Don’t be surprised (or put off) if your doctor asks you at your next visit whether you use illicit drugs—or orders hepatitis C or HIV testing. According to a trio of updated recommendations released by the U.S. Preventive Services Task Force (USPSTF), most adults should now be screened for unhealthy drug use as well as for both of these viruses, regardless of whether they have risk factors for them.
In a recommendation statement published in JAMA in June 2020, the USPSTF advises primary care providers to screen all patients ages 18 and older, including pregnant women, for unhealthy drug use. The guidance replaces the group’s previous recommendation, from 2008, which concluded that there was insufficient evidence to recommend for or against such screening in people who don’t have an established drug use disorder. The screening entails asking one or more questions about whether and how often an individual has used various substances and can be done in person, on paper, or by phone or video conference. People who acknowledge unhealthy drug use should be referred for diagnosis (by urine or blood tests) and, if needed, for treatment.
The USPSTF defines unhealthy drug use as “the use of substances that are illegally obtained or the nonmedical use of prescription psychoactive medications”—that is, using medications for reasons or in amounts other than those prescribed, or taking medication that was prescribed to someone else. About 12 percent of Americans, and 5 percent of pregnant women, report current unhealthy drug use, primarily cannabis. But the actual numbers may be higher. Unhealthy drug use, along with excess alcohol consumption, is a leading cause of preventable death, injuries, and disability in the U.S.
In an updated recommendation issued in March 2020, the USPSTF advises one-time screening for this virus in all adults ages 18 to 79 who have no symptoms of liver disease, with periodic follow-up screening in high-risk people. Previous USPSTF recommendations called for routine screening only in people born between 1945 and 1965. The expanded recommendation was driven in part by a dramatic rise in hepatitis C cases in the past decade, the authors wrote. In addition, it makes sense to screen more people because newer and shorter-duration antiviral treatments (8 to 12 weeks as opposed to 24 to 48 weeks for less effective, older treatments) are now available that can cure up to 95 percent of cases with a high degree of safety.
The main risk factors for hepatitis C, which can cause severe liver disease, are injection drug use and having had a blood transfusion before 1992. Sharing cocaine straws (or straws used to inhale other drugs) is also a risk factor. Sexual transmission is rare but rises with multiple partners or concomitant HIV infection.
Everyone ages 15 to 65 and all pregnant women, as well as older and younger people at increased risk, should be screened for HIV infection, the USPSTF continues to strongly advise, based on an updated review of evidence released in 2019. Tests for HIV—the virus that causes AIDS—are very accurate, and early detection and early treatment with antiretroviral therapy (ART) is highly effective in reducing complications and deaths from AIDS and in reducing transmission of the virus to uninfected sexual partners. (People on ART are extremely unlikely to transmit the infection during sexual contact.)
In a separate new recommendation, released at the same time, the USPSTF advises that people at high risk of acquiring HIV (such as those in a sexual relationship with someone who has HIV) should be offered pre-exposure prophylaxis (PrEP). HIV infection can be transmitted through sexual contact and injection drug use and from mother to baby during pregnancy, labor, delivery, and breastfeeding (though the number of perinatally acquired infections has dropped substantially in the U.S.—to under 100 in 2016).
After about five years of significant decreases, the annual number of new cases of HIV infection in the U.S. (most in men who have sex with other men) from 2013 to 2018—the last year for which statistics are available—has remained stable at around 38,600. More than 1 million Americans are living with HIV, but about 1 in 7 are unaware that they are infected. Since 1981, about 700,000 deaths have been attributed to HIV infection in the U.S.
This article first appeared in the UC Berkeley Wellness Letter.