Challenges and Controversies

HCV treatment with 8 weeks of glecaprevir-pibrentasvir is highly effective, particularly in someone who is young and treatment naive. In my practice, I would proceed with retreatment and not wait to repeat the HCVRNA. This most likely represents reinfection I want to offer her treatment as soon as possible while she is engaged in care.

This is a very low HCV RNA result, so it's difficult to know if this is virologic relapse vs. re-infection. With excellent adherence to glecaprevir-pibrentasvir, it's less likely the regimen failed. Ideally, we would send an HCV genotype now and see if there has been a switch in genotype; however, this very low viral level makes it difficult to perform this test. The laboratory often needs a viral level >500 IU/ml to run the genotype. I would repeat the viral level in 12 weeks and, if still positive, see if the lab can run the genotype. If she has the same genotype, I would treat as a failure and use sofosbuvir-velpatasvir-voxilaprevir. If she has a different genotype, I'd consider her to have been re-infected and just use glecaprevir-pibrentasvir or sofosbuvir-velpatasvir and treat her as treatment naive. If the repeat HCV RNA is negative, I'd consider her to be cured. Also, it's important to talk with the patient about other potential routes of transmission (sexual, sharing razors, etc...) and make sure to counsel about risk mitigation. Lastly, this could be an opportunity to discuss medications for substance use disorder and see if she would be willing to work towards sobriety.