COMMENTARY

Antiviral Therapy for HCV During Pregnancy to Prevent Transmission: 6 Reasons in Favor of a Controversial Concept

Digestive Disease Week (DDW) 2018

Nancy Reau, MD

Disclosures

July 23, 2018

The increasing rates of hepatitis C virus (HCV) in women of childbearing age and the resultant increase in the prevalence of HCV in children has become an important topic as we, particularly gastroenterologists and hepatologists, strive to achieve the World Health Organization (WHO) goal of eliminating HCV in the United States.

During this year's Digestive Disease Week in Washington, DC, I was asked to present an argument in favor of the controversial concept of giving antiviral therapy to pregnant patients with HCV to disrupt mother-to-child transmission (MTCT). I must clearly state that this concept is neither evidence-based nor is it recommended by any of the current treatment guidelines. Universally, national and societal guidelines, as well as experts and patient advocates, recommend viral eradication of HCV prior to conception—not during pregnancy. There are, however, several reasons that support the use of HCV antiviral drugs during pregnancy.

HCV in Women of Childbearing Age Is Increasing

Despite effective therapy, the number of new cases of HCV infection in the United States continues to increase; this increase is primarily related to the opioid epidemic.[1] From 2006 to 2014, the number of reproductive-aged women with HCV exposure doubled. Prior screening efforts noted the baby boomer birth cohort (individuals born between the years 1945 and 1965) as having the highest prevalence of HCV in the United States. However, there is now a bimodal distribution of HCV in the United States, with the second peak occurring in individuals in their 20s to 30s. This trend affects screening and transmission; therefore, it is no longer sufficient to "size up" a patient simply by his or her birth date. In addition, younger patients are more likely to engage in activities that increase their risk for HCV infection and subsequent transmission, including transmission of HCV during pregnancy and childbirth.

The Rate of HCV in Pregnancy Is Increasing

By 2014, the presence of HCV infection at delivery increased by 89%,[2] though there is significant geographic variation among states. The highest rate of HCV infection in pregnancy was reported in West Virginia (22.6 per 1000 live births), whereas the lowest rate was reported in Hawaii (0.7 per 1000 live births).[2] Such geographic data may not be granular enough for effective intervention. For example, Tennessee reported data by county, and while the prevalence of maternal HCV increased 163% from 2009 to 2014 in this state, there was substantial geographic variation, with the highest rates seen in its 52 Appalachian counties.[3]

The Rules for HCV Screening Are Changing

Prior to May 24, 2018, the Centers for Disease Control and Prevention (CDC) and most of the academic societies advocated for risk-based screening during pregnancy or for the screening of only women who participate in high-risk behaviors. Unfortunately, this strategy not only has been ineffective in identifying new cases of HCV, but there also has been an increase in the prevalence of HCV in women of childbearing age. In response, the American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) now recommend that all pregnant women be tested for HCV, ideally at the initiation of prenatal care.[4] This strategy parallels the policy recently passed by the state of Kentucky, where it is now mandatory to test all pregnant women for HCV.[5]

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