What is the next step for a patient with positive Hepatitis C Virus (HCV) RNA and HCV antibody results?

Management of HCV RNA and HCV Antibody Positive Patient

For a patient with positive HCV RNA and HCV antibody results, the next step is to provide appropriate counseling and link the patient to medical care for treatment with direct-acting antiviral therapy, as this confirms current HCV infection. 1

Interpretation of Test Results

The combination of positive HCV antibody and positive HCV RNA definitively indicates current HCV infection 1, 2. This pattern requires:

• Reporting to local health departments (as HCV is a notifiable condition in most jurisdictions)
• Patient counseling regarding transmission prevention
• Linkage to care for evaluation and treatment

Initial Evaluation Before Treatment

Before initiating treatment, the following assessments should be performed:

1. Liver disease severity assessment:

   • Complete blood count
   • Liver function tests (AST/ALT, alkaline phosphatase, bilirubin, albumin)
   • Prothrombin time
   • Abdominal ultrasound to assess for cirrhosis and hepatocellular carcinoma 2

2. HBV coinfection screening:

   • Test for HBsAg and anti-HBc before starting HCV treatment
   • This is critical as HBV reactivation can occur during HCV treatment with direct-acting antivirals 3, 4

3. Confirmation of HCV RNA positivity:

   • It is recommended to retest for HCV RNA in a subsequent blood sample to confirm HCV RNA positivity before initiating antiviral therapy 1

Treatment Approach

Direct-acting antiviral (DAA) therapy is the standard of care for HCV infection 2. Treatment selection should be based on:

• HCV genotype
• Presence or absence of cirrhosis
• Prior treatment history
• Comorbidities

Common DAA regimens include:

• Glecaprevir/pibrentasvir (Mavyret) 4
• Sofosbuvir/velpatasvir (Epclusa) 3

Important Considerations and Pitfalls

HBV Reactivation Risk

• HBV reactivation has been reported in HCV/HBV coinfected patients during or after HCV treatment with direct-acting antivirals
• Some cases have resulted in fulminant hepatitis, hepatic failure, and death 3, 4
• For patients with evidence of HBV infection, monitor for clinical and laboratory signs of hepatitis flare during and after HCV treatment

Risk of Hepatic Decompensation

• Patients with advanced liver disease require careful monitoring during treatment
• MAVYRET is contraindicated in patients with moderate or severe hepatic impairment (Child-Pugh B or C) or those with any history of prior hepatic decompensation 4

Drug Interactions

• Assess for potential drug interactions before starting treatment
• Certain medications like amiodarone, rifampin, St. John's wort, and carbamazepine may be contraindicated or require dose adjustments 3, 4

Follow-up and Monitoring

• The goal of treatment is to achieve sustained virological response (SVR), defined as undetectable HCV RNA 12 weeks after completion of therapy 1, 2
• For patients with cirrhosis, continued surveillance for hepatocellular carcinoma is required even after achieving SVR 1
• Patients should be counseled on alcohol abstinence, as heavy alcohol use significantly increases the risk of liver disease progression 2

Reporting Requirements

"Acute hepatitis C" and "hepatitis C (past or present)" are nationally notifiable conditions and are subject to mandated reporting to health departments by clinicians and laboratories 1.

By following this structured approach, patients with confirmed HCV infection can receive timely and appropriate care to prevent complications of HCV-related liver disease and reduce transmission.