September 20, 2019
U.S. Preventive Services Task Force
5600 Fishers Lane Mail Stop 06E53A
Rockville, MD 20857
Attention: Hepatitis C Virus Infection in Adolescents and Adults: Screening
Submitted via: uspreventiveservicestaskforce.org
To Whom It May Concern,
On behalf of the National-Nurse Led Care Consortium (NNCC), I thank you for the opportunity to comment on the proposed Recommendation Statement regarding “Hepatitis C Virus Infection in Adults and Adolescents: Screening.” As an organization, NNCC supports nurse-led care, and advocates for nurse leaders across sectors. As a part of this mission, we provide public health programming to health centers to improve testing, linkage to care, and treatment for hepatitis C virus (HCV).
I. Additional evidence and viewpoints: NNCC believes that the recommendation should include evidence that patients in active substance use have similar treatment completion rates and sustained virological response (SVR) to those who do not use substances. Several studies have found no statistical difference in treatment outcomes for patients who remained abstinent from drugs and those who either relapse or do not have co-occurring substance use disorders.
II. Clarifying the draft Recommendation Statement: NNCC recommends several ways to make the draft Recommendation Statement clearer, including:
a. Designating best practices for testing: NNCC recommends that health care providers use the HCV antibody test that automatically reflexes to test the PCR RNA as a best practice. This test uses one blood draw rather than two and requires only one appointment for patients, which avoids delay in confirming diagnoses for positive patients.
b. Denoting Screening Intervals: NNCC recommends that high-risk patients are tested every three to six months, specifically those in active injection drug use and/or those with HIV or HBV co-infection.
c. Expanding on Screening Implementation: NNCC recommends that health care staff and providers use opt-out screening language rather than voluntary testing opt-in language to increase the likelihood of patients accepting the HCV test.
d. Treatment: Although treatment is not recommended for pregnant women who are HCV positive, there should be guidance on monitoring the mother and child after birth to avoid chronic infection for the mother and discuss treatment options for the child, if HCV is transmitted during labor.
e. Update to Previous USPSTF Recommendation: NNCC suggests that the recommendation include that initiating treatment at earlier stages of disease will avoid high medical costs for complications from chronic HCV, such as liver disease, as well as fewer deaths from long term disease.
III. Excluded information: While the Draft Recommendation Statement will increase the number of people screened for HCV, it does not discuss the Medicaid treatment restrictions that pose barriers for patients to access treatment. Higher screening rates will lead to increased diagnoses of HCV, which will require increased access to treatment. Several states’ Medicaid programs still have treatment restrictions before patients can be approved for medication:
a. Fibrosis Score Restriction: Pennsylvania has eliminated Fibrosis Score restrictions for Medicaid beneficiaries that prevented diagnosed patients from receiving appropriate care. This prevented patients from accessing affordable medication to treat the disease at earlier stages, which would avoid complications and long-term health consequences.
b. Sobriety Restriction: Pennsylvania has eliminated sobriety restrictions because of aforementioned research that shows patients in active substance use can complete treatment at the same rates as those without mental health or substance use disorders. Research also shows that substance use does not interfere with success of HCV treatment. Sobriety restrictions are stigmatizing to patients with diagnosed behavioral health and substance use disorders, and prevent those patients from accessing treatment the way other patients with HCV do.
c. Provider Restriction: Due to the success of different medications that treat HCV, it is not required that a specialist, such as an infectious disease physician or hepatologist, treat patients with HCV. Primary Care Providers can gain capacity and knowledge through accessible trainings and consultation with specialists to treat their patients with HCV and successfully guide them through treatment. NNCC advocates for the USPSTF to recommend the elimination of provider restrictions nationally.
IV. Resources and Tools: NNCC requests that the USPSTF provide resources for health settings to locate increased financial support for screening tests, required labs, and treatment for under- and uninsured patients. V. Our Experience: Benefits of Early Detection or Treatment:
a. Public Health Management Corporation (PHMC) Health Centers in Philadelphia, PA started routine HCV screening for patients 18 and older in 2013. Since implementation, the PHMC health centers have more than doubled the number of patients screened, and due to increased screening, the rate of positive cases went from 4.5% to 5.3%. Therefore, PHMC health centers have seen 52.8% more patients who have completed treatment.
NNCC appreciates the opportunity to comment on this draft recommendation statement.
Sarah Hexem Hubbard, Esq.
National Nurse-Led Care Consortium