Who is Eligible for HCV Treatment?
The American Association for the Study of Liver Diseases and Infectious Diseases Society of America (AASLD-IDSA) Hepatitis C Guidance recommends treatment for ALL persons with chronic hepatitis C virus (HCV) infection, except for individuals who have a short (e.g., less than 12 months) life expectancy.[1] The landscape of hepatitis C care has been revolutionized by the discovery and widespread use of direct-acting antivirals (DAAs) to treat HCV infection. The DAAs are safe, highly effective, well-tolerated, and provide a cure to more than 95% of persons who receive an 8- or 12-week course with one of the currently recommended pangenotypic regimens. Treatment of HCV with DAAs has been shown to reduce the risk of hepatic complications such as hepatocellular carcinoma and liver-related mortality.[1] Further, HCV treatment with cure has the public health benefit of preventing transmission of HCV. Decisions regarding initiation of therapy will naturally be influenced by the individual’s willingness and readiness to start. It is important that HCV therapy not be withheld based on active substance use, older age, or mental health illness, as none of these are a contraindication to treatment.
Who is Eligible for Simplified HCV Treatment?
The AASLD-IDSA HCV Guidance has devised a simplified HCV treatment approach, which can be used most HCV treatment-naïve adult patients.[2,3] This simplified approach has been made possible with the availability of the safe, highly effective, pangenotypic DAA regimens glecaprevir-pibrentasvir and sofosbuvir-velpatasvir. The following summarizes the AASLD-IDSA HCV Guidance regarding eligibility for the simplified HCV treatment approach.[2,4,5]
This simplified HCV approach is appropriate for adults with chronic HCV, including persons with HIV, who meet the following criteria:
- Any HCV Genotype: Persons with any HCV genotype are eligible for the simplified treatment approach. This approach is made possible because the recommended regimens in the simplified treatment (glecaprevir-pibrentasvir and sofosbuvir-velpatasvir) have pangenotypic activity.
- Treatment-Naïve: Only persons who are HCV treatment-naïve adults are considered appropriate for the simplified approach. Patients are not eligible for this simplified approach if they have previously received HCV treatment since prior treatment may be associated with development of drug resistance and may necessitate adjustments to therapy.
- Without Cirrhosis or with Compensated Cirrhosis: The simplified treatment approach is considered appropriate for persons without cirrhosis and for those with compensated cirrhosis (Child-Turcotte-Pugh A). For this context, cirrhosis should have been evaluated as outlined in the prior lesson.
Who is NOT Eligible for Simplified HCV Treatment?
Although most adult patients are eligible for the simplified treatment approach, the AASLD-IDSA HCV Guidance recommends against using the simplified treatment in certain situations. The following summarizes specific conditions that, if present, should preclude use of the simplified treatment approach.[2,5]
- Prior HCV Treatment: Prior DAA exposure may result in the development of resistance-associated substitutions (RAS). Because of this, alternative regimens for HCV treatment may be needed in these populations.[6,7]
- Hepatitis B Surface Antigen-Positive: Reactivation of HBV has been increasingly recognized as a potential adverse event associated with treatment of HCV.[8,9,10] The risk of reactivation is highest among hepatitis B surface antigen (HBsAg)-positive patients, but rare cases have been described in HBsAg-negative and hepatitis B core antibody (anti-HBc) positive patients.[11,12] Patients who are HBsAg positive may need initiation of HBV antiviral therapy concurrently with initiation of HCV treatment versus close monitoring while on DAAs.[13] Patients who are HBsAg-negative but anti-HBc-positive can be monitored with alanine aminotransferase (ALT) levels at baseline, at the end of HCV treatment, and at post-treatment follow-up.[13]
- Compensated Cirrhosis with End-Stage Renal Disease: Individuals with cirrhosis that is compensated (Child-Turcotte-Pugh score <7 [Class A]) with concomitant end-stage renal disease (estimated glomerular filtration rate [GFR] <30 mL/min/1.73 m2) are not eligible for simplified treatment since these individuals may benefit from seeing a specialist for HCV treatment evaluation particularly since timing and choice of DAA therapy may be influenced by possible organ transplantation. Notably, patients with advanced kidney disease do not require DAA dose modification when using the simplified treatment approach. The Child-Turcotte-Pugh is a combined score based on the presence of each of the following: ascites, hepatic encephalopathy, total bilirubin >2.0 mg/dL, albumin ≤3.5 g/dL, or international normalized ratio (INR) ≥1.7.
- Current or Prior Decompensated Cirrhosis: Given the high morbidity and mortality associated with decompensated cirrhosis, these patients should be referred to a liver specialist (e.g., hepatologist) for further evaluation and management. Patients with moderate or severe hepatic impairment (Child-Turcotte-Pugh ≥7 [Class B or C]) are considered to have decompensated cirrhosis.
- Current Pregnancy: Due to a lack of data on the safety and efficacy of DAAs during pregnancy, HCV treatment should be prioritized before pregnancy but can be considered during pregnancy on a case-by-case basis after discussion of potential risks and benefits.
- Known or Suspected Hepatocellular Carcinoma (HCC): Patients with HCC should be evaluated by a specialist familiar with treatment options for this cancer. Furthermore, response rates to DAA therapy are reported to be lower in patients with active HCC, and many specialists will prioritize treatment of HCC prior to initiation of DAAs.
- Prior Liver Transplantation: Treatment of patients with a history of liver transplantation should be done under the supervision of a specialist familiar with such patients, as drug interactions can complicate the DAA selection.
Patients who do not meet eligibility for the simplified treatment algorithm should still be treated for HCV; however, there are additional considerations regarding treatment regimen and on-treatment monitoring that are outside the scope of this training. For additional information on these patient populations, please see the comprehensive AASLD/IDSA Guidance and the complete Hepatitis C Online curriculum.
Who is Eligible for Simplified HCV Treatment Algorithm |
Who is NOT Eligible for Simplified HCV Treatment Algorithm |
Adults with chronic HCV infection who are treatment-naïve, including:
|
Adults with chronic HCV infection who have any of the following:
|
*Child–Turcotte-Pugh A = score <7 based on presence of ascites, hepatic encephalopathy, total bilirubin, albumin, and international normalized ratio (INR). |
- AASLD-IDSA. HCV Guidance: Recommendations for testing, management, and treating hepatitis C. Simplified HCV Treatment for Treatment-Naive Adults With Compensated Cirrhosis. [AASLD-IDSA Hepatitis C Guidance]
- AASLD-IDSA. HCV Guidance: Recommendations for testing, management, and treating hepatitis C. Simplified HCV Treatment for Treatment-Naive Adults Without Cirrhosis. [[AASLD-IDSA Hepatitis C Guidance]
Test and Treat Initial Visit Approach
In March 2025, prompted by the availability of point-of-care HCV RNA testing, the AASLD-IDSA published a new Hepatitis C Point of Care Test and Treat Algorithm.[14] To download this new algorithm, go to the home page of the AASLD-IDSA Guidance. This approach is very similar to the simplified treatment approach with the major difference related to the timing of initiating HCV treatment.[14] Specifically, in settings where POC HCV RNA testing is available, or when prior HCV RNA testing results are available, HCV RNA-positive individuals can be started on same-day treatment provided all the following criteria are met:
- No prior DAA therapy for HCV,
- Not known to have positive hepatitis B surface antigen (HBsAg),
- No known history of hepatocellular carcinoma,
- No clinical evidence and/or a history of decompensated liver cirrhosis (e.g., ascites, hepatic encephalopathy, jaundice, or varices),
- No major drug interactions with preferred pan-genotypic DAAs (glecaprevir-pibrentasvir or sofosbuvir-velpatasivr).
In the setting of initiating same-day treatment, p;it remains important to obtain the recommended baseline laboratory evaluation (e.g., ALT/AS count, platelet count, hepatitis B serologic testing, HIV testing, and pregnancy testing).[14] Several of these tests, including HIV and pregnancy, can be performed using point-of-care platforms; the remaining tests need not hold up treatment initiation.[14] If, after starting same-day initiation of DAAs, the patient has a positive HBsAg test result that becomes available, the HCV treatment should continue, but the patient should be contacted to either initiate HBV antiviral therapy or monitor closely during HCV treatment for evidence of a hepatitis B reactivation and/or flare.[14] In addition, a person who has a positive HBsAg test will need a referral for long-term HBV management.[14]
Instructions
Activity Question
You must answer all of the questions before checking your work.
Which one of the following best describes the Xpert HCV point-of-care test?
Treating HCV in Persons Who Inject Drugs is a High Priority
Past or active substance-use disorder is not a contraindication to HCV treatment and persons who inject drugs should be considered excellent candidates for HCV treatment, including the simplified HCV treatment approach. To have a substantial impact on the HCV epidemic in the United States and globally, the medical and public health communities must prioritize HCV treatment for people who inject drugs, given the very high burden in this population.[15] Apart from the public health impacts of prioritizing people who inject drugs for HCV treatment, HCV treatment can improve individual health-related quality of life and reduce the risk of liver disease progression and death in this population. Historically, people who inject drugs have been reluctant to engage with the medical system.[16,17] Therefore, when people who inject drugs engage in health care and are diagnosed with HCV, they should receive a clear message that they can receive curative therapy for this infection without delay, regardless of whether they are actively injecting drugs. Treatment of HCV has the potential to serve as a catalyst for engagement in broader medical care and other health-promoting services.[18]
Instructions
Activity Question
You must answer all of the questions before checking your work.
Which one of the following groups is NOT eligible for the simplified treatment approach?
Health Care Professionals Who Can Provide Simplified Treatment
The simplified treatment approach recommended in the AASLD-IDSA HCV Guidance expands the range of health care providers able to deliver HCV therapy, thereby increasing treatment access for persons with chronic HCV. Indeed, there is a large body of evidence that supports the concept of HCV care delivery by a variety of non-specialist and non-physician providers, including primary care physicians, advanced practice providers, and pharmacists. Studies have demonstrated that these individuals can deliver HCV care with comparable outcomes to specialist providers.[19,20]