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Public Unhealth

Expert Panel's Decision to Recommend Against Routine HCV Screening Draws Community Ire

June 2004

A note from TheBody.com: Since this article was written, the HIV pandemic has changed, as has our understanding of HIV/AIDS and its treatment. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!

"Inconsistent With Other Bodies"

In March of 2004, the U.S. Prevention Services Task Force's "Screening for Hepatitis C Virus Infection in Adults: Recommendation Statement" was published in the Annals of Internal Medicine. The USPSTF found insufficient evidence -- based on long-term health outcomes -- "to recommend for or against routine screening for HCV infection in adults at high risk for infection." Tracy Swan reports.

The USPSTF is an independent panel of experts in prevention and primary care that systematically reviews the evidence of effectiveness and develops recommendations for clinical preventative services. The USPSTF is commissioned by the Agency for Healthcare Research and Quality, which is a program of the Department of Health and Human Services.

The USPSTF Recommendation Statement is not consistent with recommendations from other entities. Expert panels convened by the Department of Health and Human Services, the Centers for Disease Control and Prevention (CDC), the National Institutes of Health (NIH), the Veteran's Administration (VA) and the American Association for the Study of Liver Diseases concur; they recommend testing for people who are at risk for hepatitis C:

  • People who have shared injection equipment, even once;

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  • Anyone who has been notified that they received blood from a donor who later tested positive for hepatitis C;

  • Anyone who received a blood transfusion or solid organ transplant before July 1992;

  • Recipients of clotting factor(s) made before 1997;

  • Anyone who has ever been on long-term kidney dialysis;

  • Persons with evidence of liver disease such as persistently elevated ALT levels; and

  • Because of the overlapping modes of transmission, HCV testing is recommended for all HIV-positive people.

What is the impact of this recommendation? According to Andi Thomas, founder and Executive Director of Hep-C Alert and President of the National Hepatitis C Advocacy Council, "We'll see it over time, as the USPSTF Recommendation Statement gets incorporated into evidence-based prevention programming, CME activities and the education of new doctors."

In fact, a CME program incorporating these guidelines has already appeared on Medscape. The inconsistency between the USPSTF Recommendation Statement and the HCV screening recommendations from NIH and CDC are listed only in the last three bullet points (of 21). One of two "Pearls for Practice" summarizing this CME states:

"There is insufficient evidence that newer treatments improve long-term health outcomes and disease progression. The USPSTF also cannot determine the benefits vs. harms of screening adults at high risk at this time."

The failure to recommend HCV testing for high-risk individuals has disturbing implications for the fundamental right to medical care. People at risk for a chronic, potentially life-threatening illness are entitled to testing, even in the absence of data on the long-term outcomes of those treated for the condition. The Recommendation Statement may have a deleterious effect on public health; without testing, key prevention opportunities are forfeited as people with hepatitis C go undiagnosed.

Under-funded entitlement programs may use the USPSTF Recommendation Statement as a rationale for denying reimbursement for HCV testing. This will have the greatest impact on those at highest risk for HCV infection: current and former injection drug users (up to 90% may be infected), prisoners (estimated prevalence of 30-40%), and African American men from 40 to 49 years of age, among whom HCV is far more prevalent than the general population (9.8% vs. 1.8%).

According to Thomas, "this is a symptom of a much bigger problem: the lack of funded infrastructure for hepatitis C services in the U.S." Thomas and her colleagues at the National Hepatitis C Advocacy Council have written legislation to create the needed infrastructure (see www.hepcnetwork.org/legislation.htm for more information about the Hepatitis C Epidemic Prevention and Control Act).

The CDC just announced that they are trimming two million dollars from their already meager Viral Hepatitis budget; now less funding will be going towards integration of HCV education and testing into HIV programming (among other demonstration projects). We need these programs; what benefits people who are at risk for, or infected with, hepatitis C will benefit coinfected people as well. Hepatitis C is an opportunistic infection of HIV disease. End-stage liver disease resulting from hepatitis C coinfection has become a leading cause of death among people with HIV.

A note from TheBody.com: Since this article was written, the HIV pandemic has changed, as has our understanding of HIV/AIDS and its treatment. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!



  
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This article was provided by Treatment Action Group. It is a part of the publication TAGline.
 
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