CASE Pregnant woman with chronic opioid use and HIV, recently diagnosed with HCV
A 34-year-old primigravid woman at 35 weeks' gestation has a history of chronic opioid use. She previously was diagnosed with human immunodeficiency virus (HIV) infection and has been treated with a 3-drug combination antiretroviral regimen. Her most recent HIV viral load was 750 copies/mL. Three weeks ago, she tested positive for hepatitis C virus (HCV) infection. Liver function tests showed mild elevations in transaminase levels. The viral genotype is 1, and the viral load is 2.6 million copies/mL.
How should this patient be delivered? Should she be encouraged to breastfeed her neonate?
The scope of HCV infection
Hepatitis C virus is a positive-sense, enveloped, single-stranded RNA virus that belongs to the Flaviviridae family.1 There are 7 confirmed major genotypes of HCV and 67 confirmed subtypes.2 HCV possesses several important virulence factors. First, the virus's replication is prone to frequent mutations because its RNA polymerase lacks proofreading activity, resulting in significant genetic diversity. The great degree of heterogeneity among HCV leads to high antigenic variability, which is one of the main reasons there is not yet a vaccine for HCV.3 Additionally, HCV's genomic plasticity plays a role in the emergence of drug-resistant variants.4
Virus transmission. Worldwide, approximately 130 to 170 million people are infected with HCV.5 HCV infections are caused primarily by exposure to infected blood, through sharing needles for intravenous drug injection and through receiving a blood transfusion.6 Other routes of transmission include exposure through sexual contact, occupational injury, and perinatal acquisition.
The risk of acquiring HCV varies for each of these transmission mechanisms. Blood transfusion is no longer a common mechanism of transmission in places where blood donations are screened for HCV antibodies and viral RNA. Additionally, unintentional needle-stick injury is the only occupational risk factor associated with HCV infection, and health care workers do not have a greater prevalence of HCV than the general population. Moreover, sexual transmission is not a particularly efficient mechanism for spread of HCV.7 Therefore, unsafe intravenous injections are now the leading cause of HCV infection.6
Consequences of HCV infection. Once infected with HCV, about 25% of people spontaneously clear the virus and approximately 75% progress to chronic HCV infection.5 The consequences of long-term infection with HCV include end-stage liver disease, cirrhosis, and hepatocellular carcinoma.
Approximately 30% of people infected with HCV will develop cirrhosis and another 2% will develop hepatocellular carcinoma.8 Liver transplant is the only treatment option for patients with decompensated cirrhosis or hepatocellular carcinoma as a result of HCV infection. Currently, HCV infection is the leading indication for liver transplant in the United States.9
Continue to: Risk of perinatal HCV transmission...