This Patient Does Not Require Treatment at This Time
This 37-year-old woman has cleared her hepatitis C infection spontaneously and should not receive antiviral therapy, but requires monitoring and further evaluation for her elevated transaminases.
Understanding the Clinical Picture
The key diagnostic finding here is HCV RNA negative despite positive antibody tests (ELISA and RIBA positive). This serologic pattern indicates spontaneous viral clearance rather than active chronic infection 1. The positive antibody tests simply reflect prior exposure to HCV, while the negative RNA confirms no active viral replication is occurring.
- Approximately 15-25% of individuals exposed to HCV will spontaneously clear the virus, leaving them with detectable antibodies but no viremia 1
- Antiviral therapy is only indicated for patients with detectable HCV RNA - the presence of active viral replication is an absolute prerequisite for treatment 1
- Current guidelines from EASL (2020) and AASLD/IDSA (2020) uniformly require confirmed HCV RNA positivity before initiating direct-acting antiviral therapy 1
Why Treatment is Contraindicated
No HCV RNA means no treatment indication, period. The modern DAA regimens (glecaprevir/pibrentasvir, sofosbuvir/velpatasvir) target active viral replication 1. Without circulating virus, these medications serve no purpose and would expose the patient to unnecessary risks and costs.
- The 2020 AASLD/IDSA guidelines explicitly state that HCV RNA testing with a quantitative amplification assay is required for all candidates for antiviral therapy 1
- Even the older 2006 AGA guidelines required "the presence of HCV RNA" as a prerequisite for treatment candidacy 1
Addressing the Elevated Transaminases
The patient's transaminases are 2x normal, which requires investigation for alternative causes of liver injury since HCV is not active:
Immediate workup should include:
- Metabolic evaluation: Fasting lipid profile, glucose, HbA1c to assess for non-alcoholic fatty liver disease (NAFLD), which is extremely common and can cause this degree of transaminase elevation 2
- Autoimmune markers: Anti-smooth muscle antibody (ASMA), anti-nuclear antibody (ANA), and anti-liver-kidney microsomal antibody (anti-LKM1) 2
- Hepatitis B testing: HBsAg and anti-HBc to exclude HBV infection 1, 2
- Alcohol use assessment: Quantify current alcohol consumption given her substance use history 1
- Medication review: Identify any hepatotoxic medications 2
Monitoring strategy:
- Repeat liver enzymes in 2-4 weeks to assess trajectory 2
- Monitor functional hepatic indicators (bilirubin, albumin, INR) rather than focusing solely on transaminase trends, as these correlate better with actual liver function 2
- Continue monitoring every 2-4 weeks until complete normalization or alternative diagnosis is established 2
Follow-Up Considerations
- Confirm sustained viral clearance: Repeat HCV RNA testing in 6 months to document persistent negativity 1
- Hepatitis A and B vaccination: She should receive HAV and HBV vaccines if not immune, as recommended for all persons with prior HCV exposure 1
- Reinfection counseling: Given her history of IV drug use (though 10 years abstinent), counsel about reinfection risk if she returns to drug use 1
Common Pitfall to Avoid
Do not confuse positive HCV antibodies with active infection. The antibody tests (ELISA, RIBA) detect immune response to prior exposure and remain positive for life even after viral clearance. Only HCV RNA testing distinguishes active infection from resolved infection 1. Treating based on antibodies alone would be inappropriate and wasteful.