Expert Conversations: Expanding HCV Screening to Include Tough-to-Reach Populations

In this podcast, Talia Segal and Michael Waxman, MD, MPH, talk about their research that investigated the demographics of patients with hepatitis C virus (HCV) before and after the US Preventive Services Task Force updated its screening guidelines.

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Talia Segal

Talia Segal is a first-year medical student at New York Medical College in Valhalla, New York, and a former research coordinator for the hepatitis C team and the emergency department at Albany Medical Center.

Michael Waxman

Michael J. Waxman, MD, MPH, is an attending physician and faculty in the Department of Emergency Medicine at Albany Medical College, as well as an emergency physician and a preventive medicine specialist.



Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

In March 2020, the US Preventive Services Task Force (USPSTF) updated its recommendation for screening for hepatitis C virus (or HCV), which aimed to widen the age range for screening to include more eligible patients. In support of this shift, the medical team at Albany Medical Center widened their screening practices as well. Their study aimed to better understand the demographics of HCV antibody and RNA positivity at their emergency department.

Today I’ll be speaking to 2 authors of the study to find out more about their findings.

Talia Segal: Hi, my name is Talia Segal. I'm a first-year medical student at New York Medical College in Valhalla, New York, and I'm a former research coordinator working with the hepatitis C team and the emergency department at Albany Medical Center.

Michael Waxman: My name is Michael Waxman, and I’m an attending physician and faculty in the Department of Emergency Medicine at Albany Medical College. I'm an emergency physician and a preventive medicine specialist as well.

Amanda Balbi: Thank you both for joining me today. To start, can you talk a little bit about the USPSTF’s changes and how they influenced your study?

Michael Waxman: Actually, the USPSTF screening recommendation happened after we initiated our study. We started screaming maybe about 2 years ago for hepatitis C and what we found was that we captured a lot of Baby Boomers who were antibody positive. There was a very low RNA positivity rate amongst the Baby Boomers who were antibody positive.

But the RNA positivity rate was higher amongst those who were in the younger cohort of folks, including those who injected intravenous drugs. We noticed this phenomenon going on, which was a little bit counterintuitive to the screening of all Baby Boomers and then targeted testing after that.

So, the USPSTF recommendations came out after our study. I think they complement each other and support one another in this idea to not necessarily just screen Baby Boomers and then targeted screening after that, but rather to do universal screening.

Amanda Balbi: Your abstract mentions that there has been a shift away from older adults with active infection and more toward younger adults who are RNA positive. What factors do you think contributed to this shift?

Talia Segal: I think, especially with the demographic shift as Dr Waxman was pointing out, is that while in the past we did notice that there were higher rates potentially of hepatitis C RNA-positive patients within the Baby Boomer cohort, we've noticed that a lot of those people tended to have already been treated and, fortunately, aren't hepatitis C RNA-positive anymore.

The younger age groups tended to have some of the demographics that lead to higher-risk activities, such as people who are using intravenous drugs. We also looked at the homeless population.

And so, certainly those 2 factors we did notice that they had higher RNA positivity rates amongst their groups. Such factors that lead to higher-risk activities are more so contributing to this higher RNA positivity rate and maybe shifting away from this Baby Boomer cohort.

Michael Waxman: Those factors, and we don’t know this for sure, but maybe those Baby Boomers are linked into care a little bit more. Maybe Baby Boomers are more likely to have a primary care doctor who have already screen for this, or maybe they have been overly screened because the USPSTF recommendations already had that. I think all those factors probably contribute, probably the ones that Talia said.

Amanda Balbi: What demographics of HCV antibody and RNA positivity did your team find?

Talia Segal: Specifically, our team looked into these 2 categories of people that either were people who use intravenous drugs or were in the homeless population.

And those 2 populations, we did note had higher risks of being RNA-positive as compared to people who didn't fall into those categories. Those were just 2 major categories that we did notice these higher differences of RNA positivity rate. However, our team has also looked into other demographics, such as gender or insurance. But as of now, we are still looking at that data and we have not noticed any stark differences between those 2 groups.

Amanda Balbi: What is the overall take-home message from your study?

Talia Segal: I believe that the overall take home message from our study is that, as we talked about previously, with these updated USPSTF screening recommendations, they do fall in line with what we've noticed within our own emergency department screening program is that there has been this shift away from just this baby boomer cohort into now potentially screening the population that is aged 18 to 79, including people with these high-risk factors.

Hopefully, what we could do with improving our screening techniques and also just updated recommendations for hepatitis C screening across the country, is that potentially will be finding people at an earlier stage within their infection and we can treat them so that this infection doesn't leave them with more complications down the road.

Michael Waxman: That just occurred to me one of the thoughts we had when we did this: the USPSTF recommendations used to recommend screening Baby Boomers and then other folks

as appropriate based on risk. Well, in the emergency department setting, it's a little hard to assess risk at the bedside. I think what a reasonable policy may have been in the emergency department was to set up a process by which all Baby Boomers were screened for hepatitis C, which sounded like a reasonable thing to do at the time.

I think our data go along and support the USPSTF screening recommendations that that's probably not a great strategy to just go after the Baby Boomers. I think everyone's in agreement so that's our overall take home message. For the better, the USPSTF screening recommendations now state that.

Amanda Balbi: What is the next step in your research?

Talia Segal: For our research in the future, I think that we will be incorporating these changes that the USPSTF screening program recommended into our screening program at Albany Medical Center in the emergency department.

And so, potentially, we will see a shift in the demographics that we previously noted in our current poster presentation and potentially seeing a change in these demographics and what that would be. We don't know, but potentially we could see that over time.

Michael Waxman: The next challenge is really getting the hard-to-reach populations like folks who use intravenous drugs and folks who are homeless. These are some tough-to-reach populations, and there's a lot of work to be done in making sure that they're found, linked to care, and treated.

Amanda Balbi: What steps are necessary to reach the homeless population and get them into care?

Michael Waxman: It's hard. First of all, it's a big challenge. I'll just speak to some of stuff that we've noticed. I don't know that we've researched this or there's any data that show that this is better.

We don't consider ourselves the only cog in the wheel here. We're part of a community-based team. This is a community team effort. And so, for example, we work with our local federally qualified health center called Whitney Young and another community-based organization called Project Safe Point, which is part of a larger organization called Catholic Charities—who've been absolutely integral in terms of getting these folks linked to care.

So, we view this very much as a team-based sport here, not only within our institution but within the entire community. It seems to me like that's an absolute must in terms of reaching these hard-to-reach populations. That's not what we researched necessarily in our program, but it is something that we found anecdotally.

And it's still challenging, despite all this help that we get from our community partners.

Amanda Balbi: Thank you both for joining me today and answering all my questions about your research.

Talia Segal: Thank you so much for having us, Amanda.

Michael Waxman: Great. Thank you so much, Amanda. It was a real privilege.