Management of Reactive HCV Antibody with Non-Reactive HCV RNA
This patient does not have current HCV infection and requires no antiviral treatment. 1
Interpretation of Test Results
A reactive HCV antibody with non-reactive (not detected) HCV RNA indicates one of two scenarios: 1
- Past resolved HCV infection (most common) - the patient spontaneously cleared the virus or successfully completed treatment in the past
- Biologic false positive antibody test (less common) - the initial antibody test was falsely reactive
The patient should be informed they do not have evidence of current HCV infection and are not infectious to others. 1
When Additional Testing is Indicated
Repeat HCV RNA Testing Should Be Performed If: 1
- Ongoing HCV infection risk factors are present (active injection drug use, high-risk sexual practices, occupational exposures)
- Recent exposure suspected within the past 6 months - the patient may be in the window period before RNA becomes detectable
- Clinical evidence of HCV disease is present (elevated liver enzymes, symptoms of hepatitis)
- Immunocompromised status - these patients may have delayed or failed antibody seroconversion 1
- Concerns about specimen handling or storage exist
Distinguishing Past Infection from False Positive: 1
If either the clinician or patient wishes to determine whether the positive antibody represents resolved infection versus a false positive:
- Test with a different FDA-approved HCV antibody assay (different from the initial test)
- A false positive typically does not occur with two different assays due to varying antigens, test platforms, and performance characteristics 1
- This distinction is optional and does not change clinical management in most cases 1
Clinical Management
For Most Patients (No Further Action Required): 1
- No antiviral therapy is indicated
- No specific monitoring is needed
- Patient is not infectious and cannot transmit HCV to others 1
For Patients with Ongoing Risk Factors: 1
- Counsel on HCV transmission prevention if risk behaviors continue
- Consider periodic HCV RNA retesting to detect potential reinfection
- HCV antibody will remain positive even after viral clearance, so only RNA testing can detect reinfection 1
For Patients with Recent Exposure (Within 6 Months): 1
- Repeat HCV RNA testing at appropriate intervals
- Consider follow-up HCV antibody testing to demonstrate seroconversion if RNA testing is not feasible 1
Common Pitfalls to Avoid
Do not treat this patient with antiviral therapy - HCV RNA negativity definitively rules out current infection requiring treatment. 1
Do not assume the patient has never been infected - the positive antibody likely represents past resolved infection rather than false positivity, but this distinction rarely matters clinically. 1
Do not order repeated antibody tests - the antibody will remain positive indefinitely after exposure; only RNA testing can detect active infection. 1
Do not miss the window period - if exposure occurred within the past 6 months, the patient may be in early acute infection before RNA becomes detectable, requiring repeat testing. 1