Hepatitis C Cascade of Care Among Pregnant Women on Opioid Agonist Pharmacotherapy Attending a Comprehensive Prenatal Program

Postpartum Treatment for Chronic Hepatitis C Virus Among People With Opioid Use Disorder: A Prospective Pilot Clinical Trial

OBJECTIVE

The objective of this study was to evaluate the feasibility and acceptability of postpartum hepatitis C virus (HCV) treatment integrated within a substance use treatment program for pregnant and postpartum people with opioid use disorder (OUD).

METHODS

We conducted a prospective pilot clinical trial of sofosbuvir/velpatasvir (SOF/VEL) treatment among postpartum people with OUD and HCV. Feasibility outcomes included rates of HCV treatment utilization and completion, medication adherence, and sustained virologic response 12 weeks after treatment completion (SVR12). Acceptability was measured through self-reported adverse effects and medication adherence.

RESULTS

From January 2018 to August 2021, 164 pregnant people received care for OUD at the study site. Among those, 64 (39.0%) were HCV antibody positive and 45 (27.4%) had active HCV infection. Among 45 eligible patients, 32 (71.1%) enrolled and 21 (46.7%) initiated HCV treatment. Of 21 participants who initiated treatment, 16 (76.2%) completed the SOF/VEL treatment, and 11 (52.4%) completed the SVR12. All participants who completed treatment were cured. Common reasons for dropout during the HCV clinical care cascade were OUD treatment discontinuation, illicit substance use recurrence, and lost to follow-up. Participants reported high satisfaction with HCV treatment, including minimal adverse effects, and no HCV treatment concerns.

CONCLUSIONS

Nearly half of pregnant people with HCV initiated postpartum treatment within an integrated care model of HCV treatment within a substance use treatment program. Postpartum SOF/VEL was efficacious, tolerable, and acceptable. Despite this, postpartum HCV treatment among people with OUD remains challenging, and many barriers remain.

Postpartum Hepatitis C Linkage to Care Program in a Co-located Substance Use Disorders Treatment Model

PURPOSE

Hepatitis C virus (HCV) is increasingly prevalent in pregnancy and among people with substance use disorders (SUD). Highly effective treatments are now available for chronic HCV. Qualifying for HCV treatment often requires preauthorization and several clinical criteria, including laboratory assessment of liver function and other infectious diseases and liver imaging to assess for fibrosis. Linkage to care (LTC) models have been shown to assist with obtaining the necessary clinical information (laboratory assessment/liver imaging) and improving HCV treatment rates in non-pregnant individuals.

DESCRIPTION

Beginning in December 2020, a specialized LTC team identified patients with HCV viremia who were interested in postpartum treatment. The LTC team assisted patients with completing the necessary clinical criteria (laboratory assessment and liver imaging) for HCV treatment. Patients were then linked to infectious disease specialists who prescribed treatment to patients via telemedicine. Most patients identified with HCV were enrolled in our institution's co-located obstetric and SUD program, which provides continued care until 1 year postpartum.

ASSESSMENT

In 2019, an internal review identified that none of the 26 pregnant patients with HCV viremia in our co-located obstetric and SUD program were prescribed direct-acting antiviral (DAA) treatment within 12 months postpartum. Between December 2020 and July 2022, our HCV LTC team identified 34 patients with HCV who were eligible for treatment. Of these patients, 55% (19/34) obtained all necessary laboratory and liver imaging requirements and 79% (15/19) were prescribed DAA treatment after a telehealth visit with an infectious disease specialist. All fifteen patients who were prescribed treatment participated in the co-located obstetric and SUD program. The largest barrier to obtaining treatment was completing the necessary laboratory and liver imaging requirements for prescribing DAA. Only one patient who did not receive care in our co-located obstetric and SUD program had completed the necessary laboratory and liver imaging requirements to proceed with treatment but did not follow up with the infectious disease specialist for DAA treatment.

CONCLUSION

Our HCV LTC program was successful in treating postpartum patients for HCV if they participated in the co-located obstetric and SUD program at our institution. Creating a partnership with an infectious disease specialist and utilizing telemedicine were beneficial strategies to connect patients to treatment for HCV during the postpartum period.

Guideline No. 443b: Opioid Use Throughout Women's Lifespan: Opioid Use in Pregnancy and Breastfeeding

OBJECTIVE

To provide health care providers the best evidence on opioid use and women's health. Areas of focus include pregnancy and postpartum care.

TARGET POPULATION

The target population includes all women currently using or contemplating using opioids.

OUTCOMES

Open, evidence-informed dialogue about opioid use will improve patient care.

BENEFITS, HARMS, AND COSTS

Exploring opioid use through a trauma-informed approach provides the health care provider and patient with an opportunity to build a strong, collaborative, and therapeutic alliance. This alliance empowers women to make informed choices about their own care. It also allows for the diagnosis and possible treatment of opioid use disorders. Opioid use should not be stigmatized, as stigma leads to poor "partnered care" (i.e., the partnership between the patient and care provider). Health care providers need to understand the effect opioids can have on pregnant women and support them to make knowledgeable decisions about their health.

EVIDENCE

A literature search was designed and carried out in PubMed and the Cochrane Library databases from August 2018 until March 2023 using following MeSH terms and keywords (and variants): opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome, and breastfeeding.

VALIDATION METHODS

The authors rated the quality of evidence and strength of recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. See online Appendix A (Tables A1 for definitions and A2 for interpretations of strong and conditional [weak] recommendations).

INTENDED AUDIENCE

All health care providers who care for pregnant and/or post-partum women and their newborns.

TWEETABLE ABSTRACT

Opioid use during pregnancy often co-occurs with mental health issues and is associated with adverse maternal, fetal, and neonatal outcomes; treatment of opioid use disorder with agonist therapy for pregnant women can be safe during pregnancy where the risks outnumber the benefits.

SUMMARY STATEMENTS

RECOMMENDATIONS.

Directive clinique no 443b : