Hepatitis C screening in the United States: current models and challenges

Background: The prevalence of hepatitis C in the United States is estimated to be 1-1.5% (2.7 to 3.9 million persons). Birth-cohort screening with linkage to care is recommended to augment risk-based screening programs in reducing hepatitis C-associated morbidity and mortality. However, only a small percentage of hepatitis C patients are identified and have received treatment. Aims: To better understand the challenge of screening and linkage to care, we review the reported prevalence of hepatitis C infection among different risk groups in the United States, examine current hepatitis C screening models, identify barriers for hepatitis C screening, and discuss approaches for improving screening. Methods: We searched electronic databases (PubMed and Cochrane Library) to identify articles published from 2008 to 2014 on risk-based and birth-cohort hepatitis C screening programs. Results: Studies have revealed that risk-based and birth-cohort screening programs alone are insufficient to reduce hepatitis C-related morbidity and mortality. Hepatitis C infection is more prevalent in high-risk groups such as persons who inject drugs, incarcerated inmates, persons living with HIV, and persons born between 1945 and 1965. Barriers to hepatitis C screening are observed in patients, providers, and structural insufficiency in the health care system. Gaps exist in the linkage to care after hepatitis C diagnosis, which include bridging patients to subspecialty care providers, medication access with resources for on-treatment monitoring, and patient motivation to receive treatment. Conclusions: Risk-based screening approaches should be expanded to birth-cohort screening to improve the capture rate of patients infected with hepatitis C. Hepatitis C remains an underdiagnosed and undertreated disease in the United States. Thus, patient and physician education with structured programs are needed to address the issues of implementing risk-based and birth-cohort screening. Further studies are needed to determine the appropriate model of linkage to care after identifying those patients from screening as current therapies are highly effective and treatment can reduce disease progression with the possibility of global eradication of hepatitis C infection.