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• W2066890868 abstract "Podcast interview: www.gastro.org/gastropodcast. Also available on iTunes. Podcast interview: www.gastro.org/gastropodcast. Also available on iTunes. Hepatitis C virus (HCV) is the most common bloodborne infection in the United States. Approximately 3.2 million Americans are chronically infected with HCV1Armstrong G.L. Wasley A. Simard E.P. et al.The prevalence of hepatitis C virus infection in the United States, 1999 through 2002.Ann Intern Med. 2006; 144: 705-714Crossref PubMed Scopus (1716) Google Scholar; most are undiagnosed2Volk M.L. Tocco R. Saini S. et al.Public health impact of antiviral therapy for hepatitis C in the United States.Hepatology. 2009; 50: 1750-1755Crossref PubMed Scopus (197) Google Scholar, 3Spradling P. Rup L. Moorman A.C. et al.Hepatitis B and C virus infection among 1.2 million persons with access to care: factors associated with testing and infection prevalence.Clin Infect Dis. 2012; 55: 1047-1055Crossref PubMed Scopus (140) Google Scholar, 4Southern W.N. Drainoni M.L. Smith B.D. et al.Hepatitis C testing practices and prevalence in a high-risk urban ambulatory care setting.J Viral Hepat. 2011; 18: 474-481Crossref PubMed Scopus (58) Google Scholar, 5Roblin D.W. Smith B.D. Weinbaum C.M. et al.Hepatitis C virus screening practices and prevalence in a managed care organization.Am J Manag Care. 2011; 17: 548-555PubMed Google Scholar and have been infected for more than 20 years.6Armstrong G.L. Alter M.J. McQuillan G.M. et al.The past incidence of hepatitis C virus infection: implications for the future burden of chronic liver disease in the United States.Hepatology. 2000; 31: 777-782Crossref PubMed Scopus (456) Google Scholar Because complications of HCV increase with the duration of infection, the prevalence of cirrhosis and related complications in persons with chronic HCV infection continue to increase. A decision modeling study by Davis et al estimated that 25% of HCV-infected individuals had developed cirrhosis by 2010.7Davis G.L. Alter M.J. El-Serag H. et al.Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression.Gastroenterology. 2010; 138: 513-521Abstract Full Text Full Text PDF PubMed Scopus (758) Google Scholar A national study of US veterans with HCV found a remarkably similar estimate; 18% of HCV-infected veterans seeking health care in 2006 had a diagnosis of cirrhosis.8Kanwal F. Hoang T. Kramer J.R. et al.Increasing prevalence of HCC and cirrhosis in patients with chronic hepatitis C virus infection.Gastroenterology. 2011; 140: 1182-1188Abstract Full Text Full Text PDF PubMed Scopus (317) Google Scholar The percentage of HCV-infected individuals with cirrhosis in the United States is expected to reach a peak of 45% in 2020, and hepatic decompensation and hepatocellular carcinoma (HCC) will likely continue to increase in the next 2 decades.7Davis G.L. Alter M.J. El-Serag H. et al.Aging of hepatitis C virus (HCV)-infected persons in the United States: a multiple cohort model of HCV prevalence and disease progression.Gastroenterology. 2010; 138: 513-521Abstract Full Text Full Text PDF PubMed Scopus (758) Google Scholar HCV-related morbidity and mortality are potentially preventable.9van der Meer A.J. Veldt B.J. Feld J.J. et al.Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis.JAMA. 2012; 308: 2584-2593Crossref PubMed Scopus (1172) Google Scholar Successful treatment with antiviral therapy slows progression of liver disease, improves health-related quality of life, and reduces liver-related mortality.10Spiegel B.M. Younossi Z.M. Hays R.D. et al.Impact of hepatitis C on health related quality of life: a systematic review and quantitative assessment.Hepatology. 2005; 41: 790-800Crossref PubMed Scopus (305) Google Scholar With the advent of direct-acting antiviral (DAA) agents, sustained virologic response (SVR) can be achieved in as many as 90% of patients with treatment duration as short as 12 weeks in the absence of interferon in the next 3 to 5 years.11Gane E.J. Stedman C.A. Hyland R.H. et al.Nucleotide polymerase inhibitor sofosbuvir plus ribavirin for hepatitis C.N Engl J Med. 2013; 368: 34-44Crossref PubMed Scopus (631) Google Scholar, 12Poordad F. Lawitz E. Kowdley K.V. et al.Exploratory study of oral combination antiviral therapy for hepatitis C.N Engl J Med. 2013; 368: 45-53Crossref PubMed Scopus (259) Google Scholar However, the increasing proportion of HCV-infected patients with cirrhosis (and related decompensation) coupled with aging of the HCV cohort (and related comorbidity) is rapidly closing the window of opportunity for new treatments to effectively change the projected natural history of HCV. Patients with cirrhosis and medical comorbidity are excluded from most clinical trials of DAA treatment, such that safety, efficacy, and appropriate dose regimens for patients in greatest need are not available. Indeed, recent data show that a significant proportion of patients are excluded from approved DAA-based treatment on the basis of advanced liver disease and medical comorbidity.13Chen E.Y. Sinclair S.N. Czul F. et al.Triple therapy for hepatitis C infection in the real world: practice trends following the release of boceprevir and telaprevir (abstr).Hepatology. 