When people seek help at a drug treatment center for opioid addiction, concerns about having contracted hepatitis C are generally low on their list. They have often reached a crisis point in their lives, said Marie Sutton, the CEO of Imagine Hope, a consulting group that provides staff training and technical assistance to facilitate testing for the liver-damaging virus at more than 30 drug treatment centers in Georgia.

"They just want to handle [their drug problem]," she said. "Sometimes they don't have the bandwidth to take on too many other things." Even though health care facilities that serve people who use drugs are well-positioned to initiate screening, too often that is not happening, recent studies have shown. Not testing these patients for hepatitis C is an enormous missed opportunity, public health experts agree.

"It's a disease that can be cured the moment we identify somebody," said Tom Nealon, president, and CEO of the American Liver Foundation. "Not testing is incomprehensible when you look at what hepatitis C does to their bodies and their livers."

Hepatitis C infection

As the number of people who inject drugs has soared, the rate of hepatitis C infection, frequently tied to sharing needles, has climbed steeply, too. People who are infected with hepatitis C can go for years without symptoms, so they may not have any inkling that they are sick. That delayed onset makes screening important, advocates say, since people may unwittingly infect others.

Screening people who misuse drugs for the deadly virus is a commonsense strategy to get people cured and break the cycle of transmission. But there are obstacles — sometimes a lack of money, staff or other resources.

"Reimbursement rates for hepatitis C testing often don't match the cost," said Andrew Reynolds, hepatitis C and harm reduction manager at Project Inform, an advocacy group. If patients test positive, they need to be linked to treatment, and financial support for staffing to do that is often limited, he said.

Only 27.5 percent of 12,166 substance abuse facilities reported offering to test for hepatitis C in 2017, according to research published on the blog for the journal Health Affairs in October.

It is one of the first studies to look at this issue since the federal government began reporting on testing for HIV and hepatitis C in its national survey of substance abuse and treatment services in 2016.

When researchers narrowed their analysis to the much smaller number of opioid treatment programs that are federally certified to use methadone and other drugs in the treatment, a higher, but still not overwhelming, proportion just over 63% said they offered to screen for hepatitis C.

"We certainly thought the numbers would be higher," said Asal Sayas, a co-author of the analysis and director of government affairs at amfAR, the Foundation for AIDS Research. "Testing is one of the most fundamental forms of prevention."

In primary care settings, the situation sometimes isn't much better, even when patients have a diagnosed "opioid-use disorder." An analysis by Boston Medical Center researchers of nearly 270,000 medical records of people aged 13 to 21 who visited federally qualified health centers from 2012 to 2017 found that 36 percent of the 875 patients with that diagnosis were tested for hepatitis C.

"Even in a setting with an identified risk factor in opioid-use disorder, too few youths are being screened for hepatitis C," said Dr. Rachel Epstein, a postdoctoral research fellow in infectious diseases at Boston Medical Center and a co-author of the study, which was presented at the annual meeting of the Infectious Diseases Society of America in early October.

Hepatitis C is a virus that causes inflammation to the liver, in some cases leading to scarring, liver cancer, and death. It is transmitted through blood, including contaminated needles that people share when they inject drugs.

The initial test for hepatitis C is an inexpensive blood test to check for antibodies in the blood that indicate exposure to the virus. If that antibody test is positive, a second test is necessary to find out if the virus is circulating in the bloodstream, which would mean someone is infected with the virus. The second test can cost several hundred dollars, experts say.

To be sure, some federally qualified health centers have made testing for hepatitis C a priority. Clinicians at two community health centers run by Philadelphia FIGHT — which was established as an AIDS service organization — a test many of their patients who are at high risk because of injection drug use or unsafe sexual practices, such as having sex with an infected partner. The screenings are often done on an annual basis, with a reminder to the medical personnel in the patient's electronic medical record.