Q&A: How to improve HCV care among women who use opioids
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Key takeaways:
- Perinatal transmission is the main way children are infected with HCV.
- Despite very effective treatment, few women with HCV are treated.
Less than 10% of reproductive aged women with opioid use disorder and hepatitis C virus are treated for HCV, according to findings published in Clinical Infectious Diseases.
“We know that women with substance use disorders face challenges to accessing health care, such as lack of child care and the stigma associated with drug use,” Breanne E. Biondi, MPH, a PhD candidate at Boston University School of Public Health, told Healio in an interview. “Reproductive age women who become pregnant can transmit HCV to their child, and even though perinatal transmission rates are low, it is the primary way that children become infected with HCV.”
“Our goal is to understand the current testing, linkage to treatment trends and disparities in reproductive age women to highlight what steps of the cascade should be targeted to help treat women to prevent disease progression and to prevent perinatal transmission and decrease pediatric HCV,” she said.
Biondi and colleagues calculated HCV testing and treatment rates among 104,625 women aged 15 to 44 years whohad been diagnosed with opioid use disorder.
Overall, the researchers found that 44.6% of the women in their study had been tested for HCV, among whom 22.9% tested positive.
Biondi said Asian and Black or African American women were less likely to be tested for HCV antibodies, which could have lasting impacts on their health.
“If individuals are not tested and made aware of their HCV infection, they cannot be treated and risk progression to poor outcomes like liver disease, liver cancer and death,” Biondi said. “We already know that minoritized groups have higher mortality rates in general compared with white individuals, and so untreated HCV could further exacerbate these disparities.”
Among the participants who tested positive for HCV, the study showed that about half (55.2%) were linked to care, and only 9.1% received a prescription for direct-acting antivirals.
Rachel L. Epstein, MD, MScE, infectious disease clinician-scientist at Boston Medical Center and assistant professor of medicine and pediatrics in the section of infectious diseases at Boston University Chobanian and Avedisian School of Medicine, told Healio the treatment rate among women with substance use disorders is much lower than the national average. The CDC reported in 2023 that an average of 35% of all people diagnosed with HCV were cured or cleared in the United States.
“What this shows is that more needs to be done to help women achieve cure,” Biondi said.
We spoke with Biondi and Epstein about their study and how physicians can improve testing and treatment rates among their patients.
Healio: What are the effects of undiagnosed and untreated HCV infection?
Epstein: Undiagnosed and untreated HCV can lead to liver disease. It usually takes about 10 years or more to develop in adults, but it can occur faster. It can lead to poor outcomes such as liver failure, liver cancer, or death. Most children are asymptomatic early in childhood and during most of childhood, but some can have significant liver disease even during childhood, and more often, children will develop liver disease during adolescence or early adulthood as a result of being infected perinatally.
Transmission continues to be an issue in the United States, and one of the reasons there is a focus on reproductive age women. By treating women before pregnancy, we can potentially prevent transmission to a future child. By treating women or children, we are preventing future transmission to people through injection drug use or other means. Similar to HIV, treatment as prevention could be a key aspect of HCV elimination.
Healio: What are the current guidelines for HCV testing in adults and children?
Epstein: In 2020, the CDC and the United States Preventative Services Task Force recommended universal screening in all adults and during every pregnancy among people aged 15 to 44 years. In children, it's only recommended for potential exposures — either perinatal, needlesticks, children receiving dialysis, or in older adolescents if there is concern for injection drug use. That means the first step to be able to test an infant is knowing the parent has HCV. We're already a step behind if the birthing parent hasn’t been tested. Often, the birthing parent has been tested, but it has not been communicated properly from their medical record to baby's medical record in the hospital, or from baby's medical record to the local pediatricians, and then remembered later at 18 to 36 months to test baby. That is one of the reasons that the CDC changed its recommendations last fall to test infants earlier at 2 to 6 months of age if they are exposed.
Healio: How can providers ensure patients are getting tested appropriately?
Epstein: One key aspect is making testing universal. With universal testing of all adults and all pregnant people, we are not relying on physicians to remember to screen certain people or ask for risk factors or patients to feel comfortable disclosing risks. Making it routine and having best practice advisories that come up in the electronic medical record for adults during well checks and for pregnant women during each pregnancy could help make testing second nature. Hopefully, the combination of the guidelines, educating clinicians from multiple different specialties and using electronic medical record reminders will make it something that does not need to be remembered (or opted into) but rather routine and opted out of.
Healio: How can physicians improve treatment rates among women?
Epstein: In studies that have compared testing and treatment in men and women, we test women a little bit more, but treatment rates are generally much lower compared with men. There are limited data, but most show rates of 10% or lower being treated, and a large part of that is lack of treatment during pregnancy. We hopefully will see that change in the future, as direct-acting antivirals appear to be safe and efficacious during pregnancy or immediately postpartum in the small studies that have occurred so far, which are ongoing. The clinical guidance right now is for shared decision-making during pregnancy and allows for treatment of pregnant women after careful discussion of risks and benefits between the physician and the pregnant person. Treatment during pregnancy has the potential to treat the pregnant person and prevent transmission to the current pregnancy as well as to future pregnancies.
For more information:
Breanne E. Biondi, MPH, can be reached at bebiondi@bu.edu.
Rachel L. Epstein, MD, MScE, can be reached at Rachel.Epstein@bmc.org.
References:
- Biondi BE, et al. Clin Infect Dis. 2024;doi:10.1093/cid/ciae426.
- CDC. Clinical screening and diagnosis for hepatitis C. https://www.cdc.gov/hepatitis-c/hcp/diagnosis-testing/index.html. Published Dec. 19, 2023. Accessed Oct. 10, 2024.
- Tsang CA, et al. MMWR Suppl. 2023;doi:10.1555/mmwr.mm7321a4.
- U.S. Preventative Services Task Force. Hepatitis C virus infection in adolescents and adults: screening. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/hepatitis-c-screening#fullrecommendationstart. Published March 2, 2020. Accessed Oct. 10, 2024.