HCV is on many people’s minds here at the 2006 IAC for two important reasons. First of all, because HCV and HIV are spread in many of the same ways, a large number of people are co-infected with the two viruses at once. Second, because HCV causes liver failure, it magnifies the hepatoxicity of antiretroviral drugs.
I had the opportunity to attend a session on HCV yesterday, which covered several HCV-related studies. These studies ranged from HCV prevalence in Zanzibar to HCV risk factors among incarcerated Canadian youths. The information covered was all fascinating, but it was a comment from a member of the audience that really caught my attention. The young man was involved with the Committee of 10,000, an HCV advocacy organization from California. I regret not having a voice recorder, but his question as I remember it was this:
We know that the people at risk for HCV are the same as those at risk for HIV. We also know that HCV kills almost as many people as HIV, and infects more than three times as many. With those things in mind, why are we not using our thousands of HIV testing sites to also offer screening and testing for HCV?
What do you think?
I responded in the comment section, and I'm cross-posting here -- after the jump.
Good question, complicated answers -- I'll speak from a United States perspective; I'd be very interested in hearing views and experiences from other countries.
Here's several angles:
1. The majority of funding for HIV testing comes from the U.S. Centers for Disease Control & Prevention. The CDC allows community-based organizations to offer hepatitis C testing using CDC HIV prevention funds; however, my impression is that very few community groups offer hepatitis C testing through their CDC-funded programs.
2. The CDC also has a Division of Viral Hepatitis, responsible for hepatitis C activities. The current internal restructuring at the CDC will move this division into the same center as the CDC's HIV division, and will hopefully result in greater collaboration and integration. However, the Division of Viral Hepatitis receives very little funding -- only $16.7 million for hepatitis C in fiscal year 2006 (down from a peak of $19.4 million in FY 2003). Advocates have been requesting (so far unsuccessfully) that Congress increase the division's budget to $50 million.
3. The CDC's Division of Viral Hepatitis funds hepatitis C coordinators in nearly all 50 states, plus a few cities and the Indian Health Service. States only get enough funding to cover the cost of the coordinator's salary, so most coordinators have little or no budget for programs and services such as hepatitis C testing. By necessity, the coordinators and the CDC have worked hard to promote integrating hepatitis C into other programs and settings -- particularly STD clinics, HIV programs, jails and prisons, substance abuse treatment, AIDS service organizations. The CDC has funded a number of successful demonstration projects and training initiatives on integrating viral hepatitis into existing services and structures -- including a pilot study in California found that offering hepatitis C testing to injection drug users alongside HIV testing actually increased the number of people getting an HIV test (showing that adding hepatitis C testing creates an incentive for more HIV testing). Unfortunately, there's just no money to replicate and sustain this work.
4. SAMHSA (the Substance Abuse & Mental Health Services Administration, part of the federal Department of Health & Human Services) also funds hepatitis C testing in substance abuse treatment programs. However, most of this funding is bundled with HIV testing, and it's not clear to me how much directly supports hepatitis C testing, and how many tests are administered annually through these funds.
5. The main overlap in risk factors between hepatitis C & HIV comes from injection drug use, and this is where it makes the most sense to offer testing for both viruses at the same time & place. A 2001 survey of U.S. substance abuse treatment facilities found that nearly all methadone programs offered some hepatitis C testing, and 2/3rds of drug-free treatment programs offered testing. However, not all of these programs offered testing to all of their patients, and only 60% of patients offered testing provided a blood sample -- meaning that roughly 30% of substance abuse treatment patients actually got tested. A 2002 survey of syringe exchange programs found that 43% provided hepatitis C testing; that number has likely risen in the past four years. Among surveys of syringe exchange participants in New York City conducted by my organization, the overwhelming majority of injection drug users indicate that they've been tested for hepatitis C, though needle exchange programs in New York and elsewhere reach only a fraction of injectors. Jails and prisons are also (unfortunately) logical places to test for hepatitis C; various surveys find prevalence rates ranging from 15% to 40% among incarcerated persons. Yet most correctional facilities have not implemented hepatitis C testing -- and have resisted taking on responsibility for medical care and treatment.
