What is the appropriate hepatitis C treatment for a non-pregnant patient seeking preconception counseling with positive hepatitis C antibody (ELISA) and recombinant immunoblot assay (RIBA) tests, negative hepatitis C RNA, and elevated transaminases?

Management of Hepatitis C in Preconception Counseling with Negative HCV RNA

This patient has cleared hepatitis C infection (positive antibodies but negative RNA) and does not require antiviral treatment; however, the elevated transaminases warrant investigation for alternative causes of liver injury before conception. 1

Understanding the Serologic Profile

This patient's test results indicate resolved or cleared HCV infection rather than active disease:

• Positive HCV antibody (ELISA and RIBA) confirms prior HCV exposure 1
• Negative HCV RNA indicates the virus has been cleared—this occurs in approximately 20% of HCV infections 1
• The combination of positive antibodies with negative RNA distinguishes cleared infection from false-positive antibody results 1

No Antiviral Treatment Required

Direct-acting antiviral (DAA) therapy is not indicated for this patient because:

• Treatment requires detectable HCV RNA (active viremia) 1
• The goal of HCV treatment is achieving sustained virologic response (SVR), defined as undetectable HCV RNA 12-24 weeks after treatment completion 1
• This patient has already achieved viral clearance naturally 1
• DAAs are not approved for use during pregnancy and should ideally be completed before conception if treatment were needed 1, 2

Addressing the Elevated Transaminases

The two-fold elevation in transaminases with negative HCV RNA requires evaluation for alternative causes of liver injury:

Recommended workup includes:

• Screen for hepatitis B surface antigen (HBsAg) and hepatitis B core antibody (anti-HBc), as HBV has overlapping risk factors with HCV and can cause liver damage 1
• Test for hepatitis A virus (HAV) immunity, as HAV superinfection can worsen hepatic damage 1
• Evaluate for other causes: alcohol use, non-alcoholic fatty liver disease, autoimmune hepatitis, medication-induced liver injury, and metabolic disorders 1
• Obtain complete metabolic panel including albumin, bilirubin, platelet count, and prothrombin time to assess liver synthetic function 1

Preconception Counseling Recommendations

Vaccination:

• Vaccinate against hepatitis A and hepatitis B if not immune (safe during pregnancy if conception occurs before completion) 1

Lifestyle modifications:

• Counsel complete alcohol avoidance, as even modest alcohol use accelerates liver disease progression 1
• Advise against sharing personal hygiene items (razors, nail clippers, toothbrushes) to prevent transmission to household contacts 1

Screening for co-infections:

• Test for HIV, syphilis, gonorrhea, and chlamydia given overlapping risk factors 1

Acetaminophen use:

• If liver disease is present, limit acetaminophen to maximum 2 grams daily rather than 4 grams 1

Pregnancy Implications

Once pregnant, this patient requires minimal HCV-specific management:

• No serial viral load monitoring needed during pregnancy 1, 2
• Cesarean delivery is not indicated for HCV status alone 2, 3
• Breastfeeding is not contraindicated unless nipples are cracked or bleeding 1, 2, 3
• Vertical transmission risk is negligible with undetectable HCV RNA 3

Key Clinical Pitfall

Do not confuse positive HCV antibodies with active infection. The critical distinction is HCV RNA status—antibodies indicate exposure (past or present), while RNA indicates active replication requiring treatment. 1, 4 This patient's negative RNA means the infection has cleared and no antiviral therapy is warranted.