I finished my ID fellowship in 2010 with a passion for HIV and viral hepatitis. The opioid epidemic, which began in the 1990s with the rise of oral opioid prescriptions, had only worsened over the following decades. Hepatitis C virus, which had been found overwhelmingly in baby boomers, had started infecting younger people struggling with injectable drug use.
I even got trained to do liver biopsies by a hepatologist who took a young, idealistic ID fellow under his wing. I started out treating patients with pegylated interferon and ribavirin and managed drug-induced psoriasis flare-ups, anemia requiring transfusions and a host of other side effects that made me cringe — all in the hope of that illusive cure, which was achieved in less than 50% of genotype 1 patients.
When new direct-acting antivirals became available, they revolutionized HCV treatment. Patients were cured relatively quickly and easily, minus the pain of prior authorizations and the mounds of paper justifications required by insurance companies. Sofosbuvir had a price tag of $1,000 per pill when it first came out, and I would warn my patients not to drop any down the sink. The cost of this medication, the prior authorization process and the vilification of patients with HCV are topics for another day, although they are ones that I have very strong feelings about.
I treated a mom and her teenage son, who most likely acquired HCV through perinatal transmission. He sailed through the treatments without missing a day of school, whereas his mom had some side effects but mostly suffered from the guilt of her role in his infection. Around that time, a local family medicine colleague started doing medication-assisted treatment for opioid use disorder, and I started seeing more young mothers who were HCV positive who were shocked that they weren’t tested when they were pregnant.
In 2018, I read an article penned in part by a mentor of mine, Dr. Debika Bhattacharya. It clearly outlined the problem with risk-based testing of pregnant women for infectious diseases. She and her colleagues argued that this approach didn’t work for HIV or hepatitis B virus, so why would we think it would work for HCV? Only when universal screening was implemented did we really move the needle on preventing perinatal transmission of these viruses.
It took several years for the American College of Obstetricians and Gynecologists to update their guidelines, but they did. Like many, I rejoiced at the idea that pregnant people would finally get the screening that they needed. IDSA and the American Association for the Study of Liver Diseases published an update reflecting this and other changes. (As an aside, IDSA and AASLD have, in my opinion, the best living guidance that I’ve seen on an ID topic. It is updated in real time and provides a quick and reliable reference on even the most challenging patients.)
Imagine my disappointment when I read a recent publication showing that, while screening rates increased in pregnant women from 141 to 253 tests per 1,000 person-years, this was far below acceptable. This amounts to a screening rate of only 38.73% among pregnant women in the electronic health record database that was studied (which included 68 U.S. health care organizations and over 115 million patients). By comparison, just over 90% of pregnant women were screened for HIV.
Thirty-eight percent is not good enough. All pregnant patients must be tested for HCV, because, as we all know, patients do not wear signs that say “HCV” or “tuberculosis” or “gonorrhea.”
While no treatment is currently approved for HCV in pregnancy, past and current research is looking into the safety and efficacy of treatment in this population. AASLD, IDSA and the European Association for the Study of the Liver agree that treatment during pregnancy can be considered. Others recommend treatment only in the setting of a clinical trial. The TiP-HepC Registry is a place where physicians can report data on patients who are treated while pregnant.
The high rates of HIV screening in pregnant people are evidence that we can succeed in this sphere. We can do better, and we must do better.