2012; 56: 259ACrossref PubMed Scopus (41) Google Scholar Furthermore, the risk of HCC persists in patients with cirrhosis even after SVR is achieved.9van der Meer A.J. Veldt B.J. Feld J.J. et al.Association between sustained virological response and all-cause mortality among patients with chronic hepatitis C and advanced hepatic fibrosis.JAMA. 2012; 308: 2584-2593Crossref PubMed Scopus (1172) Google Scholar It is therefore clear that early diagnosis and treatment are needed to stem the rising tide of HCV-related cirrhosis and its complications. The benefits of early detection of HCV extend beyond the beneficial effects of antiviral treatment. Behavioral changes, such as reduced alcohol consumption or avoiding injection drug use, can improve health outcomes for persons with HCV infection. Counseling individuals with HCV may also help prevent spread of infection. Early diagnosis of cirrhosis is also important for delivering preventive services such as immunizations, screening of gastroesophageal varices, and screening for HCC. With these considerations, the recent recommendation from the Centers for Disease Control and Prevention (CDC) to test all persons in the United States born between 1945 and 1965 (a birth cohort with a high prevalence of HCV) is an important landmark.14Centers for Disease Control and PreventionRecommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965.MMWR. 2012; 61: 1-32Google Scholar However, almost in parallel to the CDC's recommendation, the United States Preventive Services Task Force (USPSTF) concluded that the benefit of screening all adults born between 1945 and 1965 is small.15Chou R. Cottrell E.B. Wasson N. et al.Screening for hepatitis C virus infection in adults: a systematic review to update the 2004 U.S. Preventive Services Task Force Recommendation.Ann Intern Med. 2012 Nov 27; ([Epub ahead of print])Google Scholar In this commentary, we discuss the recommendations from the CDC and USPSTF, summarize the rationale behind each recommendation, describe the differences, and pose our recommendations. In August 2012, the CDC expanded screening recommendations for HCV to cover the birth cohort born between 1945 and 1965. This new recommendation complements the previous risk-based screening recommendation.14Centers for Disease Control and PreventionRecommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965.MMWR. 2012; 61: 1-32Google Scholar The CDC also recommended that persons identified as having HCV infection should undergo a brief screening for alcohol use and receive a referral to appropriate care.14Centers for Disease Control and PreventionRecommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965.MMWR. 2012; 61: 1-32Google Scholar In making these recommendations, the CDC followed the Grades of Recommendation Assessment, Development and Evaluation (GRADE) methodology.16Guyatt G.H. Oxman A.D. Vist G. et al.GRADE Working GroupRating quality of evidence and strength of recommendations GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar GRADE is a systematic and explicit approach of grading scientific evidence and making recommendations.16Guyatt G.H. Oxman A.D. Vist G. et al.GRADE Working GroupRating quality of evidence and strength of recommendations GRADE: an emerging consensus on rating quality of evidence and strength of recommendations.BMJ. 2008; 336: 924-926Crossref PubMed Google Scholar As part of this process, the CDC conducted systematic reviews of HCV prevalence (to determine the effect of a birth year testing strategy) and the effect of testing individuals born between 1945 and 1965 on patient-important outcomes (all-cause mortality, HCC, SVR, serious adverse events, quality of life, and HCV transmission).14Centers for Disease Control and PreventionRecommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965.MMWR. 2012; 61: 1-32Google Scholar Review of data on the prevalence of HCV infection revealed a 3.25% prevalence of HCV antibody (anti-HCV) among persons born between 1945 and 1965 (Figure 1) ; these individuals accounted for more than 75% of the total anti-HCV prevalence in the United States. The systematic review by the CDC did not find direct evidence comparing the effectiveness of birth cohort–based testing