What are the diagnosis and management of Hepatitis C virus (HCV) infection?

From the Guidelines

Hepatitis C virus (HCV) infection diagnosis and management involve a combination of laboratory testing, clinical evaluation, and antiviral therapy. The primary goal of HCV therapy is to achieve a sustained virological response (SVR), defined as undetectable HCV RNA after treatment completion, which corresponds to a cure of the HCV infection 1.

Diagnosis

• HCV antibody and HCV RNA testing are recommended when acute HCV infection is suspected due to exposure, clinical presentation, or elevated aminotransferase levels 1.
• Regular laboratory monitoring (every 4-8 weeks for 6-12 months) is recommended in the setting of acute HCV infection until the ALT level normalizes and HCV RNA becomes repeatedly undetectable, suggesting spontaneous resolution 1.

Management

• Treatment of individuals with acute hepatitis C should be the same as that recommended for chronic HCV infection 1.
• Direct-acting antivirals (DAAs), such as sofosbuvir and ledipasvir, are effective in treating HCV infection, with high SVR rates reported in patients with recently acquired hepatitis C 1.
• Treatment duration may vary, with some studies suggesting that 6-12 weeks of treatment may be sufficient for patients with recently acquired hepatitis C 1.
• Follow-up after a sustained virological response is important to monitor for reinfection and extrahepatic manifestations of HCV, with guidance provided by the EASL position paper on clinical follow-up after HCV cure 1.

Key Considerations

• HCV infection is associated with a number of extrahepatic manifestations, and effective viral suppression can induce reversal of most of them 1.
• The risk of hepatocellular carcinoma (HCC) and all-cause mortality is significantly reduced, but not eliminated, in patients with cirrhosis who clear HCV compared to untreated patients and non-sustained virological responders 1.
• Counseling is recommended for patients with acute HCV infection to avoid hepatotoxic insults and reduce the risk of HCV transmission to others 1.

From the Research

Diagnosis of Hepatitis C Virus (HCV) Infection

• The diagnosis of HCV infection involves the use of serological and molecular tests, including enzyme-linked immunosorbent assays (ELISAs) and confirmatory/supplemental analytical antibody tests 2
• Specific laboratory diagnostic tests for HCV infection include serological antibody tests, which detect anti-HCV in serum or plasma, and molecular tests, which detect HCV RNA genome, investigate viral load, and determine the characteristics of the genome 2
• Various techniques, such as detection of anti-HCV immunoglobulin G immunoassays, detection of HCV RNA by identifying virus-specific molecules nucleic acid testings, recognition of core antigen for diagnosis of HCV, quantitative antigen assay, have been used to detect HCV RNA and core antigen 3

Management of HCV Infection

• The management of HCV infection is intended to eradicate the virus from the body of patients and includes examining the treatment (efficacy and protection), assessment of hepatic condition before commencing therapy, controlling the parameters upon which dual and triple therapies work, monitoring the body after treatment and adjusting the co-factors 3
• Direct-acting antiviral agents (DAAs) have become available, which target three proteins involved in crucial steps of the HCV life cycle: the NS3/4A protease, the NS5A protein and the RNA-dependent RNA polymerase NS5B protein 4
• Combination of two or three of these DAAs can cure (defined as a sustained virological response 12 weeks after treatment) HCV infection in >90% of patients, including populations that have been difficult to treat in the past 4
• Antiviral therapy with the combination of pegylated interferon alfa and ribavirin has been used to prevent HCV infection complications, and the use of serological and virological tests has become essential in the management of HCV infection to diagnose infection, guide treatment decisions and assess the virological response to antiviral therapy 5

Integration of HCV Management into Primary Care

• Elimination of HCV has been made possible with the advent of highly efficacious direct acting antivirals (DAAs), and DAA regimens offer cure of HCV with 8-12 weeks of a well-tolerated once daily therapy 6
• Engaging primary care providers greatly increases capacity to diagnose and treat chronic HCV and ultimately make HCV elimination a reality, and primary care is at the forefront of patient contact, representing the ideal place to concentrate efforts to identify barriers and implement solutions to achieve universal HCV screening and increase curative treatment 6