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 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

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

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

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

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

Age-specific unweighted mortality rates (per 1000 person-years), by calendar-period, among individuals on ART in the NA-ACCORD, 2000–2007.

<p>Note: PY, person-years; ART, combination antiretroviral therapy.</p

Flow charts showing selection into each of the two analyses.

<p>Gray indicates the population of interest for the propensity score-matched analyses.</p

Life expectancy estimates (LEE) and standard errors (SE) at age 20 years using unweighted mortality rates, by calendar period, 2000 to 2007.

<p>Note: LEE, <i>life expectancy estimate (years)</i>; SE, <i>standard error</i>; ART, <i>combination antiretroviral therapy</i>.</p

Life expectancy estimates (LEE) and standard errors (SE) at age 20 years using weighted and unweighted mortality rates, 2000 to 2007.

<p>Note: LEE, <i>life expectancy estimate (years)</i>; SE, <i>standard error</i>; ART, <i>combination antiretroviral therapy</i>.</p><p>In effort to reduce bias from informative censoring, we used weighted regression methods to estimate mortality rates, using an indicator variable that was created to identify participants who were lost to follow-up. Further details are available in <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0081355#pone.0081355.s002" target="_blank">Appendix S2</a>.</p