with risk-based testing. In the absence of direct data, the CDC considered available evidence from (1) clinical trial data on the effect of HCV treatment on achieving SVR and (2) observational data on the association between SVR and all-cause mortality and HCC that was supplemented by (3) data from a meta-analysis of randomized controlled trials on the efficacy of brief alcohol interventions in reducing alcohol use. Evidence from these studies was reviewed comprehensively to infer that birth cohort–based testing, in combination with alcohol reduction interventions, will increase identification and treatment of infected individuals and result in improved patient outcomes. A recent cost-effectiveness analysis also found that compared with risk-based screening, birth cohort–based screening followed by DAA-based triple therapy will cost an additional $35,700 per quality-adjusted life year gained.17Rein D.B. Smith B.D. Wittenborn J.S. et al.The cost-effectiveness of birth-cohort screening for hepatitis C antibody in U.S. primary care settings.Ann Intern Med. 2012; 156: 263-270Crossref PubMed Scopus (258) Google Scholar Supplementing risk-based screening with birth cohort–based screening is projected to reach most people infected with HCV in the United States. Assuming a less-than-perfect penetration of the screening recommendations and using colon cancer screening rates in the United States as a surrogate, the CDC estimates that the birth cohort–based screening recommendation will result in testing ∼12.3 million people for HCV within the first 3 years of implementation at a cost of $664 million and will identify 400,000 new persons with HCV.14Centers for Disease Control and PreventionRecommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965.MMWR. 2012; 61: 1-32Google Scholar Assuming full penetration, birth cohort–based screening will identify an additional 808,580 persons with HCV infection and prevent 82,000 HCV-related deaths compared with the current risk-based screening approach.17Rein D.B. Smith B.D. Wittenborn J.S. et al.The cost-effectiveness of birth-cohort screening for hepatitis C antibody in U.S. primary care settings.Ann Intern Med. 2012; 156: 263-270Crossref PubMed Scopus (258) Google Scholar Almost at the same time as the CDC made its recommendation, the USPSTF conducted a systematic review of the literature and issued its recommendation to screen for HCV among adults at high risk.15Chou R. Cottrell E.B. Wasson N. et al.Screening for hepatitis C virus infection in adults: a systematic review to update the 2004 U.S. Preventive Services Task Force Recommendation.Ann Intern Med. 2012 Nov 27; ([Epub ahead of print])Google Scholar This is a new recommendation from the USPSTF; in 2004, the USPSTF found insufficient evidence to recommend for, or against, screening adults at high risk for HCV.18Calonge N. Randhawa G. U.S. Preventive Services Task ForceThe meaning of the U.S. Preventive Services Task Force grade I recommendation: screening for hepatitis C virus infection.Ann Intern Med. 2004; 141: 718-719Crossref PubMed Scopus (18) Google Scholar In regard to birth cohort–based screening, the USPTF concluded that the yield of screening all adults born between 1945 and 1965 is small.15Chou R. Cottrell E.B. Wasson N. et al.Screening for hepatitis C virus infection in adults: a systematic review to update the 2004 U.S. Preventive Services Task Force Recommendation.Ann Intern Med. 2012 Nov 27; ([Epub ahead of print])Google Scholar As a result, the USPSTF neither embraces nor objects to birth cohort–based screening. Instead, it recommends that clinicians may consider a birth cohort–based screening approach for persons born between 1945 and 1965 who have no other known risk factors.15Chou R. Cottrell E.B. Wasson N. et al.Screening for hepatitis C virus infection in adults: a systematic review to update the 2004 U.S. Preventive Services Task Force Recommendation.Ann Intern Med. 2012 Nov 27; ([Epub ahead of print])Google Scholar Both organizations followed standard methodology and relied on a similar body of literature in developing their recommendations. Both accepted the association between SVR and improvement in clinical outcomes and agreed that many of the benefits from screening are likely to occur as a result of antiviral treatment. Yet, the recommendations are not entirely consistent, potentially causing confusion for practicing clinicians and their patients alike. What are the reasons underlying these conflicting recommendations? The USPSTF recommendation is based strictly on available evidence. For example, similar to the CDC review, the USPSTF review found no direct evidence on clinical benefits associated with screening compared with no screening (or of different screening