Positive HCV Antibody with Non-Reactive HCV RNA
This result indicates no current (active) hepatitis C infection—the patient either had a past infection that resolved spontaneously or through treatment, or this represents a false-positive antibody test. 1
What This Result Means
The patient does not have active HCV infection and requires no antiviral treatment. 1, 2 The combination of positive HCV antibody with undetectable HCV RNA has three possible explanations:
- Past resolved infection (most common if risk factors exist): 15-25% of adults who acquire HCV clear the infection spontaneously, with higher rates (40-45%) in those infected as children or younger adults 1, 3
- False-positive antibody result: This occurs in approximately 35% of reactive results in low-prevalence populations 2
- Successful past antiviral treatment: Antibodies persist after viral clearance 2, 3
Immediate Patient Counseling
Inform the patient they do not have evidence of current HCV infection and are not infectious to others. 1, 2 Key counseling points include:
- No isolation precautions are needed 2
- HCV antibodies do not provide protective immunity—reinfection can occur with future exposure 2, 3
- The antibodies may persist for life even after viral clearance 3
When Additional Testing Is Required
In most cases, no further testing is necessary. 1, 2, 3 However, repeat HCV RNA testing should be performed in these specific situations:
- Recent exposure within the past 6 months: During acute infection, HCV RNA may be transiently negative as antibody titers rise 1, 3
- Clinical evidence of active liver disease: Elevated transaminases, jaundice, or hepatomegaly despite negative RNA warrants repeat testing 2, 3
- Immunocompromised status: HIV infection, immunosuppressive therapy, or organ transplantation can cause delayed seroconversion or intermittent viremia 1, 2
- Ongoing high-risk behaviors: Active injection drug use or other continued HCV exposure risks 1
Optional Confirmatory Testing
If definitive clarification is desired about whether the positive antibody represents true past infection versus false positivity, repeat testing with a different HCV antibody assay can be performed. 1 A false-positive result typically does not occur with two different assays using different platforms. 1, 2
Critical Pitfalls to Avoid
- Do not treat this patient for hepatitis C—there is no active infection requiring antiviral therapy 2
- Do not assume the patient is "immune"—HCV antibodies do not prevent reinfection 2, 3
- Do not order routine serial HCV RNA testing unless one of the specific indications above is present 1, 2
- In HIV-coinfected patients, be aware that HCV RNA can rarely emerge later despite initial negative results, particularly when starting antiretroviral therapy 4
Documentation and Follow-Up
Document that the patient has been informed of their non-infectious status and counseled about reinfection risk. 2 No routine follow-up HCV testing is indicated unless new risk factors develop or the patient falls into one of the special categories requiring repeat RNA testing. 1, 3