Last updated December 18, 2021

Hepatitis C Guidance

Recommendations

ONE-TIME, UNIVERSAL HEPATITIS C SCREENING FOR ADULTS

1. One-time, routine, opt-out HCV screening is recommended for all individuals aged 18 years or older. (B, I)
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RISK-BASED HCV TESTING

2. One-time HCV testing should be performed for all persons younger than 18 years old with behaviors, exposures, or conditions or circumstances associated with an increased risk of HCV infection. (B, I)
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3. Periodic repeat HCV testing should be offered to all persons with behaviors, exposures, or conditions or circumstances associated with an increased risk of HCV exposure. (C, IIa)
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4. Annual HCV testing is recommended for all persons who inject drugs and for men with human immunodef iciency virus (HIV) infection who have unprotected sex with men. (C, IIa)
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INITIAL HCV TESTING AND FOLLOW-UP

5. HCV-antibody testing with reflex HCV RNA polymerase chain reaction testing is recommended for initial HCV screening. (A, I)
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6. Among persons with a negative HCV-antibody test who were exposed to HCV within the prior 6 months, HCV-RNA or follow-up HCV-antibody testing 6 months or longer after exposure is recommended. HCV-RNA testing can also be considered for immunocompromised persons. (C, I)
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7. Among persons at risk for reinfection after previous spontaneous or treatment-related viral clearance, HCV-RNA testing is recommended because a positive HCV-antibody test is expected. (C, I)
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8. Persons found to have a positive HCV-antibody test and negative results for HCV RNA by polymerase chain reaction should be informed that they do not have evidence of current (active) HCV infection but are not protected from reinfection. (A, I)
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9. Quantitative HCV-RNA testing is recommended prior to initiation of antiviral therapy to document the baseline level of viremia (i.e., baseline viral load). (A, I)
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10. HCV genotype testing may be considered for those in whom it may alter treatment recommendations. (A, I)
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COUNSELING AND CLINICAL CARE FOR PERSONS WITH ACTIVE HCV INFECTION

11. Persons with current HCV infection should receive education and interventions aimed at reducing liver disease progression and preventing HCV transmission. (B, IIa)
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12. Abstinence from alcohol and, when appropriate, interventions to facilitate cessation of alcohol consumption should be advised for all persons with HCV infection. (B, IIa)
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13. All persons with HCV infection should be provided education about how to prevent HCV transmission to others. (C, I)
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14. Evaluation for advanced f ibrosis using noninvasive markers (or liver biopsy, if required) is recommended for all persons with HCV infection to facilitate an appropriate decision regarding HCV treatment strategy and to determine the need for initiating additional measures for cirrhosis management (e.g., hepatocellular carcinoma [HCC] screening). (A, I)
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15. Evaluation for other conditions that may accelerate liver f ibrosis, including hepatitis B virus [HBV] and HIV infections, is recommended for all persons with active HCV infection. (B, IIb)
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16. Vaccination against hepatitis A and hepatitis B is recommended for all susceptible persons with HCV infection. (C, IIa)
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17. Vaccination against pneumococcal infection is recommended for all persons with cirrhosis. (C, IIa)
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UNIVERSAL TREATMENT OF ADULTS WITH HCV INFECTION

18. Antiviral treatment is recommended for all adults with acute or chronic HCV infection, except those with a short life expectancy that cannot be remediated by HCV therapy, liver transplantation, or another directed therapy. (A, I)
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TESTING OF PERINATALLY EXPOSED CHILDREN AND SIBLINGS OF CHILDREN WITH HCV INFECTION

19. All children born to women with acute or chronic hepatitis C should be tested for HCV infection. Antibody-based testing is recommended at or after 18 months of age. (A, I)
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20. Testing with an HCV-RNA assay can be considered in the f irst year of life, but the optimal timing of such testing is unknown. (C, IIa)
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21. Testing with an HCV-RNA assay can be considered as early as 2 months of age. (B, IIa)
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22. Repetitive HCV-RNA testing prior to 18 months of age is not recommended. (A, III)
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23. Children who are anti-HCV-positive after 18 months of age should be tested with an HCVRNA assay after age 3 to conf irm chronic hepatitis C infection. (A, I)
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24. The siblings of children with vertically acquired chronic hepatitis C should be tested for HCV infection, if born from the same mother. (C, I)
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COUNSELING PARENTS AND CHILDREN REGARDING HCV TRANSMISSION AND PREVENTION

25. Parents should be informed that hepatitis C is not transmitted by casual contact and that, as such, children with HCV infection do not pose a risk to other children and can participate in school, sports, and athletic activities and engage in all other regular childhood activities without restrictions. (B, I)
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26. Parents should be informed that universal precautions should be followed at school and in the home of children with HCV infection. Educate families and children about the risk and routes of HCV transmission and the techniques for avoiding blood exposure, such as avoiding the sharing of toothbrushes, razors, and nail clippers and the use of gloves and dilute bleach to clean up blood. (B, I)
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MONITORING AND MEDICAL MANAGEMENT

27. Routine liver biochemistries at initial diagnosis and at least annually thereafter are recommended to assess for HCV disease progression. (C, I)
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28. Appropriate vaccinations are recommended for children with HCV infection who are not immune to HBV and/or HAV to prevent these infections. (C, I)
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29. Disease severity assessment by routine laboratory testing and physical examination, as well as use of evolving noninvasive modalities (i.e., transient elastography, imaging, or serum fibrosis markers) is recommended for all children with chronic hepatitis C. (B, I)
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30. Children with cirrhosis should undergo HCC surveillance and endoscopic surveillance for varices per standard recommendations. (B, I)
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31. Hepatotoxic drugs should be used with caution in children with chronic hepatitis C after assessment of potential risks versus benef its of treatment. Use of corticosteroids, cytotoxic chemotherapy, or therapeutic doses of acetaminophen is not contraindicated in children with chronic hepatitis C. (C, II)
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32. Solid organ transplantation and bone marrow transplantation are not contraindicated in children with chronic hepatitis C. (C, II)
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33. Anticipatory guidance about the potential risks of alcohol for progression of liver disease is recommended for adolescents with chronic HCV infection and their families. Abstinence from alcohol and interventions to facilitate cessation of alcohol consumption, when appropriate, are advised for all persons with chronic HCV infection. (C, I)
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WHOM AND WHEN TO TREAT AMONG CHILDREN AND ADOLESCENTS WITH HCV INFECTION