approaches). The few available studies evaluating the performance (such as sensitivity and yield) of different screening strategies in HCV were all conducted in settings with a high prevalence of HCV.19Gunn R.A. Murray P.J. Brennan C.H. et al.Evaluation of screening criteria to identify persons with hepatitis C virus infection among sexually transmitted disease clinic clients: results from the San Diego Viral Hepatitis Integration Project.Sex Transm Dis. 2003; 30: 340-344Crossref PubMed Scopus (42) Google Scholar, 20McGinn T. O'Connor-Moore N. Alfandre D. et al.Validation of a hepatitis C screening tool in primary care.Arch Intern Med. 2008; 168: 2009-2013Crossref PubMed Scopus (31) Google Scholar, 21Zuniga I.A. Chen J.J. Lane D.S. et al.Analysis of a hepatitis C screening programme for US veterans.Epidemiol Infect. 2006; 134: 249-257Crossref PubMed Scopus (17) Google Scholar, 22Zuure F. Davidovich U. Kok G. et al.Evaluation of a risk assessment questionnaire to assist hepatitis C screening in the general population.Euro Surveill. 2010; 15: 19539Crossref PubMed Google Scholar Given the limited applicability of these studies to average- or low-risk populations, the USPSTF recommended that screening is of moderate benefit solely for populations at high risk.15Chou R. Cottrell E.B. Wasson N. et al.Screening for hepatitis C virus infection in adults: a systematic review to update the 2004 U.S. Preventive Services Task Force Recommendation.Ann Intern Med. 2012 Nov 27; ([Epub ahead of print])Google Scholar However, the relative upgrade in the USPSTF recommendations for risk-based HCV screening is not related to availability of new high-quality evidence supporting benefits of risk-based screening and has come arguably late. Waiting another decade for new evidence to emerge before recommending birth cohort–based screening is likely to lead to a sizable proportion of HCV-infected persons missing the opportunity to benefit from early diagnosis and treatment, allowing the disease to progress to cirrhosis and related complications. Robust scientific evidence about the benefits of many processes in medicine is lacking. Despite this, when a gap in care is identified, the health care system must make decisions about potential ways to improve quality of care. The CDC addressed this limitation (in available evidence) by combining the best available scientific evidence with the collective judgment of experts and key stakeholders to make its recommendation. The rationale behind the CDC's new recommendation is rather straightforward. In addition to the rising burden of HCV and availability of efficacious treatment, the CDC acknowledged that the risk-based screening recommendation, disseminated since 1998, has met with minimal, if any, success. Approximately 45% to 70% of individuals with HCV in the United States remain unaware of their infection status.2Volk M.L. Tocco R. Saini S. et al.Public health impact of antiviral therapy for hepatitis C in the United States.Hepatology. 2009; 50: 1750-1755Crossref PubMed Scopus (197) Google Scholar, 3Spradling P. Rup L. Moorman A.C. et al.Hepatitis B and C virus infection among 1.2 million persons with access to care: factors associated with testing and infection prevalence.Clin Infect Dis. 2012; 55: 1047-1055Crossref PubMed Scopus (140) Google Scholar, 4Southern W.N. Drainoni M.L. Smith B.D. et al.Hepatitis C testing practices and prevalence in a high-risk urban ambulatory care setting.J Viral Hepat. 2011; 18: 474-481Crossref PubMed Scopus (58) Google Scholar, 5Roblin D.W. Smith B.D. Weinbaum C.M. et al.Hepatitis C virus screening practices and prevalence in a managed care organization.Am J Manag Care. 2011; 17: 548-555PubMed Google Scholar For example, using national survey data from the Third National Health and Nutrition Examination Survey (NHANES), Volk et al found that 49% of respondents (with HCV) were previously unaware that they had HCV.2Volk M.L. Tocco R. Saini S. et al.Public health impact of antiviral therapy for hepatitis C in the United States.Hepatology. 2009; 50: 1750-1755Crossref PubMed Scopus (197) Google Scholar Similarly, using data from 4 large private health care organizations (including Geisinger Health System, Danville, Pennsylvania; Henry Ford Health System, Detroit, Michigan; Kaiser Permanente–Northwest, Portland, Oregon; and Kaiser Permanente, Honolulu, Hawaii), Spradling et al recently estimated that nearly half of HCV infections were unidentified.3Spradling P. Rup L. Moorman A.C. et al.Hepatitis B and C virus infection among 1.2 million persons with access to care: factors associated with testing and infection prevalence.Clin Infect Dis. 2012; 55: 1047-1055Crossref PubMed Scopus (140) Google Scholar In a study conducted in 3 community-based primary care clinics in New York, Southern et al found that only 48% of patients with risk factors for HCV were tested at least once over a 10-year time frame.4Southern W.N. Drainoni M.L. Smith B.D. et al.Hepatitis C testing practices and prevalence in a high-risk urban ambulatory care setting.J Viral Hepat. 