The next time a doctor tells you they are going to draw your blood and work up some numbers, chances are they will be looking for more than potassium: hepatitis C.
Even if you've never used needles, served time in prison, visited an unregulated tattoo parlor, undergone a blood transfusion in a remote locale, engaged in high-risk sexual behavior or any of the other risk factors for the chronic infection, if you are an adult, chances are you will be getting tested.
The change is coming thanks to the U.S. Preventive Services Task Force, an expert panel charged with evaluating the effectiveness of medical procedures for the federal government. This week, the panel closed the window for comments on a draft recommendation expanding the pool of Americans who should be routinely tested for hepatitis C. The list once included just those mentioned above and a cost-effective cohort of persons born between 1945 and 1965.
It now includes everyone between the ages of 18 and 79.
"We were thinking this was coming," says Dr. Stacy Rizza, a Professor of Medicine and specialist in infectious disease at Mayo Clinic, "just because it's cost-effective to diagnose anybody who could potentially have hepatitis C and get them treated and cured. That's a lot cheaper than treating them when they are in end-stage liver disease."
The operative word in that sentence is "cured." It's not a word you hear very often in medicine. But ever since a class of antivirals capable of curing hepatitis C in 95% of cases hit the market in 2014, the standard for who should be tested has changed.
"In the past, if someone was diagnosed we didn't have great drugs to treat them," says Rizza. "So it was almost like, what's the use of diagnosing other than helping prevent new infection? Today, people with the illness have a 95% chance of a cure. So it makes sense to do universal screening, figure out who has infections, get them linked to care, treated and cured of their infection before it causes liver disease or they have a chance to transmit it to other people. So I think it's a great thing."
The recommendations still need to pass a final review but, once adopted, will mean the test is likely to be covered by most insurers, Medicare and Medicaid. Like HIV testing, hepatitis C will become an opt-out test, meaning that clinicians will be required to disclose you are receiving it, but not ask for permission. Only patients who explicitly state they do not wish to be tested for hepatitis C will bypass the test.
"What it means is a provider doesn't have to spend time inquiring about a person's background, and can just do the test," says Rizza.
Hepatitis C is capable of causing jaundice and destroying the liver over time, requiring transplant surgery. It can progress to cancer, liver cirrhosis and early death. Though the illness affects just 3.5 million Americans, it often comes with no symptoms, increasing the need for screening. Adding to the urgency is that the infection has spread in the wake of the opioid epidemic.
The downsides of over-screening are many, including the cost and worry of false alarms, not to mention the possibility of treatment-induced harm. Because hepatitis C testing can trigger false positives, the panel is likely to recommend confirmatory testing. The real impact of universal screening will be the high cost of antivirals.
When the drugs first came onto the market, Harvoni and Sovaldi jump-started arguments over price-gouging by charging $1,000 per pill, a price point ensuring that curing the virus would run $60,000-$90,000 per patient. Other drugs have since driven down the price tag of clearing the virus, but it remains high.
"The vast majority of insurance companies will cover them," says Rizza, "because it's cheaper for them to treat hep C than end stage liver disease. The challenge is, it takes a lot of prior authorization and hoops to jump through. ... Fortunately, there are many drugs that treat hep c, and they are all very effective."
For those who ask why they need to get screened for something they don't fear having contracted, clinicians say it helps to remember that in the eyes of a doctor, your being wrong about your likelihood of having an asymptomatic infection is ultimately about more than just you.
"Infections are infectious," says Rizza. "If you don't screen for colon cancer and you miss colon cancer, one person dies. If you don't screen for HIV or hep C and miss that infection, you have one person getting sick as well as all the people they are exposing. So to an infectious disease doctor, I think this is great."