Hepatitis C Virus Guideline Updated for Unique Populations

The hepatitis C virus (HCV) guidelines for unique populations have recently been updated. These guidelines provide new testing and management recommendations for pregnant women, individuals who inject drugs, men who have sex with men (MSM), and individuals who are incarcerated. Pharmacists can play an important role in managing these unique populations as part of the healthcare team.

Managing HCV in Pregnancy

Approximately 29,000 HCV-infected women gave birth each year from 2011 to 2014.¹ The guidelines call for testing all pregnant women for HCV infection, especially at the initiation of prenatal care.¹ Women of reproductive age with known HCV infection should receive antiviral therapy before considering pregnancy to reduce the risk of mother-to-child transmission (MTCT), which is about 5-15%. Treatment during pregnancy is not recommended due to the lack of efficacy and safety data. Ribavirin is contraindicated during pregnancy due to its known teratogenicity. Additionally, the teratogenic effects can persist for up to 6 months after discontinuing ribavirin. Pregnant women 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

Injection drug use is the most common risk factor for HCV infection in the United States and Europe.¹ All individuals who currently inject drugs or have injected drugs in the past should be tested for HCV infection. An HCV-antibody test should be used, and positive results should be confirmed by immediate HCV-RNA testing. Use of HCV treatment has remained a controversial topic for patients who inject drugs. However, evidence suggests that HCV treatment with direct-acting antiviral (DAA) drugs (e.g. Epclusa® sofosbuvir/velpatasvir) along with needle/syringe exchange, and substance abuse programs can assist this patient population. Patients should undergo annual HCV-RNA testing to prevent reinfection.

HCV in MSM

Annual HCV testing is recommended for sexually active HIV-infected adolescents, and adult MSM.¹ Acute HCV infections have been recently reported in HIV-uninfected MSM who present for pre-exposure prophylaxis (PrEP).¹ Therefore, HCV testing is important at PrEP initiation and at least annually.¹ Pharmacists can play an important role in counseling patients regarding HCV prevention strategies including the use of condoms with all sex acts. Patients should also be educated that PrEP therapy can prevent sexual transmission of HIV, but it does not protect against HCV or other sexually transmitted infections. Patients infected with HCV should receive DAA treatment with ongoing counseling regarding the risk of reinfection.

HCV in Patients Who Are Incarcerated

Evidence suggests that the prevalence of HCV infection among individuals who are incarcerated ranges approximately 17-23%.¹ Additionally, most individuals in correctional facilities are unaware that they are HCV-infected. Ultimately, this can lead to HCV spreading throughout the community once patients are release from correctional facilities. There currently are not uniform standards for testing in jails and prisons; however, many facilities do perform HCV testing. The guidelines recommend HCV-antibody testing followed by HCV-RNA testing if antibody-positive.¹ Jails and prisons should encourage the continuation of HCV therapy for individuals receiving treatment at the time of incarceration. Individuals diagnosed with HCV while incarcerated should receive DAA therapy and substance use disorder treatment.

Reference

• The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America. HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. www.hcvguidelines.org/sites/default/files/full-guidance-pdf/HCVGuidance_May_24_2018a.pdf. Last updated May 24, 2018. Accessed May 25, 2018.