May is National Viral Hepatitis Awareness Month. We are at an exciting time in HCV awareness, screening and treatment. A recently updated Viral Hepatitis Action Plan, new United States Preventative Services Task Force (USPSTF) HCV screening guidelines for both the birth-cohort (the “baby boomer” guidelines of providing a one-time test for anyone born between 1945 and 1965) and risk-based populations, and advances in HCV treatments have brought a renewed focus to this historically “silent epidemic." With at least 2.7 million people chronically infected, HCV is the most common blood-borne infection in the United States.
It is also the deadliest: HCV accounts for at least 15,000 deaths per year, and is the leading indicator for liver transplants in the U.S. It is estimated that at least 300,000 or 25% of people living with HIV are also infected with HCV. HCV-related liver disease is the leading non-AIDS cause of death in HIV-infected patients, and HCV disease progression is more rapid in this group, making detection of both acute and chronic HCV extremely important in clinical practice.
Injection drug use remains the most common risk factor for HCV, but in HIV-infected persons — particularly in MSM populations — sexual transmission is a significant risk factor. Sexual transmission of HCV among HIV-infected MSM has been consistently reported in medical literature since the early 2000s, but screening recommendations for the sexual transmission of HCV are not included in the CDC risk-based or birth cohort guidelines, nor are they in the USPSTF guidelines.
However, the CDC’s 2010 Sexually Transmitted Diseases Treatment Guidelines provide excellent guidance for HCV screening in HIV-infected patients. In addition to recommending HCV screening upon initial evaluation, these recommendations also call for routine monitoring of liver function tests to identify acute HCV infection. Finally, to account for the risk of possible sexual exposure in HIV-infected MSM, they suggest HCV testing at either routine intervals or when a patient presents with an ulcerative STD.
Guidelines for frequency of HCV screening have not been established, but the following list of risk exposures for HCV suggest a need for frequent screening (every 3-6 months, but at least annually):
- Patients who report sharing injection drug using equipment (syringes, cookers, cotton, water, etc.);
- Patients who report sharing non-injectable drugs (crack/crystal meth pipes, snorting straws), especially when used in conjunction with sex;
- Patients who report sexual activity likely to cause trauma or bleeding from breaks in rectal tissues (such as fisting, multiple sex partners, use of sex toys);
- Patients who report bleeding during anal sex;
- Patients who report not using, or not consistently using barriers during anal sex (condoms, gloves for fisting);
- Patients who practice serosorting;
- Patients with a history of genital ulcerative diseases (HCV, LGV, primary syphilis).
Project Inform can help your patients who are living with HIV/HCV co-infection, or are at risk of HCV infection. We have developed a three-booklet Health and Wellness series for patients living with HIV and HCV.
Additionally, you can direct your patients to a national hepatitis C helpline, Help-4-Hep at 1-877-Help-4-Hep (877-435-7443). Trained counselors and health educators are available to talk with your patients Monday-Friday, 9am to 7pm EST. You can also order Help-4-Hep posters, brochures and tear pads online.
This month, Project Inform also plans to launch “A Toolkit for Screening, Counseling and Patient Education: Hepatitis C Infection and People Living with HIV," which includes materials for medical providers and other health care staff as well as patient fact sheets. For more information on this toolkit or to request a free copy, visit the Project Inform website, or email Andrew Reynolds, Hepatitis C Education Manager, at [email protected].