By: Marcus J. Hopkins, Blogger
At the International AIDS Society’s (IAS’) 4th Annual HIV/Viral Hepatitis Co-Infection Meeting in Paris, France, aside from all of the various data regarding rates of infection around the globe and various approaches to eradicating Hepatitis B and C (HBV/HCV, respectively) by the World Health Organization’s (WHO’s) target year of 2030, one assertion rang true throughout: all of these projections and approaches will require robust Harm Reduction measures to be put in place.
For the uninitiated, Harm Reduction measures are various laws, regulations, and statutes put into place in order to reduce injury or death from a specific cause; a good example of this would be a Seat Belt Law. As they relate to Viral Hepatitis (VH), Harm Reduction statutes include various methods of reducing the likelihood of infection (and thereby death), such as the mandatory use of Prescription Drug Monitoring Programs (PDMPs), ID requirements for the purchase of prescription opioid drugs, and prescriber education about the risks of prescribing opioids and proper opioid usage. One set of measures, however, would serve several purposes: mandatory or compulsory screening requirements for HIV, Hepatitis B, and Hepatitis C.
A handful of states (CT, FL, MA, NY, and PA) have considered or passed mandatory screening guidelines for the Birth Cohort (people born between 1945-1965). These guidelines are largely inefficient, because they rely upon an “Opt-In” method of screening, meaning that patients are offered screening, and must accept – it’s optional. Additionally, these measures focus only on the Birth Cohort, and understandably so, as they represent the largest percentage of existing HCV cases. These approaches, while well-intentioned, must be amended and updated on a national level, in order to effectively combat the spread of both HBV and HCV.
An estimated 70% of new Acute HCV infections are related to Injection Drug Use (IDU) by People Who Inject Drugs (PWIDs). That none of these screening guidelines make mention of these facts is indicative of our inability to accurately capture the data we need in order to adequately assess the scope and scale of the epidemic. Statistics at the state and national levels are largely reached using modeling that projects an estimated number that ostensibly accounts for underreporting. PWIDs are, however, notoriously difficult patients from whom to capture data, in no small part because we see them consistently in only a handful of healthcare settings: Hospitals for overdoses, Prisons, Jails, and Juvenile Detention Centers for incarceration, and Rehabilitation facilities. In addition, Syringe Services Programs (SSPs) are another excellent point of data collection, but it must be handled differently than those previously listed.
The most effective method of screening is to make it compulsory (mandatory) on an “Opt-Out” basis in which patients are informed that screening for HIV, HBV, and HCV are part of a required set of screenings, and they must provide “informed refusal” of the test. This requires that all hospitals, clinics, justice/incarceration settings, and rehabilitation facilities adopt this method of screening in order for the most effective use of time and money that will result in the most accurate data captures. When opioid and heroin users overdose and are the recipient of emergent care services, this is the prime location to capture data from PWIDs. The same holds true for those who are moved into justice settings, as well as those who enter rehabilitation services. Additionally, with the use of rapid HCV antibody testing, this can be accomplished in a relatively short period of time. The important part is ensuring that each Positive test result is followed up with an immediate secondary confirmatory screening, rather than scheduling a second appointment.
These types of compulsory screening requirements are paramount to achieving the WHO’s goal of eradication of HBV and HCV by 2030. Once patients know their status, with proper linkage to care services, they can be cured of HCV and treated for HBV with relative ease. This will, of course, require an investment on the part of state, Federal, public, and private partners, and until we have Federal movement on these issues, the best location to start is at the state-level. Personally, I am working on an endeavor with one of West Virginia’s delegates to work on building a workable and FUNDED compulsory screening requirement as close to the one I suggested above, given the complex nature of WV’s budgetary constraints. We at HEAL Blog invite you to do the same, in order to ensure that compulsory screening becomes a reality.
Disclaimer: HEAL Blogs do not necessarily reflect the views of the Community Access National Network (CANN), but rather they provide a neutral platform whereby the author serves to promote open, honest discussion about Hepatitis-related issues and updates. Please note that the content of some of the HEAL Blogs might be graphic due to the nature of the issues being addressed in it.