From the Guidelines
After successful hepatitis C treatment, patients can still test positive for hepatitis C antibodies, but should test negative for the virus itself (HCV RNA), as indicated by the most recent guidelines 1. This is because antibodies remain in the bloodstream for years or even life after infection, while successful treatment eliminates the actual virus. If a patient completed treatment but still tests positive for HCV RNA (viral load), this indicates treatment failure or reinfection. The next steps would include:
- Consulting with a hepatologist or infectious disease specialist to determine if treatment failure occurred, which might require resistance testing and a different medication regimen, as suggested by the European Association for the Study of the Liver 1.
- Discussing risk factors and prevention strategies if reinfection is suspected. Some key points to consider:
- Regular monitoring with HCV RNA testing is essential to confirm sustained virologic response, typically done 12 weeks after completing treatment, with additional testing at 24 and 48 weeks sometimes recommended to ensure long-term clearance 1.
- Patients with advanced fibrosis or cirrhosis who achieve an SVR should remain under surveillance for HCC every 6 months by ultrasound, and for oesophageal varices by endoscopy if varices were present at pre-treatment endoscopy 1.
- The risk of reinfection should be emphasized to patients at risk, and behavioural modifications should be positively reinforced, with reported rates of reinfection following successful HCV treatment among patients at high-risk being in the order of 1–8% per year 1. Common current treatments include direct-acting antivirals like Epclusa (sofosbuvir/velpatasvir), Mavyret (glecaprevir/pibrentasvir), or Harvoni (ledipasvir/sofosbuvir), typically taken for 8-12 weeks with cure rates exceeding 95% 1.
From the FDA Drug Label
The SVR12 rate was 98% overall (98% [78/80] in treatment-naïve subjects and 100% [20/20] in treatment-experienced subjects). The SVR12 rate was 99% (86/87) in subjects with genotype 1 HCV infection, and 100% (2/2) in subjects with genotype 4 HCV infection.
Hepatitis C Treatment Outcome: The treatment with ledipasvir and sofosbuvir has a high success rate in achieving SVR12, which means that the hepatitis C virus is no longer detectable in the blood 12 weeks after treatment.
- SVR12 Rates:
- 98% overall in subjects 12 years to <18 years of age
- 99% in subjects 6 years to <12 years of age with genotype 1 HCV infection
- 100% in subjects 6 years to <12 years of age with genotype 4 HCV infection
- Next Steps: If a patient has achieved SVR12, it is considered a cure, and no further treatment is needed. However, it is essential to continue monitoring the patient's liver health and overall well-being. If a patient does not achieve SVR12, the next steps would depend on the individual case and may involve retreatment or alternative treatment options 2.
From the Research
Hepatitis C Treatment and Sustained Virological Response
- Hepatitis C treatment with direct-acting antivirals (DAAs) has been shown to be highly effective in achieving sustained virological response (SVR) in patients with chronic hepatitis C infection 3, 4, 5.
- SVR is defined as undetectable HCV RNA 12 weeks after completing therapy and is considered a virologic cure 5.
- Treatment regimens such as glecaprevir/pibrentasvir or sofosbuvir/velpatasvir have been shown to result in greater than 95% cure rates in treatment-naive adults without cirrhosis or with compensated cirrhosis 5.
Factors Affecting Treatment Outcome
- The presence of liver cirrhosis and resistance-associated variants (RAVs) can affect treatment outcome 6.
- Factors that predict SVR12 include higher albumin levels, lower total bilirubin levels, absence of cirrhosis, and absence of proton pump inhibitor use 4.
Next Steps After Treatment
- Patients who achieve SVR are considered cured, but those with compensated cirrhosis should undergo post-treatment surveillance for hepatocellular carcinoma and esophageal varices 5.
- In patients without cirrhosis, no liver-related follow-up is recommended after achieving SVR 5.
- For patients who fail to respond to initial treatment, retreatment with a different regimen such as ledipasvir/sofosbuvir with ribavirin may be effective 6.