These findings are consistent with patterns in primary care12 and suggest a lack of effectiveness in the current risk-based screening strategy. Risk-based screening might fail because providers may not elicit complete risk-factor histories13 or patients deny risk behaviors.14 Regardless of the reason, our results suggest that the current find more risk-based screening is not being implemented for a large number

of infected individuals during their encounters with the healthcare system. This is particularly important, because 70%-85% of HCV-infected individuals are asymptomatic, making serological testing the major avenue by which their infection will be discovered. Approximately one third of respondents who had seen a doctor or other healthcare professional about their positive HCV test result reported that they were told they had tested positive for hepatitis C, but did not need to do anything or worry about it. This message would be appropriate for anti-HCV-positive individuals with either resolved or previously treated infections; however, 23 of 29 such individuals with HCV-RNA results available were, in fact, HCV-RNA positive check details when tested during the NHANES. There are a number of reasons why patients who were HCV-RNA positive when tested by NHANES may have reported being told they did not need to do anything or worry about their positive HCV test result, including

the following: The respondent misunderstood or misreported what they were told; a negative HCV-RNA test result was obtained at follow-up because those chronically infected with HCV can have intermittent viremia; an individual had been treated and reinfected; or their physician did not know how to manage a chronically infected case. Each of these latter reasons suggests the need for patient and provider education to ensure that correct messages are given and understood. It is encouraging to note that more than 80% of respondents had either already seen a doctor or healthcare professional about their first positive test results or had an appointment to do so.

However, having health insurance Glutathione peroxidase coverage or a usual source of medical care affected whether a person testing positive for HCV had seen a doctor or other healthcare professional. Figure 1 highlights a dramatic decline in the number of patients at each stage as they progress from seeing a physician about their positive test results to treatment for HCV infection. Only 12.9% (22 of 170) from this sample were treated for their infection. In contrast, facility-based studies suggest treatment rates closer to 30%-40%.15 With the approval of new medications (www.fda.gov/ForConsumers/ByAudience/ForPatientAdvocates/ucm151488.htm), treatment rates for HCV are expected to improve and monitoring their impact will be essential. Our finding that approximately three quarters of the respondents knew the correct answer to most of the knowledge questions is encouraging.