Universal HCV Screening Economical Over Risk-Based Screening in Pregnant Women

According to a new study from researchers at the University of Louisville, combining universal screening for the hepatitis C virus (HCV) with reflex RNA PCR in pregnant women is more cost-effective than risk-based screening. The results were presented as part of the proceedings at The Liver Meeting hosted by The American Association for the Study of Liver Diseases (AASLD), November 9-13, 2018, in San Francisco, California.

CDC speculates that a recent spike in reported HCV infections in individuals below 39 years of age could be attributed to an increased number of pregnant women with this infection and infants exposed to the virus at birth. The challenge, according to the CDC, is the current recommendation for risk-based screening among women of child-bearing age, which in turn fails to identify infected pregnant women due to the often-asymptomatic nature of the viral infection.

While CDC and the American College of Obstetrics and Gynecology (ACOG)¹ recommend risk-based screening for pregnant women, AASLD recommends universal screening.

The authors explain that increased costs associated with their recommended combination screening would be offset by the fact that women who would otherwise remain undiagnosed will now be identified and linked to care.

For their study, the authors retrospectively analyzed risk-based screening from May 1, 2014, through December 31, 2015, and conducted a prospective analysis of universal screening from May 1, 2016, through December 31, 2017. Data were gathered on about 19,453 pregnant women between 2014 and 2017—universal screening, the analysis found, increased the likelihood of a confirmatory RNA PCR result.

While universal screening cost $308 more per patient, the associated incremental cost-effectiveness ratio was $18,139 for each active infection that was identified, with a quality-adjusted life year gained of $4662, which is below the willingness-to-pay cost-effectiveness threshold, according to the authors.

“Approximately 50 percent of those infected with HCV do not know they’re infected. Diagnosis is the first step in linkage to care,” Michelle Rose, MBA, the study’s co-author, said in a statement. “Research suggests that most infants acquire HCV infection during the delivery process. Pregnant women should be made aware the infection can be transmitted to their infant.”

The study authors conclude that risk-based screening may prevent women from getting the care they need simply because they were not diagnosed, which could increase healthcare costs downstream. Universal screening, on the other hand can circumvent this problem.

Rose hopes that their findings will lead to the development of new screening policies “to allow providers to quickly identify active, chronic HCV infection and subsequently link these patients to care or a cure.”

At the authors’ institutions, nearly 80% of the HCV infections diagnosed each month are in pregnant women. This has led to a new bill in Kentucky, SB250, which recommends that all pregnant women be tested for hepatitis C and that all children of women who tested positive when pregnant be tested for HCV as well.

Rose and her co-workers have taken the study to the next level, evaluating screening and linkage to care strategies among women diagnosed when pregnant and among infants and children exposed to HCV—prenatal or in their home.

Reference

1. Society for Maternal-Fetal Medicine (SMFM); Hughes BL, Page CM, Kuller JA. Hepatitis C in pregnancy: screening, treatment, and management. Am J Obstet Gynecol. 2017;217(5):B2-B12. doi: 10.1016/j.ajog.2017.07.039.