Who is eligible for Hepatitis C (HCV) treatment?

Eligibility for Hepatitis C (HCV) Treatment

All patients with chronic HCV infection should be offered treatment without delay, regardless of disease stage, as treatment can prevent complications, improve quality of life, and prevent transmission.1

Priority Patients for Immediate Treatment

• Patients with significant fibrosis or cirrhosis (METAVIR score F2, F3, or F4), including both compensated (Child-Pugh A) and decompensated (Child-Pugh B or C) cirrhosis 1
• Patients with clinically significant extrahepatic manifestations (e.g., symptomatic vasculitis associated with HCV-related mixed cryoglobulinaemia, HCV immune complex-related nephropathy, non-Hodgkin B cell lymphoma) 1
• Patients with HCV recurrence after liver transplantation 1
• Patients at risk of rapid disease progression due to comorbidities:
  • Non-liver solid organ or stem cell transplant recipients 1
  • HBV or HIV coinfection 1
  • Diabetes 1
• Individuals at risk of transmitting HCV:
  • People who inject drugs (PWIDs) 1
  • Men who have sex with men engaging in high-risk sexual practices 1
  • Women of childbearing age who wish to get pregnant 1
  • Patients on hemodialysis 1
  • Incarcerated individuals 1

Special Considerations

• Patients with decompensated cirrhosis and MELD score ≥18-20 who are liver transplant candidates should generally be transplanted first and treated after transplantation 1
  • Exception: If waiting time for transplant is expected to exceed 6 months, treatment can be initiated before transplantation 1
• Patients with moderate fibrosis (METAVIR score F2) should receive treatment 1
• Patients with minimal or no fibrosis (METAVIR score F0-F1) without extrahepatic manifestations are still eligible for treatment, though timing may be individualized based on patient factors 1

Contraindications to Treatment

• Limited life expectancy due to non-liver-related comorbidities 1
• For regimens containing NS3-4A protease inhibitors (grazoprevir, glecaprevir, voxilaprevir):
  • Decompensated (Child-Pugh B or C) cirrhosis 1
  • History of previous decompensation episodes 1
• For regimens containing sofosbuvir:
  • Caution in severe renal impairment (eGFR <30 ml/min/1.73 m²) 1
  • Contraindicated in patients receiving amiodarone who cannot switch to another therapy 1
• Certain drug interactions, particularly with CYP/P-gp-inducing agents like carbamazepine, phenytoin, and phenobarbital 1, 2

Assessment Before Treatment

• Evaluation of liver disease severity using non-invasive methods:
  • Liver stiffness measurement (transient elastography) 1, 3
  • Fibrosis biomarker panels (FIB-4, APRI, or other established panels) 1, 3, 4
• Assessment for portal hypertension in cirrhotic patients 1
• Evaluation of renal function, diabetes status, and obesity 1
• Drug interaction screening 2
• HCV RNA quantification and genotype determination 3, 4

Treatment Outcomes and Follow-up

• Sustained virological response (SVR) is defined as undetectable HCV RNA 12 weeks (SVR12) or 24 weeks (SVR24) after end of therapy 1
• SVR corresponds to definitive cure in the vast majority of cases 1
• In patients with advanced fibrosis (F3) or cirrhosis (F4), SVR reduces but does not eliminate the risk of hepatocellular carcinoma, necessitating continued surveillance 1, 3

Clinical Pearls

• Modern direct-acting antiviral (DAA) regimens have high efficacy (>95% SVR rates), short duration (8-12 weeks), and excellent safety profiles, even in patients with cirrhosis 4, 5, 6
• Patients who have been treated should be counseled about the risk of reinfection, particularly those with ongoing risk behaviors 1
• Successful treatment significantly reduces liver-related complications and mortality, even in patients with advanced disease 7, 5, 6
• National elimination plans with unrestricted access to treatment are essential for achieving global HCV elimination goals 1