Background
Hepatitis C remains the most common blood-borne chronic viral infection in the United States. According to recent estimates1,2, as many as 5 million Americans are infected with the hepatitis C virus (HCV). Most cases will develop into chronic infection, increasing the risk for developing chronic liver diseases, such as cirrhosis and cancer. Goals for preventing chronic hepatitis C in the United States involve eliminating viral transmission and reducing morbidity and mortality among persons infected with HCV. An effective HCV screening strategy is essential for accomplishing these goals. The CDC currently recommends HCV screening for only individuals with a previous history of certain behaviors or health indicators that are associated with HCV infection, such as injection drug use, Hemodialysis, or abnormal liver function tests3,4. Despite these recommendations, most persons living with HCV remain unaware of their infection status, and many of those who are known to be positive for HCV do not receive necessary care and treatment5,6. As a result, the burden of disease and death continues to grow despite recent advances in antiviral therapies. This position paper represents the views and recommendations of the Chronic Liver Disease Foundation (CLDF) for a more effective strategy to identify patients with HCV infection and link such patients to expert care and treatment.

Current Hepatitis C Screening and Testing
The number of patients with chronic hepatitis C that will progress to cirrhosis, liver failure, HCC, and death is expected to increase dramatically over the next decade7,8. Without changes to the HCV Diagnosis and treatment paradigms, total medical costs for patients with HCV infection are expected to more than double, from $30 billion to over $85 billion over the next 20 years9. The prevalence of HCV is highest in middle-aged, non-Caucasian men and may be as high as 40% in the homeless and incarcerated5. Infection with HCV is also most prevalent among people born between 1945 and 196510,11. Unfortunately, many of these patients are unaware of their infection and remain at risk for serious complications as time passes due to the slow, progressive nature of the disease. Currently, the CDC recommends testing for HCV antibody only in individuals with identifiable health indicators or risk factors that suggest possible exposure to HCV4. Despite these recommendations, up to 75% of patients with chronic hepatitis C areunaware of their HCV infection status6. Reasons for the failure to identify patients with chronic Hepatitis C include:


(a) asymptomatic patients without any other medical problems may not seek medical attention,
(b) many primary care physicians lack knowledge about risk factors and testing for hepatitis C,
(c) patients may be reluctant to reveal risk factors, and
(d) patients may be outside healthcare system (young, poor, drug addicts).

Birth Cohort-Based HCV Screening
The prevalence of HCV infection among persons born between 1945 and 1965 is estimated to be 4.5 times higher than for persons born outside this birth cohort10,11. The CDC is evaluating the potential benefits of using a birth-cohort based approach to HCV screening to expand current screening recommendations and increase identification of HCV-positive patients12. This strategy avoids some of the limitations of a risk-based approach to HCV screening. A recent study by Rein et al. indicates that birth-cohort screening for HCV is cost effective and could potentially identify an additional 800,000 cases of chronic hepatitis C13.