Hep C Case Challenges for Primary Care

Approximately three and a half million persons in the United States are infected with hepatitis C virus (HCV). HCV infection is one of the leading causes of liver cirrhosis and mortality in this country. Unfortunately, about half of all HCV-infected patients are unaware that they are infected. Primary care will play an increasingly important role in educating patients on screening and potential treatment and in follow-up care after treatment is complete.

Test your knowledge of screening and HCV management with these three short case quizzes.

Case #1.

A 55-year-old man comes to your clinic for his annual physical examination. His past medical history includes hypertension and hyperlipidemia, both of which are under excellent control with medications. Vital signs and physical examination are normal. During his last visit, routine screening for hepatitis C virus (HCV) test was done. Laboratory studies reveal a positive HCV antibody (HCV Ab) test.

What is the most appropriate diagnostic test to perform next?

A. Obtain HCV RNA testing

B. Repeat HCV antibody test

C. Obtain HBV quantitative PCR

D. Do nothing at this time

Correct answer: A. Obtain HCV RNA testing

Current guidelines from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommend screening certain populations for HCV at least once-this includes “persons born between 1945 and 1965, without prior ascertainment of risk.” For a complete list of the affected populations, please visit the link above.

HCV screening is accomplished by testing for HCV Ab in the serum. A positive HCV Ab cannot distinguish between chronic, resolved, or recently acquired infection. In rare cases, HCV Ab can cross react with certain proteins and cause a positive HCV Ab.

If HCV Ab is returned as positive, follow-up HCV RNA testing should be done. Many laboratories have the capability to conduct a "reflex" HCV RNA test if the HCV Ab is positive.

Once exposed to HCV, the HCV Ab stays positive for life. Thus repeating the HCV Ab is not useful.

In the setting of positive HCV Ab, the confirmatory test is a HCV RNA, not HBV PCR.

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Case #2.

A 44-year-old woman is evaluated in your clinic after a recent diagnosis of hepatitis C infection. Her medical history is remarkable for injection drug use. She has been abstinent from illicit drugs (including injection drug use), tobacco, and alcohol for 10 years. She is not taking any medications. Vital signs and physical examination are normal. Laboratory studies reveal a HCV viral load (quantitative HCV RNA) of 1 million IU/mL, HCV genotype 1b. A liver biopsy was significant for stage-2 fibrosis. The patient is up to date with all her vaccines (including hepatitis A and hepatitis B).

Which of the following is the most appropriate next step in management of this patient?

A. Do nothing at this time

B. Initiate treatment of HCV

C. Repeat HCV viral load

D. Repeat HCV Ab

Correct answer: B. Initiate treatment of HCV

All patients wit8h HCV who do not have medical contraindications are candidates for HCV treatment. Those who have ongoing alcohol and/or illicit substance use issues should not be automatically excluded from HCV treatment. They should be referred to appropriate specialists who can assess patient’s adherence to HCV therapy. This patient has been abstinent from injection drug use and is a candidate for HCV treatment with an appropriate direct-acting antiviral agent. Once treatment is initiated, regular monitoring of viral load is essential.

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Case #3.

A 58-year-old woman has a 20-year history of HCV for which she has never been treated. In the past, she refused treatment with peg-interferon or ribavirin. She now expresses interest in being treated with the “one-pill-a-day” regimen. Laboratory studies reveal HCV genotype 1a and normal liver function tests. Liver biopsy performed 1 year ago was significant for mild liver fibrosis. Viral load level obtained 2 months ago was 8 million IU/mL.

What duration of HCV direct-acting antiviral (DAA) treatment is recommended for this patient?

A. 24 weeks

B. 8 weeks

C. 12 weeks

D. 18 weeks

Correct answer: C.12 weeks

The treatment duration of DAA varies because it is dependent on genotype, prior treatment, and presence of cirrhosis. If this patient’s HCV RNA levels were ≤6 million, 8 weeks of treatment should be considered. In patients with compensated cirrhosis, 24 weeks of treatment with DAA can be considered as an alternative treatment.