6. In general, sexual transmission of hepatitis C is considered rare, especially between monogamous heterosexual partners. Several reports from Europe, with some anecdotal support in the U.S., describe clusters of hepatitis C transmission among HIV+ men who have sex with men. Some U.S. surveys of people attending STD clinics have found a higher rate of hepatitis C (say, 4-10%) among gay men as well as sex workers. However, many of these cases may have resulted from injection drug use rather than sexual transmission, and much of the epidemiological data on hepatitis C (particularly in the U.S.) is likely confounded by underreporting of injection drug use due to stigma -- hence overstating the role of sexual transmission. Indeed, a recent report of a large cohort of HIV-negative gay men in Canada found no cases of new hepatitis C infections. For these reasons, hepatitis C is not typically classified as a sexually transmitted disease; sexual transmission can and does happen, but much more rarely and less efficiently than with "classic" sexually transmitted infections.
7. The U.S. Preventive Services Task Force, an independent panel with a great deal of influence on medical guidelines and reimbursement, reviewed evidence on hepatitis C testing in 2004 and recommended against screening for the "general population". They "found insufficient evidence to recommend for or against routine screening for HCV infection in adults at high risk for infection." However, other professional associations (infectious disease and liver specialists) and health officials -- along with community groups and advocates -- repudiated that assessment and recommend testing for adults at high risk. 'High risk' is defined in various ways - people who have ever injected drugs are always considered at high risk, but people with a potential sexual exposure (e.g. categories such as multiple sex partners, men who have sex with men or sex workers) are usually not considered at high risk and hepatitis C testing is not recommended (with some flexibility around sex partners of people with hepatitis C, where testing is typically framed around relieving anxiety than any actual/substantial risk of transmission).
8. U.S. guidelines on care and management of people living with HIV recommend that all PWHIV (regardless of mode of transmission) be tested for hepatitis C. Of course, guidelines don't always get translated into clinical practice. I've heard that (according to chart reviews conducted under the auspices of the state health department), over 90% of PWHIV in medical care in New York have been tested for hepatitis C. But I've also heard that hepatitis C testing is unevenly/inconsistently implemented in HIV care in many parts of the U.S. Also, there are no clear guidelines for repeat testing of people initially testing negative for hepatitis C who remain at risk -- though virtually all HIV+ injection drug users likely acquired hepatitis C before HIV.
9. The shift to oral HIV testing, and more recently rapid HIV testing, poses challenges for adding hepatitis C testing. Ideally, you could go to a testing site and provide one sample (whether it's a blood draw or oral swab) that would be tested for both viruses, and receive the results at the same time. Right now, hepatitis C testing requires a blood sample, and results take 1-2 weeks -- while in many places, you can take an HIV test with an oral swab and get the results in 20 minutes. OraSure Technologies (makers of the oral, rapid HIV test) is developing a rapid oral hepatitis C test, which may reach the market in 2007.
10. Diagnosing hepatitis C infection poses a distinct set of challenges in comparison to HIV. For both viruses, the initial test looks for virus-specific antibodies. With HIV testing, the presence of antibodies clearly and invariably indicates infection (setting aside recent concerns about false positives among people with 'preliminary positive' results on the rapid oral HIV test). With hepatitis C testing, the presence of antibodies only indicates that a person has been infected at some point -- 25% of people infected with hepatitis C clear the virus within a few months after exposure. Therefore, people receiving positive hepatitis C antibody results need a second test (qualitative viral load) to determine whether they're still (chronically) infected with hepatitis C. These hepatitis C quantitative viral load tests are only available from doctors; even health department-run HIV/STD testing sites offering hepatitis C testing don't offer anything beyond the antibody test. Moreover, people receiving positive results on hepatitis C tests (whether the initial antibody test, or the viral load test to diagnose current/chronic infection) often receive confusing or inadequate information about hepatitis C -- many report uncertainty about whether they'd been diagnosed with hepatitis C vs. hepatitis A and B, whether it's a past (resolved) or active infection, and the implications to their health and whether they need medical care or treatment.
In short -- it's a complicated issue, but ripe for advocacy: we can push for more federal funding, and advocate on the local level for more integration in HIV testing and prevention programs. And on all levels, place testing in a broader framework of hepatitis C education, support, medical care, and treatment.
Harm Reduction Coalition