Hepatitis C Virus Testing in Adults Living with HIV: A Need for Improved Screening Efforts

<div><p>Objectives</p><p>Guidelines recommend hepatitis C virus (HCV) screening for all people living with HIV (PLWH). Understanding HCV testing practices may improve compliance with guidelines and can help identify areas for future intervention.</p><p>Methods</p><p>We evaluated HCV screening and unnecessary repeat HCV testing in 8,590 PLWH initiating care at 12 U.S. HIV clinics between 2006 and 2010, with follow-up through 2011. Multivariable logistic regression examined the association between patient factors and the outcomes: HCV screening (≥1 HCV antibody tests during the study period) and unnecessary repeat HCV testing (≥1 HCV antibody tests in patients with a prior positive test result).</p><p>Results</p><p>Overall, 82% of patients were screened for HCV, 18% of those screened were HCV antibody-positive, and 40% of HCV antibody-positive patients had unnecessary repeat HCV testing. The likelihood of being screened for HCV increased as the number of outpatient visits rose (adjusted odds ratio 1.02, 95% confidence interval 1.01–1.03). Compared to men who have sex with men (MSM), patients with injection drug use (IDU) were less likely to be screened for HCV (0.63, 0.52–0.78); while individuals with Medicaid were more likely to be screened than those with private insurance (1.30, 1.04–1.62). Patients with heterosexual (1.78, 1.20–2.65) and IDU (1.58, 1.06–2.34) risk compared to MSM, and those with higher numbers of outpatient (1.03, 1.01–1.04) and inpatient (1.09, 1.01–1.19) visits were at greatest risk of unnecessary HCV testing.</p><p>Conclusions</p><p>Additional efforts to improve compliance with HCV testing guidelines are needed. Leveraging health information technology may increase HCV screening and reduce unnecessary testing.</p></div

Proportion of Patients Screened for HCV Infection, HCV Antibody Positive, and Unnecessarily Tested for HCV Infection (2006–2011).

<p><b>Abbreviations:</b> HET, heterosexual transmission; IDU, injection drug use; MSM, men who have sex with men.</p><p>*Continuous variables were dichotomized to facilitate calculation of proportions. The mean value divided the number of outpatient HIV visits during the observation period into two groups; whereas the number of inpatient and emergency department visits during the observation period differentiated between 0 and 1 or more visits.</p>†<p><i>P</i><0.05 when comparing differences in the proportion screened for HCV using the χ² test.</p>‡<p><i>P</i><0.05 when comparing differences in the proportion HCV antibody positive using the χ² test.</p>§<p><i>P</i><0.05 when comparing differences in the proportion unnecessary tested for HCV using the χ² test.</p

Proportion of Patients Screened for HCV Infection, HCV Antibody Positive, and Unnecessarily Tested for HCV Infection by HIV Outpatient Utilization. Note:

<p>The mean value divided the number of outpatient HIV visits during the observation period (13.92) into two groups – low and high.</p

Factors Associated with HCV Screening and Unnecessary Repeat HCV Testing.

<p><b>Abbreviations:</b> CI, confidence interval; HET, heterosexual transmission; IDU, injection drug use; MSM, men who have sex with men.</p

Demographic and Clinical Characteristics of HIV-infected Patients.

<p><b>Abbreviations:</b> HET, heterosexual transmission; IDU, injection drug use; MSM, men who have sex with men.</p><p>*Mean number of outpatient, inpatient, and emergency department visits over the observation period were: 13.92 (standard deviation12.03), 0.75 (1.86), and 1.41 (3.70), respectively.</p

Geographic distribution of North American AIDS Cohort Collaboration on Research and Design (NA-ACCORD) clinical sites contributing to these analyses.

<p>Non-contributing sites were interval cohorts, Canadian cohorts (excluded due to the focus on US clinical care populations), or cohorts not currently contributing HIV primary care encounter data to the NA-ACCORD.</p

Proportion of Patients Screened for HCV Infection, HCV Antibody Positive, and Unnecessarily Tested for HCV Infection by HIV Transmission Behavior. Abbreviations:

<p>HET, heterosexual transmission; IDU, injection drug use; MSM, men who have sex with men.</p

Adults retained in clinical care in the NA-ACCORD, according to demographic and clinical characteristics, 2008–2010.

<p>Retention defined by the Institute of Medicine's and Department of Health and Human Services' retention indicators.</p><p>DHHS: Department of Health and Human Services; Hetero: heterosexual contact; IDU: injection drug use; IOM: Institute of Medicine; MSM: male sexual contact with men.</p><p>DHHS Indicator: ≥1 visit in each semester (January–June or July–December), >60 days apart, over a 2-year period.</p><p>IOM Indicator: ≥2 visits in each calendar year, >90 days apart, over a 2-year period (this definition was extended from 1 to 2 years for direct comparison with the DHHS indicator).</p><p>a: all different from 0, p<0.01;</p><p>b: Area under receiver-operating characteristic curves resulting from logistic models accounting for clustering across two years with robust variances adjusted for respective covariates, with “Total” category adjusted for all covariates.</p><p>c: At first measurement in 2008 or 2009; d: For ≥6 months in 2008 and 2009 or in 2009 and 2010; e: At last measurement in 2009 or 2010.</p><p>All characteristics differed different by the percentages retained across different indicators, χ² p<<0.001. Percentages may not sum to 100 due to rounding or missing values.</p><p>Adults retained in clinical care in the NA-ACCORD, according to demographic and clinical characteristics, 2008–2010.</p

Demographic and Clinical Characteristics of the Sample and Association with Retention/Suppression Status in 2010.

<p><b>Abbreviations:</b> ART, antiretroviral therapy; HET, heterosexual transmission; HIV, human immunodeficiency virus; IDU, injection drug use; MSM, men who have sex with men; R = retained; S = suppressed (virologically); NR = not retained; NS = not suppressed (virologically).</p><p>All associations are statistically significant, p<0.001.</p><p>^a Column percentages.</p><p>^b Row percentages.</p><p>Demographic and Clinical Characteristics of the Sample and Association with Retention/Suppression Status in 2010.</p

Proportion of Patients with Virologic Suppression (≤400 copies/mL), by Age Group and Weeks from cART Initiation.

<p>Proportion of Patients with Virologic Suppression (≤400 copies/mL), by Age Group and Weeks from cART Initiation.</p