Success Story: Impact, Costs, and Effectiveness of Screening Recommendations for Hepatitis C

Hepatitis C overview

Hepatitis C (HCV) can cause a serious and sometimes fatal infection of the liver. The virus is spread primarily when blood from an infected person enters the body of someone who is not infected.

For some persons, HCV infection causes no symptoms, or only a mild illness that resolves over a few weeks. For the majority of infected persons, however, untreated HCV infection causes a serious chronic illness.

In the United States, 44% of persons living with chronic HCV infection do not know their HCV status.1 Without screening and diagnosis, these persons cannot take the first step toward lifesaving curative treatment.

Without treatment, persons with chronic HCV infection can die prematurely. In 2018, approximately 16,000 persons died in the United States because of chronic HCV infection-related causes.2

Several NEEMA projects were supported to address key gaps in information, including:

• assessing the change in screening rates for persons born between 1945-1965 following the 2012 CDC testing recommendation changes
• updating the estimated number of persons living with chronic HCV infection
• modeling the population-level outcomes and cost-effectiveness of expanding the screening recommendations to a broader age range

Background

In 2012, CDC recommended one-time screening for persons born between 1945-1965 (baby boomers). However, changes in available treatment and the impact of the opioid crisis on younger generations have resulted in a need to evaluate hepatitis C screening trends, prevalence, and options for cost-effective strategies for eliminating hepatitis C.

These studies show the effect CDC recommendations have and can have on:

• increasing testing among target populations
• providing updated information for programs on the number of persons living with chronic hepatitis C
• informing new recommendations from CDC, U.S. Preventive Services Task Force (USPSTF), and Infectious Disease Society of America/American Association for the Study of Liver Disease (IDSA/AASLD)

Approach

Assessing change in hepatitis C screening rates during 2010-20143

This project used an interrupted time series analysis with a comparison group design to look at hepatitis C screening rates in 2010-2014. It observed 2.8 million commercially insured adults in the MarketScan database.

Hepatitis C screening rates increased from 2010 to 2014, from 1.65 to 2.59 per 100 person-years. Following the new recommendations, there was a 49% increase in screening rates among people born between 1945-1965. This resulted in a 106% increase by 2014.

Estimating prevalence of hepatitis C virus infection in the United States4

This project updated previous prevalence estimates by analyzing 2013-2016 data from the National Health and Nutrition Examination Survey. It used this data to estimate the prevalence of HCV in the noninstitutionalized civilian population and used a combination of literature reviews and population size estimation approaches.

This estimated the prevalence of HCV infection and population sizes for four additional populations:

• people who are incarcerated

• people experiencing homelessness

• active-duty military personnel

• nursing home residents

The study estimated that during 2013-2016, 1.7% of all adults in the U.S. (approximately 4.1 million persons) were HCV anti-body positive. This indicates past or current infection. Additionally, 1.0% of all adults (approximately 2.4 million persons) were HCV RNA-positive, indicating current infection.

Population-level outcomes and cost-effectiveness of expanding screening recommendations5

This project used a simulation of HCV infection to estimate the effectiveness and cost-effectiveness of four different HCV testing strategies for standard of care (SOC):

• recommendations for one-time testing for all persons born 1945-1965
• recommendations for one-time testing for adults aged 40 years or older
• recommendations for one-time testing for adults aged 30 years or older
• recommendations for one-time testing for adults aged 18 years or older

Expanded age-based testing strategies increased U.S. population lifetime case identification and cure rates. Greatest increases were found in the 18 years or older strategy compared to SOC. This resulted in:

• an estimated 256,000 additional infected persons identified
• 280,000 additional cures
• 4,400 fewer cases of hepatocellular carcinoma with an estimated incremental cost-effectiveness ratio of $28,000 per quality adjusted life year

Results

In 2020, CDC recommended hepatitis C screening at least once in a lifetime for all adults aged 18 or older. It also recommended HCV screening for all pregnant persons during each pregnancy unless in settings where prevalence of HCV infection is less than 0.1%.6

HCV testing, regardless of age or setting prevalence is recommended for persons with recognized conditions or exposures. 6 The USPSTF and IDSA/AASLD also updated their recommendations to screen adults at least once in their lifetime.78

Lessons learned

These NEEMA studies illustrate the effect CDC recommendations have and can have on increasing testing among target populations. It also shows these effects on the potential for reducing hepatitis-related morbidity and mortality.

These studies also provided updated information for programs on the estimated number of persons living with chronic HCV and informed new recommendations from CDC, USPSTF, and IDSA/AASLD.