Lack of Health Insurance Limits the Benefits of HCV Screening
Lack of Health Insurance Limits the Benefits of HCV Screening
Objectives: Identifying barriers to access to hepatitis C virus (HCV) treatment among screen detected subjects is critical for any public health strategy aimed at controlling HCV infection in the general population.
Methods: Data from the National Health and Nutrition Examination Survey HCV Follow-up study from 2001 to 2010 were used. Participants who tested positive for HCV were sent a letter informing them of their test results and advised to pursue further evaluation. Information on HCV transmission and its potential complications was also provided to all positive participants. These subjects were recontacted 6 months after notification to determine what action they had taken regarding the positive result.
Results: Of 38,025 participants, 502 tested positive for HCV infection, giving a prevalence of 1.3% (95% confidence interval (CI) 0.8%, 1.8%). A total of 205 subjects participated in the 6-month follow-up interview. Those who could not be reached were more likely to be less educated, injecting drugs, and not to have health insurance. Half (50.2%) of the positive individuals were not aware of their status before notification. A total of 166 (81%) had pursued further evaluation. Only 18 (26.9%) received therapy. The main reason for not receiving treatment was high cost (19.4%). In adjusted analysis, the only barrier to pursuing downstream HCV care was the lack of health insurance (2.76, 95% CI 1.54, 7.69; P=0.007).
Conclusions: This study suggests that the lack of health insurance may attenuate the theoretical benefits of a screening program that identifies asymptomatic HCV-infected individuals who are less likely to pursue downstream care.
Hepatitis C virus (HCV) is the leading cause of chronic liver disease, hepatocellular carcinoma, and the most common indication for liver transplantation in the United States. A majority of individuals infected with HCV acquired infection in the remote past and are at increased risk for HCV-related complications. Unfortunately, the majority of HCV-infected persons are asymptomatic and unaware of their status. It is estimated that about 45–85% of US adults with HCV are undiagnosed.
In light of the dramatically changing hepatitis C therapeutic landscape, identification of subjects infected with HCV infection is critical. The Center for Diseases Control (CDC) and USPSTF (US Preventive Services Task Force) recommend "birth-cohort" and risk-based screening for chronic HCV infection. A majority of infected persons do not receive antiviral treatment primarily because they are unaware of their infection. While the CDC and USPSTF recommendations for HCV screening are likely to lead to an increase in the detection of asymptomatic individuals, how likely a positive test will lead to downstream HCV care is not known. Identifying and overcoming barriers to downstream access to HCV care is critical for the successful implementation of any public health program aimed at controlling HCV infection in the United States.
The nationally representative National Health and Nutrition Examination Survey (NHANES) data provide a unique window into understanding the scale of challenges in the treatment of HCV-infected individuals identified via screening. We analyzed data from NHANES participants who tested positive for HCV infection between 2001 and 2010 and were reached 6 months later to determine what action they had taken following notification of a positive test result. The main objective was to identify barriers to downstream care after first becoming aware of a screen-positive HCV test. Specifically, we evaluated the influence of demographics, knowledge about HCV infection, and health insurance on downstream care after a screen-positive HCV result.
Abstract and Introduction
Abstract
Objectives: Identifying barriers to access to hepatitis C virus (HCV) treatment among screen detected subjects is critical for any public health strategy aimed at controlling HCV infection in the general population.
Methods: Data from the National Health and Nutrition Examination Survey HCV Follow-up study from 2001 to 2010 were used. Participants who tested positive for HCV were sent a letter informing them of their test results and advised to pursue further evaluation. Information on HCV transmission and its potential complications was also provided to all positive participants. These subjects were recontacted 6 months after notification to determine what action they had taken regarding the positive result.
Results: Of 38,025 participants, 502 tested positive for HCV infection, giving a prevalence of 1.3% (95% confidence interval (CI) 0.8%, 1.8%). A total of 205 subjects participated in the 6-month follow-up interview. Those who could not be reached were more likely to be less educated, injecting drugs, and not to have health insurance. Half (50.2%) of the positive individuals were not aware of their status before notification. A total of 166 (81%) had pursued further evaluation. Only 18 (26.9%) received therapy. The main reason for not receiving treatment was high cost (19.4%). In adjusted analysis, the only barrier to pursuing downstream HCV care was the lack of health insurance (2.76, 95% CI 1.54, 7.69; P=0.007).
Conclusions: This study suggests that the lack of health insurance may attenuate the theoretical benefits of a screening program that identifies asymptomatic HCV-infected individuals who are less likely to pursue downstream care.
Introduction
Hepatitis C virus (HCV) is the leading cause of chronic liver disease, hepatocellular carcinoma, and the most common indication for liver transplantation in the United States. A majority of individuals infected with HCV acquired infection in the remote past and are at increased risk for HCV-related complications. Unfortunately, the majority of HCV-infected persons are asymptomatic and unaware of their status. It is estimated that about 45–85% of US adults with HCV are undiagnosed.
In light of the dramatically changing hepatitis C therapeutic landscape, identification of subjects infected with HCV infection is critical. The Center for Diseases Control (CDC) and USPSTF (US Preventive Services Task Force) recommend "birth-cohort" and risk-based screening for chronic HCV infection. A majority of infected persons do not receive antiviral treatment primarily because they are unaware of their infection. While the CDC and USPSTF recommendations for HCV screening are likely to lead to an increase in the detection of asymptomatic individuals, how likely a positive test will lead to downstream HCV care is not known. Identifying and overcoming barriers to downstream access to HCV care is critical for the successful implementation of any public health program aimed at controlling HCV infection in the United States.
The nationally representative National Health and Nutrition Examination Survey (NHANES) data provide a unique window into understanding the scale of challenges in the treatment of HCV-infected individuals identified via screening. We analyzed data from NHANES participants who tested positive for HCV infection between 2001 and 2010 and were reached 6 months later to determine what action they had taken following notification of a positive test result. The main objective was to identify barriers to downstream care after first becoming aware of a screen-positive HCV test. Specifically, we evaluated the influence of demographics, knowledge about HCV infection, and health insurance on downstream care after a screen-positive HCV result.
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