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Division of Liver Diseases
Icahn School of Medicine at Mount Sinai
New York, New York
Tatyana Kushner, MD, MSCE, has disclosed that she has received consulting fees from Gilead Sciences.
During prenatal care, women undergo extensive testing to evaluate their own health, optimize pregnancy outcomes, and ensure delivery of a healthy infant. Until recently, universal testing for HCV infection was not part of the standard recommended prenatal testing. During the past 2 years, these recommendations have changed.
What were the previous recommendations for HCV testing during pregnancy?
Previously HCV testing during pregnancy was recommended only for women with known risk factors for HCV. This included both risk factors that women endorsed to their providers (eg, history of injection drug use or illicit intranasal drug use, history of incarceration, or history of possible parenteral exposure in an unregulated setting [typically, getting a tattoo in an unlicensed parlor]) and risk factors obtained from the patient’s medical history, including having received a blood transfusion or an organ transplant before 1992 (when blood products started to be screened for HCV), having other sexually transmitted infections such as HIV, or having evidence of liver disease. However, the challenge in identifying these patients was that women often underreport risk factors—particularly in the context of pregnancy—and providers may not perform a comprehensive risk assessment. The net result was that many women with risk factors for HCV were not being identified.
Why has there been a need to update guidance for HCV testing in pregnancy?
Multiple recent epidemiologic studies have demonstrated increases in the diagnosis of HCV among women of childbearing age and increases in acute infection rates among pregnant women, largely as a result of the opioid epidemic. In addition, there have been reports of increases in HCV diagnoses among infants born to mothers with HCV. Given the rise in HCV burden in this population, screening during pregnancy has become more important. Finally, analyses have demonstrated the cost-effectiveness of universal screening for HCV when compared with risk-based screening. One study estimated that universal screening of approximately 5 million women in 2018 might have identified an additional 33,000 women and 300 children born with HCV and allowed for earlier treatment of both populations.
What are the recent updates in screening recommendations?
As of April 2018, the joint American Association for the Study of Liver Diseases/Infectious Diseases Society of America HCV guidance changed its recommendation to include HCV screening for all pregnant women, regardless of risk. Subsequently, the US Preventive Services Task Force also made a recommendation to screen all adults 18-79 years of age for HCV regardless of risk, including pregnant women. Finally, the CDC has made the recommendation that all women be screened for HCV during each pregnancy, regardless of risk. As of this writing, the American College of Obstetrics and Gynecology (ACOG) has not endorsed these recommendations and currently recommends only risk-based HCV screening. However, this recommendation is under consideration by the ACOG guideline panel.
What are the implications of updated screening recommendations?
Given that testing during pregnancy is done primarily by obstetric providers, broad implementation of the recommendation for universal screening will not be easily accomplished without endorsement by ACOG. Otherwise, there will continue to be diverse practice patterns across health settings. If universal screening is endorsed more broadly during pregnancy, there will be opportunity to identify more cases of HCV among women and their infants and to provide earlier care to avoid long-term consequences of HCV-related liver disease.
Have you changed or do you plan to change your practice based on the updated HCV screening recommendations? What barriers have you encountered, or do you anticipate encountering, in trying to expand HCV screening for women during pregnancy? Please join the conversation and share your experiences in the comments box.