5 HCV Cases: How Would You Proceed?

Hepatitis C virus (HCV) infection impacts millions of people worldwide with an estimated 2.7 to 3.9 million people infected in the US alone.² Baby boomers, injection drug users (current and past), healthcare workers, and men who have sex with men are all at high risk for HCV infection.

Following are 5 case scenarios each followed by a question that tests your knowledge of disease course and treatment in the context of patient counseling.

1. A 60-year-old man has chronically elevated liver function tests. He tests positive for HCV antibody and HCV RNA. Management should include all of the following except:

A. Alcohol Use Disorders Identification Test (AUDIT)-C test
B. Linkage to care
C. Mini-mental state exam
D. Education about sexual transmission

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Answer: C. Mini-mental state exam. Baby boomers (adults born between 1945 and 1965) are at increased risk for HCV, with disease prevalence 5 times higher in this age group vs other adults. The CDC recommends that people who test positive for HCV should receive alcohol education and screening with the AUDIT or AUDIT-C (a shorter 3-item tool), linkage to care, and education about decreasing transmission through sex and blood contact.¹

2. A 36-year-old former injection drug user tests positive for chronic HCV and wants to know the likelihood of cure if she completes treatment. How should you counsel her?

A. Because HCV can never be cured, she will need lifelong treatment
B. >50% of patients who complete direct-acting antiviral (DAA) treatment attain sustained virologic response
C. >90% of patients who complete DAA treatment attain sustained virologic response
D. She is not a candidate for treatment because she has chronic HCV

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Answer: C. >90% of patients who complete DAA treatment attain sustained virologic response. More than 90% of patients with chronic HCV who complete treatment with DAAs attain sustained virologic response (undetectable HCV RNA for ≥12 weeks after completing treatment). Early treatment with new DAAs can decrease treatment duration and may increase the chance for cure.^2,3

3. A 24-year-old injection drug user tests positive for HCV. The last time he injected drugs was 2 weeks ago. He just started a detox program and would like to delay HCV treatment until after he has completed it. How should you counsel him?

A. Early treatment increases the chance of virologic cure
B. Early treatment may decrease the likelihood of transmitting HCV to others
C. Delaying treatment may increase the chance of morbidity and mortality
D. All of the above

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Answer: D. All of the above. IV drug use represents the most common risk factor for HCV infection in the US, accounting for approximately 70% of new infections. According to guidelines from the American Association for the Study of Liver Disease and the Infectious Disease Society of America (AASLD/IDSA), current or recent IV drug use should not be considered a contraindication to treatment. Treatment of IV drug users should occur in a multidisciplinary setting to decrease the risk of reinfection, and to treat addiction and psychiatric comorbidities. Early treatment can decrease transmission of HCV, increase the chance of virologic cure, and improve survival.³

4. A 36-year-old man tells you that he often has sex with men he does not know and rarely uses a condom. He is HIV-positive and takes antiretrovirals. He is complaining of abdominal pain, nausea, and dark-colored urine. He tests positive for acute HCV infection. All of the following are important in the management of this patient except:

A. Safe sex counseling
B. Antiretrovirals should be interrupted during HCV treatment
C. HIV/HCV coinfection is associated with more rapid liver fibrosis
D. He should be tested for hepatitis B virus (HBV)

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Answer: B. Antiretrovirals should be interrupted during HCV treatment (incorrect). According to recommendations from the AASLD/IDSA, antiretrovirals should not be interrupted for the purposes of HCV treatment in individuals coinfected with HIV/HCV. Such individuals are at increased risk for more rapid liver fibrosis, HBV infection, and HBV reactivation during HCV treatment. This patient should also be counseled on safe sex.³

5. A 45-year-old nurse tested positive for HCV after receiving a needle stick while at work. After completing treatment, she shows virologic cure for 15 weeks with no evidence of liver fibrosis. How often should she be followed up?

A. Every 2 months
B. Every 3 months
C. Every 6 months
D. The same as someone without HCV

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Answer: D. The same as someone without HCV. According to the AASLD/IDSA, patients who achieve sustained virologic response should receive standard medical care as if they were never infected with HCV. While such patients are no longer at risk for HCV-related liver injury, they remain at risk for other types of liver disease, such as nonalcoholic fatty liver disease and alcoholic liver disease.³

Please scroll down for links to additional Patient Care articles on HCV infection.

References:

1. Centers for Disease Control and Prevention. A guide to comprehensive hepatitis C counseling and testing. https://www.cdc.gov/hepatitis/resources/professionals/pdfs/CounselingandTestingPC.pdf. Accessed February 27, 2019.

2. Centers for Disease Control and Prevention. The ABCs of hepatitis. https://www.cdc.gov/hepatitis/resources/professionals/pdfs/ABCTable.pdf. Updated 2016. Accessed February 27, 2019.

3. American Association for the Study of Liver Diseases and the Infectious Diseases Society of America. HCV guidance: Recommendations for testing, managing, and rreating hepatitis C. https://www.hcvguidelines.org/. Updated May 24, 2018. Accessed February 27, 2019.