From the Guidelines
For a patient who is hepatitis C antibody positive with high-risk sexual behaviors, the next step is to confirm active infection with an HCV RNA test, and if HCV RNA is detected, initiate direct-acting antiviral (DAA) therapy without awaiting spontaneous clearance, as recommended by the American Association for the Study of Liver Diseases-Infectious Diseases Society of America 1. The current standard treatment for hepatitis C is DAA therapy, typically consisting of medications like sofosbuvir/velpatasvir (Epclusa) for 12 weeks, glecaprevir/pibrentasvir (Mavyret) for 8-12 weeks, or ledipasvir/sofosbuvir (Harvoni) for 8-12 weeks, depending on viral genotype, liver status, and prior treatment history. These regimens have cure rates exceeding 95% with minimal side effects, as noted in the 2020 Hepatology guidance update 1. Additionally, the patient should be screened for other sexually transmitted infections including HIV, hepatitis B, syphilis, gonorrhea, and chlamydia, and counseled on safer sex practices including consistent condom use, reducing number of partners, and avoiding sex while under the influence of substances. Key considerations in managing the patient include:
- Counseling to reduce liver disease progression and prevent HCV transmission 1
- Abstinence from alcohol and interventions to facilitate cessation of alcohol consumption 1
- Evaluation for advanced fibrosis using noninvasive markers or liver biopsy 1
- Vaccination against hepatitis A and hepatitis B for all susceptible persons with HCV infection 1
- Vaccination against pneumococcal infection for all persons with cirrhosis 1 Successful treatment prevents liver complications like cirrhosis and hepatocellular carcinoma while reducing transmission risk to others. It is also essential to assess liver disease severity and provide education on how to avoid transmitting the virus to others, as this serves as an essential primary prevention measure to curb and eventually eliminate the hepatitis C epidemic 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Next Steps and Treatment for Hepatitis C
Given the patient's hepatitis C antibody positive status and high-risk sexual behaviors, the following steps and treatment options are considered:
- The patient should undergo further testing to determine the hepatitis C virus (HCV) genotype and assess the extent of liver damage 2, 3, 4.
- The current treatment for HCV genotype 1 chronic infection is the addition of direct-acting antivirals (DAAs) with a protease inhibitor to the pegylated interferon (PEG-IFN) and ribavirin (RBV) regimen 2.
- Sofosbuvir, a potent HCV-specific nucleotide analog, has shown high efficacy and safety in treating HCV genotype 1 infection, with or without ribavirin, and has a high barrier to resistance 2, 5.
- For patients with acute HCV monoinfection, an 8-week treatment with sofosbuvir plus velpatasvir has been shown to be highly effective and well-tolerated 3.
- Ledipasvir/sofosbuvir, a fixed-dose combination, has been associated with high sustained virological response rates in treatment-naive and -experienced adults and adolescents with chronic HCV genotype 1 infection, including those with compensated cirrhosis or HIV co-infection 4.
Sexual Transmission and Risk Factors
- HCV can be transmitted by sexual contact, although the risk is lower than for other sexually transmitted viruses, such as hepatitis B and HIV 6.
- The risk of HCV transmission by sexual contact differs by the type of sexual relationship, with persons in long-term monogamous partnerships at lower risk than those with multiple partners or at risk for sexually transmitted diseases 6.
- HIV coinfection appears to increase the rate of HCV transmission by sexual contact, and current recommendations about sexual practices are different for persons with chronic HCV infection who are in steady monogamous partnerships versus those with multiple partners or in short-term sexual relationships 6.