{"id":62,"date":"2013-06-28T13:56:08","date_gmt":"2013-06-28T13:56:08","guid":{"rendered":"http:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/?p=62"},"modified":"2017-08-21T13:15:33","modified_gmt":"2017-08-21T13:15:33","slug":"primary-care-corner-with-geoffrey-modest-md-hepatitis-c-and-hiv-screening","status":"publish","type":"post","link":"https:\/\/stg-blogs.bmj.com\/bmjebmspotlight\/2013\/06\/28\/primary-care-corner-with-geoffrey-modest-md-hepatitis-c-and-hiv-screening\/","title":{"rendered":"Primary Care Corner with Geoffrey Modest MD: Hepatitis C and HIV screening"},"content":{"rendered":"

new recommendations from cdc (and adopted by US Prev Service Task Force) for hep c screening<\/b> (see link:\u00a0http:\/\/www.uspreventiveservicestaskforce.org\/uspstf12\/hepc\/hepcfinalrs.htm<\/a>\u00a0for USPSTF recommendations and\u00a0http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK115423\/<\/a>\u00a0for the Agency for Health Care Research full paper). both formally released in past month or so. \u00a0basically,<\/p>\n

–common (anti-HCV Ab in 1.6% of noninstitutionalized adults), 3\/4 of HCV cases in people born between 1945-1965 and peak prevalence of 4.3% in those aged 40-49. Hep C is most common indication for liver transplant, 30% of cases. also, about 1\/2 of the 3-fold increase in hepatocellular carcinoma over the past few decades attributable to hep c.<\/p>\n

–benefits of early detection: no direct evidence that screening helps. but good data that treatment leads to improved clinical outcomes<\/p>\n

–risk assessment: major risk factor is injection drug use, or pts with hemophilia (significant percutaneous exposure) in 60-90% of cases. less significant percutaneous exposure in 10-30% (eg hemodialysis, tattoos). also sexual exposure in 1-10% (data are pretty consistent across many studies i’ve seen of discordant couples that with <10 years exposure, about 4-8% get HCV, after 10 years it goes up some to the 10-15% range). blood transfusions, esp if before 1992, is a risk factor. also, maternal-child transmission<\/p>\n

–evaluation: HCV Ab test is best. a prior large study i saw found that using ALT levels to screen was inadequate, since about 50% of HCV positive people would be missed. about 80% of people with HCV Ab have current infection (as determined by HCV viral load)<\/p>\n

–treatment: standard interferon treatments work and when achieve sustained viral response dramatically decrease risk of hepatocellular cancer (by 75%) and developing advanced fibrosis\/cirrhosis (by 75% also)<\/p>\n

and… there are some really impressive treatment regimens on the horizon (and seem to be getting closer to being available generally), with dramatically improved response rates and several with interferon-free regimens.<\/p>\n

— recommendation: 1-time sceening if born between 1945-1966. more often if indicated.<\/p>\n

for HIV screening\u00a0<\/b>(see\u00a0http:\/\/www.uspreventiveservicestaskforce.org\/uspstf13\/hiv\/hivsumm.htm<\/a>\u00a0for summary of HIV screening recommendations from USPSTF,\u00a0http:\/\/www.ncbi.nlm.nih.gov\/books\/NBK114872\/<\/a>\u00a0for full report):<\/p>\n

–high risk (men who have sex with men, injection drug use are highest risk; also people with multiple sex partners, esp with recurrent sexually transmitted infections)<\/p>\n

–recommendation: all individuals aged 15-65 and at low risk should get a single screen. also anyone of any age with increased risk for infection and pregnant women (at each pregnancy).<\/p>\n

–screening intervals. data not great on this. those at low risk, prob one screen sufficient. for those in high-prevalence setting (>1% seroprevalence, as in STD clinics, correctional facilities, homeless shelters, TB clinics, clinics serving MSM, and adolescent clinics with high prevalence HIV) — screen at least annually. \u00a0more frequently as risk is higher<\/p>\n

–rationale: limited data suggest that universal testing finds HIV-positive people have higher CD4 counts than with targeted screening. still more than 1\/2 of HIV patients present with CD4 <350 and 75% with CD4 <500. \u00a0implementing antiretroviral therapy is good for the patient (better clinical outcomes when start with higher CD4 count), and perhaps most importantly, dramatically decrease risk of HIV transmission to others<\/p>\n

just a note of caution: we have found some HIV cases in seemingly very low-risk patients (eg, a man and wife in their 70s). the fact that one partner is low risk does not necessarily dictate that his\/her partner is low-risk (ie, i think the one-time screen for low-risk is reasonable on a population basis, but we should always keep\u00a0in mind\u00a0the possibility of HIV even after a negative screen)<\/p>\n

geoff<\/p>\n","protected":false},"excerpt":{"rendered":"

Primary Care Corner: Hepatitis C and HIV screening […]<\/p>\n

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