unclear whether tattooing and body piercing are risk factors for infection or surrogates for other etiologic factors. As mentioned in Chapter 1, there is a high prevalence of HCV infection in Egypt, so Egyptian immigrants to the United States should be considered for serologic testing.

The issue of risk-factor screening and testing for HCV is controversial. In 1998, the US Public Health Service (USPHS) recommended a process of screening persons for HCV risk factors followed by laboratory testing for those potentially exposed to HCV (CDC, 1998). The 1998 USPHS recommendation to screen for risk factors among adults in the general population and to test those at risk was endorsed by a number of organizations, including the American Association for the Study of Liver Diseases (AASLD), the Infectious Diseases Society of America, and the American College of Physicians (Alter et al., 2004; Ghany et al., 2009). CDC recommends that all patients be evaluated for risk factors for HCV infection (Alter et al., 2004). In 2004, a separate group, the US Preventive Services Task Force (USPSTF), concluded that there was no direct evidence of the benefit of serologic testing for HCV infection in the general adult population and that there were inadequate data for determining accurately the benefits and risks associated with serological testing for HCV infection in otherwise healthy asymptomatic at-risk adults (Chou et al., 2004). As outcomes of treatment for chronic HCV infection improve, the controversy regarding screening and testing may diminish. An example of how improvements in treatment can change the value of identifying infected people can be seen in the advances in treatment for HIV. As effective antiretroviral therapies emerged, recommendations for screening and testing were expanded (Myers et al., 2009; Paltiel et al., 2005; Sanders et al., 2005).

Serologic Testing for Hepatitis B Virus and Hepatitis C Virus

Serologic tests to detect a history of exposure or to ascertain infection or immune status with respect to HBV and HCV use virus-specific antigens and antibodies, recombinant immunoblot assays (RIBAs), and viral nucleic acid (DNA and RNA) tests.

Rapid HBV and HCV detection tests are not available in the United States although they are available in other countries (Randrianirina et al., 2008). Rapid tests for HBsAg are available in developing countries and have high sensitivity and specificity (Randrianirina et al., 2008). Rapid te-Rapid testing in HIV interventions has been demonstrated to add substantial value in engaging hard-to-reach populations (Begley et al., 2008; Bowles et al., 2008; Clark et al., 2008; Kassler et al., 1997; Keenan and Keenan, 2001; Liang et al., 2005; Molitor et al., 1999; Reynolds et al., 2008; Schulden et al., 2008; Shrestha et al., 2008; Smith et al., 2006; Spielberg et al., 2001, 2003, 2005; Sullivan et al., 2004). The availability of rapid tests in the

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