Early HCV Identification, Follow-up Key to Reducing Risk in Pregnancy

Early identification of women infected with hepatitis C (HCV) and improved follow-up for HCV-positive mothers and their babies are among strategies to help stem the rise of the virus during childbearing years, the National Viral Hepatitis Roundtable (NVHR) suggests.

Maternal HCV infections at the time of a baby’s delivery almost doubled to 3.4 per 1000 live births in 2014, from 1.8 per 1000 in 2009 in states reporting such data, the US Centers for Disease Control and Prevention (CDC) found.

This uptick coincides with nationwide heroin and opioid epidemics and a recent surge in opioid use among pregnant women, according to the CDC.

In a December webinar on HCV prevalence among women of childbearing age, the Washington, DC-based health care organization noted that identifying effective management strategies that reduce transmission risk is an “important clinical and public health concern.”

So far, there is no intervention that clearly reduces the risk of HCV infection from a mother to her child, known as vertical transmission. And while highly effective treatments for HCV are available, none are approved for use during pregnancy. This makes it especially important to prevent and treat HCV before pregnancy, and to continue care after birth to counter potential infection should a woman have more babies, panelists noted.

“We don’t currently have an intervention to prevent mother to child transmission of hepatitis C, but we do know that identifying women with HCV provides an opportunity to offer treatment before pregnancy or after delivery,” Tina Broder, MSW, MPH, Program Director, NVHR, told MD Magazine.

The best way to prevent future pregnancy transmission risks is to cure the woman of HCV, Broder said.

Mothers and their babies may benefit from an expanded approach to HCV screening, some panel members said. Current guidelines call for assessment of a person’s risk for contracting the virus, such intravenous drug use or co-infection with HIV.

“We know that providers don’t often assess for risk factors and/or patients do not always disclose risk factors,’’ Broder said.

Given the significant increase in HCV among pregnant women, many of the panelists recommended moving to HCV screening of all adults — or at least screening of all pregnant women, Broder said.

“This may be particularly important for women whose only time engaging with the healthcare system is during their pregnancy,” she said.

Pregnant women on opioid agonist therapy (OAT) for a substance use disorder require ongoing HCV surveillance and testing, research by panelist Kimberly Page, PhD, MPH, showed.

“Pregnant women on opioid pharmacotherapy should be tested for HCV and counseled regarding test results, risks for transmission, and the need for clinical follow if they are HCV infected, including the availability of curative HCV treatment,’’ Page, Professor and Chief of Epidemiology, Biostatistics & Preventive Medicine, University of New Mexico Health Sciences Center, told MD Magazine.

Physicians should refer women with HCV for treatment following delivery. Physicians should also be aware of the risks and non-risks for HCV transmission from infected mothers to neonates, Page said.

The Society for Maternal Fetal Medicine in October released guidelines for obstetric care providers in light of rising HCV infections. These include screening at-risk women during their first prenatal visit and, if the test is negative, screening them again later in pregnancy if risk factors persist.

For HCV-positive women, the recommendations include testing for other sexually transmitted infections (STIs) and vaccinating for hepatitis A and B during pregnancy.

“Importantly, the guidelines also are meant to bring attention to obstetric providers that there are new therapies that can essentially cure hepatitis C outside of pregnancy, so it is important to link women to care either prior to of following pregnancy,” lead author and SMFM member Brenna L. Hughes, MD, MSc, told MD Magazine.

The NVHR panel noted that the US healthcare system generally does a poor job of providing follow-up care to HCV positive women and their babies.

“HCV infection among pregnant women is an increasing and potentially modifiable threat to maternal and child health,’’ the panel said. “Clinicians and public health officials should consider individual and population-level opportunities for prevention and risk mitigation.’’

Page reported a positive sign in her own research. She said in a sample of pregnant women on opioid pharmacotherapy attending a comprehensive prenatal services clinic in Albuquerque, New Mexico, almost all (97%) received HCV screening as part of their prenatal care.

The screening revealed that more than half (53.4%) of women in this setting had antibodies to HCV indicating exposure. Overall 38% of women had evidence of chronic HCV infection.

“The high rates of testing were a pleasant surprise,’’ Page said. “Our research showed that more women are receiving the full range of testing, including antibody and RNA testing, than they were 9 years ago in the same clinic.’’

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