What is the follow-up for a patient with a hepatitis C (HCV) reactive test but a negative viral load?

Follow-up for Hepatitis C Reactive Test with Negative Viral Load

For patients with a hepatitis C (HCV) reactive antibody test but negative viral load, no further testing is required as this indicates either past resolved infection or false positive antibody result, and the patient should be reassured. 1

Understanding the Results

When a patient has a positive (reactive) HCV antibody test but a negative HCV RNA (viral load), this can indicate one of three possibilities:

• Past HCV infection that has resolved (spontaneously or through treatment) 1
• False positive antibody test result 1
• Very rarely, intermittent viremia in chronic infection 1

Recommended Follow-up Algorithm

1. Confirm Antibody Status

• If there is concern about the accuracy of the initial antibody result, perform a second HCV antibody test using a different assay platform 1
• Different antibody assays use different antigens and test platforms, making biologic false positivity unlikely to occur across multiple tests 1

2. Assess for Recent Exposure

• If the patient might have been exposed to HCV within the past 6 months, repeat HCV RNA testing is recommended 1
• During acute infection, HCV RNA may be transiently negative as antibody titers rise 1

3. Consider Patient's Immune Status

• For immunocompromised patients, consider repeat HCV RNA testing as they may have false negative results 1
• Immunocompromised patients occasionally have persistent HCV infection despite negative antibody tests 1

4. Clinical Assessment

• Review for signs or symptoms of liver disease 1
• If clinical evidence of HCV disease exists despite negative RNA, repeat RNA testing 1

Special Considerations

Intermittent Viremia

• Although rare, intermittent HCV RNA positivity has been observed in some chronically infected individuals 1
• If clinical suspicion is high despite negative RNA, consider repeating the RNA test 1

Resolution Rates

• Among anti-HCV positive persons who acquired infection as older adults (>45 years), 15-25% spontaneously resolve their infection 1
• Higher resolution rates (40-45%) are seen in those who acquired infection as children or younger adults 1

Patient Education

• Patients with resolved infection should be reassured that they are not infectious 1
• Explain that antibodies may persist for life even after the virus has been cleared 1
• Clarify that they do not need to take precautions to prevent transmission to others 1

Common Pitfalls to Avoid

• Don't assume active infection: A positive antibody test alone does not indicate current infection and should not lead to unnecessary treatment referrals 1
• Don't miss acute infection: In recently infected patients, HCV RNA may be transiently negative as antibody titers rise 1
• Don't over-test: For most patients with confirmed positive antibody but negative RNA, no further testing is required unless there is recent exposure or clinical suspicion 1
• Don't confuse with "healthy carrier" status: Patients with positive antibody but negative RNA are different from those with positive RNA and normal liver enzymes (who may still have histological liver disease) 1

By following this evidence-based approach, clinicians can appropriately manage patients with HCV antibody reactive but RNA negative results, avoiding unnecessary follow-up while ensuring proper care for those who may need additional testing.