What is the next step for a patient with a positive Hepatitis C (HCV) screening?

Management of a Patient with a Positive Hepatitis C Screening

For patients with a positive hepatitis C screening test, the next step should be confirmatory HCV RNA testing to determine if active infection is present. 1

Diagnostic Algorithm Following Positive HCV Screening

Step 1: Confirm Active Infection

• Initial screening is typically done with anti-HCV antibody testing 1
• When anti-HCV antibodies are detected, HCV RNA testing should be performed immediately to confirm active infection 1
  • Ideally, reflex HCV RNA testing should be set up to avoid requiring patients to return for a second visit 1
  • Use a sensitive molecular method with detection level ≤25 IU/mL 1

Step 2: Interpret Results Based on HCV RNA Testing

1. If HCV RNA is positive:

   • Confirms current (active) HCV infection 1
   • Patient requires:
     • Medical evaluation for chronic liver disease 1
     • Assessment for treatment 1
     • Counseling on preventing liver damage and reducing transmission risk 1

2. If HCV RNA is negative:

   • Indicates one of the following:
     • Past infection that has resolved spontaneously
     • False positive antibody test
     • Very early acute infection (in window period)
   • Anti-HCV positive, HCV RNA-negative individuals should be retested for HCV RNA 3 months later to confirm definitive clearance 1

Additional Testing for Patients with Confirmed Active Infection

• Baseline laboratory assessment:

  • Liver function tests (ALT, AST, bilirubin, albumin, etc.)
  • Complete blood count
  • Prothrombin time/INR
  • Renal function tests

• Assessment of liver disease severity:

  • Liver fibrosis assessment through:
    • Liver biopsy (traditional gold standard but invasive) 1
    • Non-invasive tests: transient elastography, APRI score, FibroTest, etc. 1
  • Determining presence of cirrhosis is critical as it affects treatment approach and prognosis 1

• Additional testing:

  • HCV genotype testing (may be considered if it would alter treatment recommendations) 1
  • Screening for co-infections (HBV, HIV)
  • Hepatitis A and B immunity status (for vaccination if non-immune) 1

Patient Education and Counseling

For patients with confirmed HCV infection, provide counseling on:

• Liver protection measures:

  • Avoid alcohol consumption 1
  • Consult with healthcare provider before starting any new medications (including over-the-counter and herbal remedies) 1
  • Get vaccinated against hepatitis A and B if liver disease is present 1

• Preventing transmission:

  • Do not donate blood, organs, tissue, or semen 1
  • Do not share personal items that might have blood on them (toothbrushes, razors, etc.) 1
  • Cover cuts and sores to prevent spreading infectious blood 1
  • For sexual partners, discuss the low but present risk of transmission 1

• For pregnant women:

  • Approximately 5% risk of vertical transmission to infants 1
  • No need to avoid pregnancy or breastfeeding 1
  • Mode of delivery does not affect transmission risk 1

Common Pitfalls to Avoid

1. Failing to confirm active infection: Anti-HCV antibodies alone do not confirm current infection; HCV RNA testing is essential 1

2. Misinterpreting indeterminate results: Indeterminate supplemental test results may indicate recent infection, chronic infection, or false-positive screening 1

3. Missing intermittent viremia: Some patients may have intermittent HCV RNA positivity; a single negative HCV RNA result should be interpreted with caution in high-risk patients 1

4. Inadequate counseling: Patients need comprehensive education about preventing liver damage and reducing transmission risk 1

5. Overlooking co-infections: Testing for other viral hepatitis and HIV is important, especially in high-risk populations 1

By following this structured approach to evaluating patients with positive HCV screening, you can ensure appropriate diagnosis, staging, and preparation for potential treatment, ultimately improving patient outcomes in terms of morbidity, mortality, and quality of life.