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IDSA/AASLD changes in HCV guidance:
An update on the latest recommendations
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Download the PDF here
5/30/23
Hepatitis C Guidance 2023 Update: AASLD-IDSA Recommendations for Testing, Managing, and Treating Hepatitis C Virus Infection
Clinical Infectious Diseases
25 May 2023
Abstract
The Infectious Diseases Society of America and the American Association for the Study of Liver Diseases have collaboratively developed evidence-based guidance regarding the diagnosis, management, and treatment of hepatitis C virus (HCV) infection since 2013. A panel of clinicians and investigators with extensive infectious diseases or hepatology expertise specific to HCV infection periodically review evidence from the field and update existing recommendations or introduce new recommendations as evidence warrants.
This update focuses on changes to the guidance since the previous 2020 published update, including ongoing emphasis on recommended universal screening; management recommendations for incomplete treatment adherence; expanded eligibility for simplified chronic HCV infection treatment in adults with minimal monitoring; updated treatment and retreatment recommendations for children as young as 3 years old; management and treatment recommendations in the transplantation setting; and screening, treatment, and management recommendations for unique and key populations.
Implementation of Universal HCV Screening
The guidance panel first recommended universal HCV screening for all adults aged ≥18 years in 2019 [5], concomitant with congruous draft recommendations from the US Preventive Services Task Force (USPSTF) and the CDC. The USPSTF subsequently recommended universal HCV screening for adults aged 18 to 79 years in March 2020 [8]. In April 2020, the CDC recommended HCV screening at least once in all adults aged ≥18 years and for all pregnant persons during each pregnancy, except in settings where HCV prevalence is <0.1% [9]. The rationale for universal HCV screening includes cost-effectiveness [10-13]; improved HCV case finding [8, 9]; shifting epidemiology of HCV infection with incident infections occurring primarily in young adults [14-16]; and the availability of safe, cost-effective direct-acting antiviral (DAA) treatment [17]. Universal screening is a crucial and necessary component of any HCV elimination strategy [1-4] because it is the entry point into the HCV continuum of care [18,19]. For initial HCV testing, the guidance panel recommends HCV antibody screening with reflex HCV RNA testing to establish the presence of active infection (as opposed to spontaneous or treatment-induced viral clearance).
Recommendations without rigorous implementation, however, are ineffectual.
HCV screening, diagnosis, and treatment were significantly adversely affected by the COVID-19 pandemic [20]. The number of HCV antibody and HCV RNA tests processed by a large US, multicenter, commercial clinical laboratory decreased precipitously beginning in mid-March 2020 [21] coincident with the US federal government declaring a national state of emergency due to COVID-19 [22]. HCV RNA positive test results decreased 62% in March 2020 and remained 39% below baseline in July 2020, with a concomitant decline in the number of DAA prescriptions dispensed [21]. Investigators who conducted a similar study in Ontario, Canada reported comparable decreases in HCV antibody screening and confirmative HCV RNA testing during each of the first 3 waves of the COVID-19 pandemic [23]. The reduced level of HCV testing negatively affecting initiation of HCV treatment appears corroborated by findings from a US national, retrospective study wherein only 23% of people on Medicaid with a positive HCV RNA test between January 30, 2019 and October 31, 2020 initiated treatment DAA within 360 days of diagnosis [24]. A survey conducted among European Association for the Study of the Liver members representing 48 clinical centers also demonstrated decreased HCV testing, diagnosis, and treatment in 2020 compared with 2019 (prepandemic) [25]. Collectively, these findings underscore the critical importance of ongoing, rigorous, universal HCV screening for case identification and linkage to care. In addition, monitoring the proportion of persons meeting steps in the HCV cascade of care will be critical to assessing the quality of HCV care.
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