Outcomes along the HCV care cascade: HCV antibody testing completed (anti-HCV tested), HCV seropositive (anti-HCV positive), HCV RNA testing completed, HCV RNA detected, and HCV genotype completed. One patient with HCV treatment initiated not shown (the first direct acting antiviral therapy was not approved for 12- to 17-year-olds until April 2017). Percentages in panel C are conditional.
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Epstein RL, Wang J, Hagan L, et al. Hepatitis C Virus Antibody Testing Among 13- to 21-Year-Olds in a Large Sample of US Federally Qualified Health Centers. JAMA. 2019;322(22):2245–2248. doi:10.1001/jama.2019.16196
Hepatitis C virus (HCV) incidence is increasing in the United States,1 with most new transmissions occurring among people younger than 30 years who inject drugs.2 Fifteen- to 24-year-olds represent an increasing proportion of reported chronic HCV infections, rising from 3.8% in 2009 to 9.1% in 2013-2016.1 Although HCV testing and linkage to care are crucial steps toward eliminating HCV, to our knowledge no studies have specifically examined HCV testing practices among youths. Current guidance recommends HCV testing for children or adults with HCV risk,3 including anyone who has injected drugs, the most frequently identified risk factor.1,2 We sought to characterize HCV testing and the HCV care cascade among 13- to 21-year-olds accessing US federally qualified health centers (FQHCs), an important health care source for underserved communities.4
This study included individuals aged 13 to 21 years at study end who had 1 or more visits to an OCHIN (previously the Oregon Community Health Information Network)–affiliated FQHC from January 2012 to September 2017. OCHIN comprises a 57-FQHC (19 states) network sharing a common electronic health record. We excluded individuals with HCV diagnosed by an International Classification of Diseases, Ninth Revision (ICD-9) or International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10) code before observed HCV testing.
We obtained characteristics, including demographics, substance use documentation by ICD-9/10 code or from the electronic health record social history section (Table), medication lists, and completed laboratory results. Documented opioid, amphetamine, or cocaine use, shown to have 80% sensitivity and 81% specificity for reported injection drug use,5 were considered a proxy for HCV risk. We characterized the HCV care cascade for all included individuals: HCV antibody testing completed (anti-HCV tested), anti-HCV positive, HCV RNA testing completed, HCV RNA detected, HCV genotype completed, and HCV treatment initiated (by medication order). The Boston Medical Center institutional review board approved this study with a waiver of informed consent given the use of deidentified, pooled data.
Among 269 124 youths who met inclusion criteria (54.7% female; 62.5% nonwhite; 0.3% with diagnosed opioid use), 6812 (2.5%) were anti-HCV tested; of these, 122 (1.8% of those tested) were anti-HCV positive (Table). Mean age at first anti-HCV test was 18.5 (SD, 2.2) years and at first positive anti-HCV test result was 19.1 (SD, 2.2) years. Among 2573 individuals (1.0%) with documented opioid, amphetamine, or cocaine use, 761 (29.6%) were anti-HCV tested, of whom 54 (7.1% of those tested) were anti-HCV positive (Table). Ninety-two individuals (75.4% of those anti-HCV positive) had HCV RNA testing; of those, 41 (44.6%) had detectable RNA, indicating current infection, and 15 (36.6% of those with detectable RNA) completed genotype testing (Figure). Only 1 individual had documented initiation of HCV treatment.
In this large sample of 13- to 21-year-olds accessing a network of FQHCs, 30% with identified opioid, amphetamine, or cocaine use were tested for HCV, and only 1 had documented HCV treatment. Since not all individuals with opioid, amphetamine, or cocaine use inject drugs, ICD-9/10 codes used as a proxy for HCV infection risk might overestimate the population at risk due to injection use.5 Given underdiagnosis of substance use, however, it is likely that fewer individuals with any injectable substance use were HCV tested than the observed 30% with documented use.
In fact, most youths tested lacked documented injectable substance use or another known testing indication. Although clinicians may have HCV tested diagnostically or for other uncaptured risk, testing may also signal undocumented injection use or inappropriate testing. Improved substance use screening and documentation are critical for successful guideline-concordant HCV testing.
Other study limitations include the use of pooled data from FQHCs in 19 states, which may limit generalizability and precluded analysis by US geographical region. Also, youths accessing FQHCs may be HCV tested or treated elsewhere, but this unlikely fully mitigates the low observed screening and treatment rates.
Early identification of HCV is critical to cure current infections, prevent transmission and morbidity from disease progression, and eliminate HCV, particularly with effective treatments now approved in 12- to 17-year-olds.6 Low HCV testing and treatment rates in youths with documented opioid, amphetamine, or cocaine use in this study suggest that program design and policy improvements are needed.
Accepted for Publication: September 12, 2019.
Corresponding Author: Rachel L. Epstein, MD, MSc, Section of Infectious Diseases, Boston Medical Center, 801 Massachusetts Ave, Crosstown Center, Second Floor, Boston, MA 02118 (Rachel.Epstein@bmc.org).
Author Contributions: Dr Epstein had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Concept and design: Epstein, Linas, Assoumou.
Acquisition, analysis, or interpretation of data: All authors.
Drafting of the manuscript: Epstein, Assoumou.
Critical revision of the manuscript for important intellectual content: All authors.
Statistical analysis: Epstein, Wang, Assoumou.
Obtained funding: Linas, Assoumou.
Administrative, technical, or material support: Epstein, Hagan, Mayer, Puro, Linas, Assoumou.
Supervision: Puro, Linas, Assoumou.
Conflict of Interest Disclosures: Dr Epstein reported receiving grants from the National Institute of Allergy and Infectious Diseases (NIAID), National Institute on Drug Abuse (NIDA), and National Center for Advancing Translational Sciences through the Boston University Clinical and Translational Sciences Institute during the conduct of the study. Dr Linas reported receiving grants from the Centers for Disease Control and Prevention (CDC) National Center for HIV, Viral Hepatitis, STD, and TB Prevention Epidemiologic and Economic Modeling Agreement, NIDA, NIAID, and Providence/Boston Center for AIDS Research during the conduct of the study. Dr Assoumou reported receiving funding/grants from NIDA. No other disclosures were reported.
Funding/Support: This project was funded by the CDC National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention Epidemiologic and Economic Modeling Agreement (5U38PS004644). Support was also obtained from NIDA (K23DA044085, P30DA040500, R25DA013582), NIAID (5P30AI042853-18), the National Center for Advancing Translational Sciences through the Boston University Clinical and Translational Sciences Institute (1UL1TR001430), and the Providence/Boston Center for AIDS Research (P30AI042853).
Role of the Funders/Sponsors: Except for the CDC, which participated in interpretation of data and review and approval of the manuscript, the funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
Disclaimer: The findings and conclusions of this study are those of the authors and do not necessarily represent the official position of the CDC or the National Institutes of Health.
Meeting Presentation: A selection of results from this study were preliminarily presented at IDWeek 2018, October 6, 2018; San Francisco, California.
Additional Contributions: We thank C. Robert Horsburgh, MD (Department of Epidemiology, Boston University School of Public Health), William W. Thompson, PhD (National Center for HIV/AIDS, Viral Hepatitis, STD, and TB Prevention, CDC), and Colin Marchant, MD (Boston University School of Medicine), for critical review, study design, and data visualization advice; and Scott Hadland, MD, MPH, and Alexander Walley, MD, MSc (Boston University School of Medicine), for subject matter expertise consultation. None of these individuals received compensation for their role in the study. We also thank all OCHIN patients for making this study possible.
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