34. DAA treatment with an approved regimen is recommended for all children and adolescents with HCV infection aged ≥3 years as they will benef it from antiviral therapy, regardless of disease severity. (B, I)
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35. The presence of extrahepatic manifestations—such as cryoglobulinemia, rashes, and glomerulonephritis— as well as advanced fibrosis should lead to early antiviral therapy to minimize future morbidity and mortality. (C, I)
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HCV ANTIVIRAL THERAPY FOR CHILDREN AND ADOLESCENTS AGED ≥3 YEARS, WITHOUT CIRRHOSIS OR WITH COMPENSATED CIRRHOSIS (CHILD-PUGH A)

36. An 8-week course of the daily fixed-dose combination of glecaprevir (300 mg)/pibrentasvir (120 mg) is recommended for treatment-naive adolescents aged ≥12 years or weighing ≥45 kg with any HCV genotype, without cirrhosis or with compensated cirrhosis. (B, I)
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37. A 12-week course of the combination of ledipasvir/sofosbuvir (weight-based dosing) is recommended for treatment-naive or interferon-experienced children aged ≥3 years with HCV genotype 1, 4, 5, or 6 infection, without cirrhosis or with compensated cirrhosis. (B, I)
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DIAGNOSIS OF ACUTE HCV INFECTION

38. HCV-antibody and HCV-RNA testing are recommended when acute HCV infection is suspected due to known exposure, clinical presentation, or elevated aminotransferase levels. (C, I)
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MEDICAL MANAGEMENT AND TRANSMISSION PREVENTION

39. After the initial diagnosis of acute HCV with viremia (def ined as quantif iable RNA), HCV treatment should be initiated without awaiting spontaneous resolution. (B, I)
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40. Counseling is recommended for patients with acute HCV infection to avoid hepatotoxic insults, including hepatotoxic drugs (e.g., acetaminophen) and alcohol consumption, and to reduce the risk of HCV transmission to others. (C, I)
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41. Referral to an addiction medicine specialist is recommended for patients with acute HCV infection related to substance use. (B, I)
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ACUTE HCV INFECTION TREATMENT

42. Due to high eff icacy and safety, the same regimens that are recommended for chronic HCV infection are recommended for acute infection. (C, IIa)
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CONSIDERATIONS FOR USE OF HCV-VIREMIC DONOR ORGANS IN HCV-NEGATIVE RECIPIENTS

43. Informed consent should include the following elements:
• Risk of transmission from an HCV-viremic donor (and with a US Public Health Service–defined increased risk donor, the potential risks for other viral infections)
• Risk of liver disease if HCV treatment is not available or treatment is unsuccessful
• Benefits, specifically reduced waiting time and possibly lower waiting list mortality
• Unknown long-term consequences (hepatic and extrahepatic) of HCV exposure (even if cure is attained)
• Risk of allograft failure
• Risk of HCV transmission to partner
(C, I)
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44. Transplant centers should have a programmatic strategy to:
• Document informed consent.
• Assure access to HCV treatment and retreatment(s), as necessary.
• Ensure long-term follow-up of recipients (beyond SVR12).
(C, I)
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TREATMENT OF HCV-NEGATIVE RECIPIENTS OF ALLOGRAFTS FROM HCV-VIREMIC DONORS

Recommendation Regarding Timing of DAA Therapy
45. Prophylactic/preemptive DAA therapy with a pangenotypic regimen is recommended.
• Treatment with a pangenotypic DAA regimen within the first week after transplantation, even if results of the HCV RNA test are not available, is a reasonable alternative. A genotype-specific regimen may be used if genotype information from the donor or recipient is available to guide therapy.
(B, II)
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Recommendations for DAA Therapy

46. An 8-week course of the pangenotypic daily fixed-dose combination of glecaprevir (300  mg)/ pibrentasvir (120 mg) is recommended.

(C, I)
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47. A 12-week course of the pangenotypic daily f ixed-dose combination of sofosbuvir (400  mg)/ velpatasvir (100 mg) is recommended. (C, I)
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48. A 12-week course of the daily fixed-dose combination of ledipasvir (90  mg)/sofosbuvir (400  mg) is recommended for patients with genotype 1, 4, 5, or 6 only. (C, I)
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Recommendation Grading

Overview

Title

Hepatitis C Guidance

Authoring Organizations

Publication Month/Year

December 1, 2019

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

IDSA HCV guidance disseminates up-to-date, peer-reviewed, unbiased, evidence-based recommendations to aid clinicians making decisions regarding the testing, management, and treatment of HCV infection.

Target Patient Population

Patients with hepatitis C infection

Inclusion Criteria

Female, Male, Adolescent, Adult, Child, Older adult

Health Care Settings

Ambulatory, Hospital, Outpatient

Scope

Assessment and screening, Diagnosis, Management, Treatment

Diseases/Conditions (MeSH)

D006505 - Hepatitis, D006526 - Hepatitis C, D019698 - Hepatitis C, Chronic

Keywords

hepatitis C, hepatitis

Source Citation

Hepatology, VOL. 71, NO. 2, 2020