Is widespread screening for hepatitis C justified?

In 2012, the advent of new treatments for hepatitis C led the US Centers for Disease Control and Prevention (CDC) to recommend screening of everyone born during 1945-65 since it estimates that three quarters of all people infected are in that age cohort.1 Previously, the CDC had recommended testing for people at high risk, such as intravenous drug users, transfusion recipients before 1992, and patients on haemodialysis. Cohort testing was also endorsed by the US Preventive Services Task Force (grade B recommendation),2 which under the Affordable Care Act mandates insurers to provide the screening without any charges to the individual.3 In April 2014, the World Health Organization called for expanded screening,4 and in October 2013, New York State went further, passing legislation making it mandatory for hospitals to offer testing to all patients born in 1945-65.5

The recommendations have received strong support from many experts.6 7 8 Widespread screening has been hailed as an opportunity to save hundreds of thousands of lives worldwide. Advocates often cite the substantial prevalence of hepatitis C infection, the burden of end stage liver disease, and now the availability of seemingly highly effective treatments to support expanded screening. However, since most people infected with hepatitis C never develop symptoms and will die from other causes, exposing them to the harms of treatment with no possible benefit might outweigh the benefits for the minority who develop end stage liver disease (decompensated cirrhosis or hepatocellular cancer). We discuss the natural course of hepatitis C infection, examine the treatment strategies, and suggest how we can determine …