2011; 18: 474-481Crossref PubMed Scopus (58) Google Scholar Roblin et al found that only 29% of adults with at least one of the 5 identifiable HCV risk factors underwent anti-HCV screening.5Roblin D.W. Smith B.D. Weinbaum C.M. et al.Hepatitis C virus screening practices and prevalence in a managed care organization.Am J Manag Care. 2011; 17: 548-555PubMed Google Scholar There are several reasons for the currently low rates of HCV case identification in clinical practice. Inadequate health insurance coverage and limited access to regular health care is likely the leading barrier to HCV testing.2Volk M.L. Tocco R. Saini S. et al.Public health impact of antiviral therapy for hepatitis C in the United States.Hepatology. 2009; 50: 1750-1755Crossref PubMed Scopus (197) Google Scholar However, even in individuals covered by regular health insurance, many with documented risk factors remain untested and undetected.3Spradling P. Rup L. Moorman A.C. et al.Hepatitis B and C virus infection among 1.2 million persons with access to care: factors associated with testing and infection prevalence.Clin Infect Dis. 2012; 55: 1047-1055Crossref PubMed Scopus (140) Google Scholar, 5Roblin D.W. Smith B.D. Weinbaum C.M. et al.Hepatitis C virus screening practices and prevalence in a managed care organization.Am J Manag Care. 2011; 17: 548-555PubMed Google Scholar This failure can be related to either poor performance of risk-based screening or difficulty in implementing such screening in routine practice. Several studies show that the presence of risk factors, when elicited, is strongly associated with the yield of screening tests. In the review conducted by the USPSTF, several cross-sectional studies found that screening strategies targeting multiple risk factors were associated with sensitivities of more than 90%19Gunn R.A. Murray P.J. Brennan C.H. et al.Evaluation of screening criteria to identify persons with hepatitis C virus infection among sexually transmitted disease clinic clients: results from the San Diego Viral Hepatitis Integration Project.Sex Transm Dis. 2003; 30: 340-344Crossref PubMed Scopus (42) Google Scholar, 20McGinn T. O'Connor-Moore N. Alfandre D. et al.Validation of a hepatitis C screening tool in primary care.Arch Intern Med. 2008; 168: 2009-2013Crossref PubMed Scopus (31) Google Scholar, 21Zuniga I.A. Chen J.J. Lane D.S. et al.Analysis of a hepatitis C screening programme for US veterans.Epidemiol Infect. 2006; 134: 249-257Crossref PubMed Scopus (17) Google Scholar, 22Zuure F. Davidovich U. Kok G. et al.Evaluation of a risk assessment questionnaire to assist hepatitis C screening in the general population.Euro Surveill. 2010; 15: 19539Crossref PubMed Google Scholar; these data provided the rationale for the USPSTF recommendation for a screening strategy targeting known risk factors for HCV. However, with the exception of one Veterans Administration study,21Zuniga I.A. Chen J.J. Lane D.S. et al.Analysis of a hepatitis C screening programme for US veterans.Epidemiol Infect. 2006; 134: 249-257Crossref PubMed Scopus (17) Google Scholar none of these studies prospectively implemented risk-based screening; all evaluated the sensitivity and specificity of “potential HCV risk factor–based screening” retrospectively (among patients tested for HCV who also had complete information regarding risk factors). We are thus aware of only one study, by Drainoni et al, in which a well-structured risk-based screening intervention was implemented in 3 clinics in Bronx, New York.23Drainoni M.L. Litwin A.H. Smith B.D. et al.Effectiveness of a risk screener in identifying hepatitis C virus in a primary care setting.Am J Public Health. 2012; 102: e115-e121Crossref PubMed Scopus (35) Google Scholar The intervention involved prompting physicians with clinical sticker reminders, on-site education sessions, environmental reminders, and regular visits from project staff to place stickers on all progress notes. Despite these interventions, risk screening was completed in 36% of the patients seen, highlighting the difficulty in adopting risk-based screening in clinical practice.23Drainoni M.L. Litwin A.H. Smith B.D. et al.Effectiveness of a risk screener in identifying hepatitis C virus in a primary care setting.Am J Public Health. 