Management of HCV Antibody Positive with Undetectable HCV RNA
A patient with positive HCV antibody and undetectable HCV RNA does not have current HCV infection and requires no antiviral treatment. 1
Interpretation of Test Results
Persons with reactive HCV antibody and negative (undetectable) HCV RNA should be informed they do not have evidence of current HCV infection. 1 This serologic pattern indicates either:
- Resolved HCV infection (spontaneous or treatment-related viral clearance) 1
- Biologic false positive antibody test 1
The distinction between these two scenarios is typically unnecessary for clinical management, though if either clinician or patient wishes to clarify, repeat testing with a different HCV antibody assay can be performed—a false positive typically does not occur with two different assays. 1
When Additional Testing Is Warranted
HCV RNA testing can be repeated for persons with ongoing HCV infection risk or high index of suspicion for recent infection. 1 Specific scenarios requiring repeat RNA testing include:
- Ongoing risk factors such as active injection drug use, HIV-positive men who have unprotected sex with men, or ongoing high-risk exposures 1, 2
- Recent exposure within 6 months where the patient may be in the seroconversion window period 1, 3
- Immunocompromised patients who may have delayed or failed seroconversion despite active viremia 1
The World Health Organization recommends retesting HCV RNA 3 months later to confirm true clearance in anti-HCV positive, HCV RNA negative individuals with ongoing risk. 4
Critical Pitfall to Avoid
Do not assume a negative HCV antibody excludes infection in immunocompromised patients or those with recent exposure—consider direct HCV RNA testing in these populations. 3 Immunocompromised persons may be HCV antibody negative due to delayed or failed seroconversion despite active infection. 1
No Treatment Required
Additional testing is typically unnecessary and no antiviral therapy is indicated for patients with positive HCV antibody and undetectable HCV RNA. 1 These patients have either spontaneously cleared the virus or successfully completed prior treatment, and research in immunosuppressed kidney transplant patients followed for over 10 years showed no HCV reactivation, suggesting complete viral eradication. 5
Reinfection Monitoring
HCV RNA testing is required to detect reinfection after previous viral clearance because HCV antibody positivity persists. 1 For patients with continued high-risk behaviors: