Screening all adults who visit emergency department for hepatitis C virus (HCV), regardless of their risk profile, uncovered significantly more cases than a more targeted approach, according to study findings published in JAMA. But despite improved detection, only about 1 in 10 newly diagnosed patients ultimately started treatment and achieved a functional cure, underscoring persistent gaps in follow-up care.

Over time, chronic hepatitis C can lead to serious liver complications, including cirrhosis and liver cancer. But the infection is often asymptomatic at early stages, and a majority of people are not aware they carry the virus. HCV screening has traditionally been based on risk factors, such as injection drug use. Direct-acting antiviral therapy, which has a cure rate above 90%, prevents both disease progression and onward transmission of the virus, but most people who could benefit from treatment are not getting it.

While emergency departments offer an opportunity to screen people for HCV—especially those in underserved communities—the right approach to screening in these settings is not well established. Jason Haukoos, MD, of Denver Health, and colleagues conducted a study to assess the best way to screen for HCV in an emergency department setting (NCT04003454).

The researchers compared the effectiveness of nontargeted versus targeted screening, in which testing is recommended after a risk assessment. The study was conducted at three high-volume emergency departments in Denver, Baltimore and Jackson, Mississippi. They included data from 147,498 patient visits. About half the participants were men, 42% were Black, 32% were white, 21% were Latino, and the median age was 41 years.

Among the 73,847 people offered universal, nontargeted HCV screening, 13% were tested and 154 new cases were found. In comparison, the targeted approach identified risk factors for 32% of 73,651 participants, but only 6% were tested, leading to 115 new diagnoses.

Overall, nontargeted screening uncovered more new infections, but in both groups, few people made it through the full treatment process. Just 20% of those diagnosed through universal screening and 24% diagnosed through targeted screening received follow-up care. A similar proportion in both groups started treatment (16% and 17%, respectively) and completed therapy (12% in each group), but only 9% in the nontargeted group and 10% in the targeted groups achieved a sustained virological response at 12 weeks post-treatment (SVR12).

In an accompanying editor’s note, Preeti Malani, MD, of the University of Michigan, and Stephen Schenkel, MD, of the University of Maryland, highlighted that while nontargeted screening reached three times as many patients and tested more than twice as many, it yielded only a modest increase in new diagnoses and showed similar treatment outcomes compared to targeted screening.

“In this multicenter randomized clinical trial, a nontargeted screening approach was superior to targeted screening for identifying new HCV infections among patients seen in three urban EDs,” the authors wrote. “The substantial decrease in patients who went from diagnosis to SVR12 highlights an urgent need for innovative models of HCV treatment.”

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