What is the next step in management for a patient who is Hepatitis C (HCV) reactive?

Management of Hepatitis C Reactive Patient

For a patient with a reactive Hepatitis C (HCV) antibody test, the next step in management should be HCV RNA testing by nucleic acid testing (NAT) to confirm current infection. 1

Diagnostic Algorithm for HCV Reactive Patients

Step 1: Confirm Active Infection

• When HCV antibody test is reactive, immediately test for HCV RNA to determine if the patient has:
  • Current active infection (HCV RNA positive)
  • Resolved past infection (HCV RNA negative)
  • False positive antibody result (HCV RNA negative) 1

The CDC recommends the following operational approaches for HCV RNA testing:

1. Submit blood from a subsequent venipuncture for HCV RNA testing if the initial sample is reactive for HCV antibody
2. Collect two specimens in separate tubes during a single venipuncture: one for initial HCV antibody testing and a second for HCV RNA testing if the antibody test is reactive 1

Step 2: Additional Testing for Confirmed Active Infection

If HCV RNA is detected (confirming current infection):

• Determine HCV genotype (especially important for patients with prior treatment failure) 1
• Evaluate for liver fibrosis using non-invasive markers or liver biopsy 1
• Screen for coinfections (HBV, HIV) 1
• Check hepatitis A and B immunity status for vaccination planning 1

Management Considerations

For Patients with Confirmed Active HCV Infection:

1. Refer to a specialist experienced in HCV management for comprehensive evaluation and treatment consideration 1

2. Patient education about:

   • Disease progression and complications
   • Measures to reduce liver damage (alcohol abstinence, weight management)
   • Prevention of transmission to others 1

3. Preventive measures:

   • Vaccination against hepatitis A and B if not immune 1
   • Pneumococcal vaccination for patients with cirrhosis 1

4. Antiviral therapy consideration:

   • Current guidelines recommend treatment for all patients with chronic HCV infection except those with limited life expectancy due to non-hepatic causes 1
   • Treatment regimens typically include direct-acting antiviral agents (DAAs) 2, 3

For Patients with Negative HCV RNA (Resolved Infection):

• Retest for HCV RNA 3 months later to confirm resolved infection 1
• Educate patient that they are not currently infected and not infectious 1

Special Considerations

HBV Reactivation Risk

• Test all patients for evidence of current or prior HBV infection (HBsAg and anti-HBc) before initiating HCV treatment 2, 3
• Monitor patients with serologic evidence of HBV infection for clinical and laboratory signs of hepatitis flare or HBV reactivation during and after HCV treatment 2, 3

Monitoring During Treatment

• Regular follow-up visits to monitor treatment progress and manage side effects 1
• For patients with cirrhosis, continue HCC surveillance every 6 months by ultrasound even after achieving SVR 1

Common Pitfalls to Avoid

1. Incomplete testing: Failing to perform HCV RNA testing after a reactive antibody test can lead to misdiagnosis and inappropriate management 1, 4

2. Loss to follow-up: Only 13-18% of persons with chronic HCV infection receive treatment in the US; ensure proper referral and follow-up 1

3. Ignoring comorbidities: Factors such as alcohol use, obesity, and insulin resistance can accelerate fibrosis progression 1

4. Missing HBV coinfection: Failure to test for HBV can lead to serious complications during HCV treatment 2, 3

5. Inadequate patient education: Patients need clear information about their infection status and strategies to prevent liver damage and transmission 1