get tested?

A: All patients who display one or more of the aforementioned risk factors or comorbidities should be screened for HCV. In addition, people born in non-Western countries, including the Eastern bloc and third-world countries in Asia and Africa are at higher risk for HCV than in Western countries. Individuals born in such countries may not have the standard risk factors that are prevalent in the United States, but are more susceptible to the disease because their medical providers, perhaps many years ago, often reused needles on patients due to lack of equipment. Therefore, if a PCP has a patient from one of those countries, they should also be checked for HCV.

Q: What do PCPs need to know about treatment options and regimens for HCV?

A: The new treatments are so simple, effective and well-tolerated that really anyone can do it, but the vast majority of HCV patients are referred by a PCP to a gastroenterologist, hepatologist or an infectious disease specialist for therapy. For the most part, what PCPs need to be aware of is that we now have simple regimens for 2 or 3 months that consist of one or a small number of pills each day. In placebo-controlled trials, the treatments had essentially no or minimal adverse effects, and cured HCV in 2 to 3 months in more than 95% of almost all patient groups that have the disease. The bottom line is that there are well tolerated and highly effective regimens out there, and we can cure almost everybody now in a very short period of time. This is why it’s so important to identify patients with HCV.

PCPs should also know that HCV is the leading cause of liver transplantation in the entire Western world and is a major cause of death. Despite the fact that many people have no symptoms and have had HCV for decades before it causes cirrhosis, it often wreaks havoc on people in the end. If we identify the patients when they are asymptomatic before they are sick and treat them appropriately, we can cure them before it’s too late. It has really been a revolution in therapy. The PCP should not be fooled by patients not feeling sick or hepatic blood tests that are not markedly abnormal because that’s characteristic of HCV and in the end, it catches up with many people.

Q: Are there drug-drug interactions with medications for HCV treatment that clinicians need to monitor?

A: There are drug-drug interactions with all the new medications for HCV, but they are manageable. Treating physicians become familiar with the drug-drug interactions with each regimen and manage them appropriately. I think what’s important for PCPs to know, if they’re not the actual treating doctor, is that if a patient is on therapy for HCV for only 2 or 3 months, they should clear any new medications for the patient with the gastroenterologist, hepatologist or infectious disease specialist that is treating the HCV before a new medication is started to ensure that there isn’t an interaction, or wait until the HCV medication is finished.

Disclosure: Flamm reports doing research for and consulting with Merck, Gilead and AbbVie.