A bird in the hand or two in the bush? On ethics of HCV screening in pregnancy

By Marielle Gross.

Since the beginning of my medical career, the American opioid crisis-turned-epidemic made nearly daily headlines. It reflected a complex set of challenges for our healthcare system which concern me not only as a physician and surgeon, but as a bioethicist focused on dismantling “prejudice-based medicine.” It is a perfect storm of moneyed interests, incomplete understanding of pain, addiction or their optimal management, and a confluence of historic and cultural factors ranging from advances in pharmaceutical science, institutionalized racism, class-and-actual-warfare, and a tangled knot of government and professional regulations.

One of the most insidious and indelible consequences of surging opioid use disorder and injection drug use is the parallel epidemic of Hepatitis C Virus (HCV). Already the leading infectious cause of death in the U.S., we have seen but the tip of HCV’s iceberg. A coinciding paradigm shift is a rare silver lining in the narrative. When I started medical school in 2010, HCV was an incurable, lifelong disease; when I finished in 2014, there was an effective, well-tolerated cure.

Later, as an OB/GYN resident in Baltimore, the professed “heroin capital of the U.S.,” I became acutely aware of the epidemic’s significance for women’s health. One practical aspect related to risk-stratified HCV screening for pregnant women, chiefly on the basis of injection drug use history, and to a lesser extent, sexually transmitted infection risks. It troubled me to base such an important screening on factors prone to both underreporting by patients and underasking by providers.

Once, my chief yelled at me for stereotyping a patient by including HCV in her lab panel when she presented for term delivery without having received any prenatal care. At the time I had reasoned that lack of prenatal care conferred higher likelihood of underlying substance use, which conferred risk of opioid use disorder, which in turn meant potential injection drug use. I insisted that I was doing the right thing by deviating from clinical guidelines on the patient’s behalf.

Since then, I have gathered anecdotal and qualitative evidence that it’s common for providers to informally broaden their screening criteria (e.g., marijuana or other non-injection, non-intranasal drug use, “scant prenatal care,” even subjective “shadiness” of a patient or her FOB) in a well-intended attempt to avoid missed cases. I have also grown suspicious that my chief was right all along: these are not described risk factors of HCV as much as they are markers of moral reproach…

As a postdoc fellow in 2019, I came across a high-quality study suggesting that availability of a cure and high likelihood of severe liver complications without treatment meant that universal HCV screening in pregnancy was cost effective. Of course! On a meta-level, we know that secondary prevention requires short-term investment, but saves a bundle long-term when we don’t send quite so many ambulances to proverbial cliff-bottoms.

This put the fact that we universally screen U.S. pregnant women for HIV, HBV, and syphilis into sharp relief. Why exclude HCV, particularly given its increasing incidence, clinical latency, and the rare opportunity for underserved, high-risk women to access relatively robust, albeit temporary, healthcare resources? Despite what we like to think, prenatal care is not exactly known for its evidence-basis or cost-effectiveness…and we already have their blood.

I couldn’t shake the lingering questions. Should we screen all pregnant women for HCV? Better yet, why weren’t we? The exploration that followed revealed another perfect storm.

Untreated, HCV has a decades-long, asymptomatic course—a can too easily kicked down the road. Injection drug use is the primary means of transmission, a highly stigmatized risk factor that’s even more stigmatized during pregnancy—there is a perception that people who inject drugs deserve to suffer. The treatment is effective but notably expensive, and most people who will need it are reliant on Medicaid. Pregnancy guarantees and motivates women to access healthcare, giving us the ability to apply universal screening. However, there is no HCV treatment approved for use in pregnancy, and thus no way to effectively prevent transmission to offspring—the prevailing focus of our interest in infectious disease screening during pregnancy.

In our forthcoming piece, Respect Women, Promote Health, and Reduce Stigma: Ethical Arguments for Universal Hepatitis C Screening in Pregnancy, my co-authors and I conclude that risk-based HCV screening of pregnant women amounts to “exchanging a bird in hand for two in the bush.” We show how failure to screen universally treats women as mere means (“the wrapper”), contradicts health interests of women and infants, especially regarding the imperative to advance treatment for use in pregnancy, and increases stigma against HCV, injection drug use and pregnant women at large. Join us in the call for universal prenatal HCV screening!

Paper: Respect Women, Promote Health, and Reduce Stigma: Ethical Arguments for Universal Hepatitis C Screening in Pregnancy

Paper authors: Marielle S. Gross,1 Alexandra R. Ruth,1,2 and Sonja A. Rasmussen3,4

Affiliations:

  1. Johns Hopkins University Berman Institute of Bioethics; Baltimore, MD, U.S.
  2. Johns Hopkins University Bloomberg School of Public Health; Baltimore, MD, U.S.
  3. University of Florida College of Medicine Department of Pediatrics; Gainesville, FL, U.S.
  4. University of Florida School of Public Health Department of Pediatrics; Gainesville, FL, U.S.

Competing interests: None

Social media account of post author: @GYNOBioethicist

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