2012; 102: e115-e121Crossref PubMed Scopus (35) Google Scholar Although the exact reasons underlying the low rates of screening for risk factors were unclear, possibilities include limited time of primary care visits, awkwardness of discussing behavioral risks, and undisclosed or unknown risks on behalf of the patients. In a recent analysis of national health survey data by the CDC, 55% of persons ever infected with HCV reported a high risk exposure, and the remaining 45% did not report any known risk factor.14Centers for Disease Control and PreventionRecommendations for the identification of chronic hepatitis C virus infection among persons born during 1945–1965.MMWR. 2012; 61: 1-32Google Scholar Gunn et al found that 40% of their patients with HCV infection who had not reported injection drug use during their clinic visit admitted to having injected drugs after they were informed of their positive test results.19Gunn R.A. Murray P.J. Brennan C.H. et al.Evaluation of screening criteria to identify persons with hepatitis C virus infection among sexually transmitted disease clinic clients: results from the San Diego Viral Hepatitis Integration Project.Sex Transm Dis. 2003; 30: 340-344Crossref PubMed Scopus (42) Google Scholar Indeed, a recent consensus report from the Institute of Medicine concluded that the current approach to the prevention and control of HCV is not working and called for improved screening and surveillance efforts to prevent HCC- and liver disease–related mortality in the United States.24Institute of Medicine ReportHepatitis and liver cancer A national strategy for prevention and control of hepatitis B and C.www.iom.edu/viralhepatitisGoogle Scholar Expanding the target group to include a readily identifiable and potentially high-yield group may improve the rates of new diagnosis of HCV-infected individuals. However, we acknowledge that neither the feasibility nor the effectiveness of cohort-based screening have been tested in prospective studies. Issues related to patient consent and buy-in, reimbursement, and possibly an increase in false-positive test results may reduce its overall effectiveness. The ultimate success of HCV screening will depend on the degree of its adoption in clinical practice. Data show that passive approaches to disseminating clinical recommendations do not induce change or improve care.25Freemantle N. Harvey E.L. Wolf F. et al.Printed educational materials: effects on professional practice and health care outcomes.Cochrane Database Syst Rev. 2000; (CD000172)Google Scholar Implementation of any intervention is enhanced when it fits with the structure and context of the clinical setting.26McCormack B. Kitson A. Harvey G. et al.Getting evidence into practice: the meaning of ‘context’.J Adv Nurs. 2002; 38: 94-104Crossref PubMed Scopus (494) Google Scholar With the federal mandate for electronic health records, electronic clinical reminders for HCV screening may be implemented in primary care settings, but risk-based screening will still rely on patients recognizing or acknowledging that they belong to one of the high-risk groups. In parallel with risk-based screening, a one-time testing of all individuals born between 1945 and 1965 triggered by the date of birth may accelerate the identification of most HCV-infected persons before progression to cirrhosis. In summary, the burden of HCV remains high. New HCV treatment is likely to be simpler, better tolerated, and more efficacious than current treatment, but its safety and effectiveness will remain relatively low in patients with cirrhosis and older patients with multiple comorbidities. Early diagnosis is crucial for infected persons to benefit from new HCV treatment and to decrease the burden of HCV. We support the CDC's recommendation that in addition to risk-based screening, a one-time screening of all persons born between 1945 and 1965 should be considered for implementation in clinical practice except for those with significant comorbidities and limited life expectancy. Health care reforms may help with the leading barrier to testing and treatment by providing insurance benefits to the currently uninsured and eliminate concerns about denial of coverage for preexisting illness. We are at the dawn of a major breakthrough in HCV treatment11Gane E.J. Stedman C.A. Hyland R.H. et al.Nucleotide polymerase inhibitor sofosbuvir plus ribavirin for hepatitis C.N Engl J Med. 2013; 368: 34-44Crossref PubMed Scopus (631) Google Scholar, 12Poordad F. Lawitz E. Kowdley K.V. et al.Exploratory study of oral combination antiviral therapy for hepatitis C.N Engl J Med. 2013; 368: 45-53Crossref PubMed Scopus (259) Google Scholar and should ensure that HCV-infected persons are diagnosed and diagnosed early enough to benefit from these treatments such that the trajectory of burden of HCV can be terminated earlier than predicted." @default.
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