What is the appropriate referral process to an Infectious Disease (ID) specialist for a patient with a positive Hepatitis C Virus (HCV) Polymerase Chain Reaction (PCR) result and how should their treatment be managed?

How to Write a Referral to Infectious Disease for Positive HCV PCR

All patients with a positive HCV PCR (confirming active viremia) should be referred immediately to a specialist with expertise in hepatitis C management—this can be an infectious disease specialist, hepatologist, or gastroenterologist experienced in HCV treatment. 1

Essential Information to Include in Your Referral

Patient Demographics and Clinical Summary

• Patient identification: Name, date of birth, contact information 1
• Brief clinical summary: Include how HCV was discovered (screening, elevated liver enzymes, symptoms) 1
• Risk factors for HCV: Document any history of injection drug use, blood transfusions before 1992, hemodialysis, incarceration, or other relevant exposures 1

Laboratory Results to Attach

• HCV antibody test result (date and result) 1, 2
• HCV RNA (PCR) result with quantitative value if available 1, 3
• HCV genotype if already performed (though specialist will often order this) 1
• Complete liver function tests: ALT, AST, alkaline phosphatase, bilirubin, albumin, INR 1, 3
• Complete blood count to assess for cytopenias 3
• Creatinine and eGFR for renal function assessment 1

Additional Testing Results (if available)

• HIV test result (essential due to overlapping risk factors and impact on treatment) 3, 4
• Hepatitis B surface antigen (HBsAg) to rule out coinfection 3, 4, 5
• Fibrosis assessment if already performed (FIB-4 score, APRI, or FibroScan results) 1, 3
• Abdominal imaging if available (ultrasound showing liver texture, presence of cirrhosis) 3

Clinical Context That Affects Urgency

• Presence of cirrhosis or advanced fibrosis: These patients require expedited evaluation 1
• Elevated liver enzymes: Document ALT/AST trends if available 1
• Active substance use status: Note if patient is on medication-assisted treatment (MAT) or in recovery—this is NOT a contraindication to treatment 3, 4
• Pregnancy status in women of childbearing age 1
• Immunosuppression: HIV coinfection, transplant recipients, or immunosuppressive medications 1

Sample Referral Template

To: Infectious Disease/Hepatology Specialist

Re: [Patient Name, DOB]

Reason for Referral: Positive HCV RNA confirming active hepatitis C infection requiring specialist evaluation and treatment consideration

Clinical Summary:

• HCV antibody positive on [date]
• HCV RNA positive on [date] with viral load of [value] IU/mL
• [Genotype if known]
• ALT [value], AST [value], other LFTs [summarize]
• [Risk factors: e.g., "Patient reports history of injection drug use in 1990s, currently stable on buprenorphine/naloxone"]
• HIV status: [negative/positive/pending]
• HBsAg: [negative/positive/pending]

Current medications: [List, especially noting any potential drug interactions]

Urgency indicators: [Note if cirrhosis suspected, significantly elevated transaminases, or other concerning features]

Patient has been counseled about: Diagnosis of active hepatitis C, need for specialist evaluation, high cure rates with current treatments (>95%), and importance of follow-up 1, 3, 4

Critical Points for Patient Counseling Before Referral

What to Tell Your Patient

• HCV is curable: Modern direct-acting antiviral treatments cure >95% of patients, typically with 8-12 weeks of oral medication 1, 4, 6
• Active substance use is NOT a barrier: Patients on MAT or with ongoing substance use can and should be treated 3, 4
• Importance of specialist evaluation: The specialist will assess liver damage severity and determine the best treatment regimen 1
• Transmission prevention: Counsel on not sharing needles, razors, toothbrushes, or other items that may have blood; covering wounds; and not donating blood 1, 3

Common Pitfalls to Avoid

• Do not delay referral waiting for additional testing—the specialist will order what's needed 1, 7
• Do not assume active substance use is a contraindication—this outdated approach prevents treatment of those who need it most 3, 4
• Do not tell patients they need a liver biopsy first—non-invasive fibrosis assessment is now standard, and biopsy is rarely needed 1, 3
• Do not lose patients between positive antibody and RNA testing—use reflex PCR testing when possible to avoid this common gap 2, 8
• Do not forget to test for HIV and HBV—coinfection significantly impacts management 3, 4, 5

Urgency of Referral

Expedited Referral (Within 1-2 Weeks)

• Evidence of cirrhosis (clinical, laboratory, or imaging findings) 1
• Significantly elevated transaminases (ALT/AST >5x upper limit of normal) 1
• Extrahepatic manifestations of HCV (cryoglobulinemia, glomerulonephritis) 4
• HIV or HBV coinfection 3, 4
• Immunosuppressed patients 1

Routine Referral (Within 4-6 Weeks)

• Confirmed viremia without above features 1
• Mildly elevated or normal transaminases 1

Follow-Up Responsibility

Ensure the patient actually attends the specialist appointment—studies show significant loss to follow-up between diagnosis and specialist evaluation, which undermines HCV elimination efforts 7, 8, 9. Consider:

• Direct scheduling of the specialist appointment before the patient leaves your office 8
• Phone call reminder from your office staff 8
• Documentation in your EMR to track referral completion 9