What is the recommended screening and treatment approach for Hepatitis C (HCV)?

Hepatitis C Screening and Treatment Approach

Universal one-time screening is recommended for all adults aged 18 years and older, with no upper age limit, to identify HCV infection and prevent complications including cirrhosis, liver failure, and hepatocellular carcinoma. 1

Screening Recommendations

Who to Screen

• All adults aged ≥18 years should undergo one-time HCV screening regardless of risk factors 1
• Persons younger than 18 years with risk factors should receive one-time screening 1
• Periodic testing for those with ongoing risk factors 1:
  • Annual testing specifically for:
    • People who inject drugs
    • HIV-positive men who have unprotected sex with men

Screening Method

• Initial screening: HCV antibody testing with reflex HCV RNA testing (from same sample) 1, 2
• Interpretation of results:
  • Positive antibody + positive RNA = current active infection
  • Positive antibody + negative RNA = resolved infection or false positive
  • Negative antibody with recent exposure (within 6 months) = repeat testing after 6 months 1
  • For immunocompromised patients, consider direct HCV RNA testing even with negative antibody 2

Post-Screening Assessment

For patients with confirmed active HCV infection (positive HCV RNA):

1. Baseline testing:

   • Quantitative HCV RNA to document baseline viral load 1
   • HCV genotype testing (may be considered if it alters treatment recommendations) 1
   • Assessment of liver disease severity 2:
     • Liver function tests (ALT, AST, bilirubin, albumin)
     • Evaluation for fibrosis/cirrhosis

2. Coinfection screening:

   • Test for HBV (HBsAg, anti-HBc) before starting treatment 3, 4
   • Test for HIV

Treatment Approach

Goals of Treatment

• Cure HCV infection to prevent complications including cirrhosis, decompensation, HCC, and death 1
• Treatment endpoint is sustained virological response (SVR), defined as undetectable HCV RNA 12 weeks after treatment completion 1

Treatment Regimens

• Direct-acting antiviral (DAA) therapy is the standard of care 1
• Treatment selection based on:
  • HCV genotype
  • Presence/absence of cirrhosis
  • Prior treatment history
  • Comorbidities

Specific Treatment Options

1. For genotypes 1,4,5, or 6 3:

   • Ledipasvir/sofosbuvir for 12 weeks (8 weeks may be considered in treatment-naïve patients without cirrhosis with HCV RNA <6 million IU/mL)

2. For all genotypes (1-6) 4:

   • Sofosbuvir/velpatasvir for 12 weeks

3. For patients with decompensated cirrhosis:

   • DAA therapy plus ribavirin 3, 4

Special Considerations

• HBV coinfection: Test all patients for HBV before starting treatment; monitor for HBV reactivation during and after HCV treatment 3, 4
• Pregnancy: DAAs are not generally recommended during pregnancy due to limited safety data 1
• Patients with renal impairment: Dosage adjustments may be needed based on specific DAA regimen

Follow-up and Monitoring

• Monitor HCV RNA during and after treatment to confirm cure (SVR12) 1
• For patients with advanced fibrosis or cirrhosis, continue surveillance for HCC even after achieving SVR 1
• Counsel patients with resolved infection that they remain at risk for reinfection 1

Implementation Considerations

• Screening should be voluntary with patient knowledge and understanding 1
• Consider reflex testing to prevent loss to follow-up 2
• For high-risk populations with limited healthcare access, integrate testing into substance use treatment programs and needle/syringe service programs 1

By following these evidence-based screening and treatment recommendations, clinicians can identify HCV infections early, initiate appropriate treatment, and significantly reduce morbidity and mortality associated with chronic HCV infection.