New Testing & Disease Management Guidelines for Hepatitis C Virus Infections in Unique Populations

The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America has released new guidelines on the testing and management of hepatitis c virus (HCV) in special populations, including, pregnant women, individuals who inject drugs, men who have sex with men (MSM), and individuals who are incarcerated. An explanation of these updates for each population is included below.

Managing HCV in Pregnancy

Under the new guidelines, all pregnant women should be tested for HCV infection, particularly at the start of their prenatal care. Women of reproductive age with known HCV infection should receive antiviral therapy before considering pregnancy to reduce the risk of mother-to-child transmission, which is current data indicates is 5% to 15%. It is not recommended to treat women who are infected while they are pregnant as there is a lack of safety and efficacy data around doing so. Ribavirin is contraindicated during pregnancy because of its known teratogenicity. Furthermore, the teratogenic effects can persist for up to 6 months after discontinuing the drug. Women who are pregnant and infected with HCV should receive HCV RNA and routine liver function tests. Breastfeeding is not contraindicated unless the mother has cracked, damaged, or bleeding nipples, or HIV coinfection.

HCV in Individuals Who Inject Drugs

The most common risk factor for HCV infection in the United States and Europe is the use of injection drugs. As a result, all individuals who currently inject drugs or have injected drugs in the past should be tested for HCV infection with an HCV-antibody test. Positive results should be confirmed by immediate HCV-RNA testing. Treatment with direct-acting antivirals (DAAs)—for example, sofosbuvir/velpatasvir—as well as needle/syringe exchange, and substance abuse programs can assist this patient population. Annual HCV-RNA testing should be performed to prevent reinfection.

HCV in MSM

Sexually-active adolescents who are infected with HIV, as well as adult MSM, should undergo annual HCV testing. The new guidelines indicate that acute HCV infections have been recently reported in HIV-uninfected MSM who present for pre-exposure prophylaxis (PrEP). As a result, the new guidelines state that HCV testing should be performed at PrEP initiation at least once a year. Counseling on the importance of the use of condoms during all sex acts and additional HCV prevention strategies is recommended. Patients should also be educated that although PrEP therapy can prevent sexual transmission of HIV, it does not protect against HCV or other sexually transmitted infections. Those patients who are infected with HCV should receive DAAs with ongoing counseling on the risk of reinfection.

HCV in Patients Who Are Incarcerated

The prevalence of HCV infection among individuals who are incarcerated ranges approximately 17% to 23%, according to the new guidelines. Furthermore, most individuals in correctional facilities are unaware that they are HCV-infected, which can lead to the spread of HCV throughout a community once an infected individual is released from the correctional facility. Althogh uniform standards for testing in jails and prisons do not exist, many facilities do perform HCV testing. The new guidelines recommend HCV-antibody testing followed by HCV-RNA testing if antibody-positive. The continuation of HCV therapy for individuals receiving treatment at the time of incarceration should be encouraged. Those individuals who are diagnosed with HCV infection while incarcerated should receive DAA therapy and substance use disorder treatment.

An earlier version of this article appeared on PharmacyTimes.com.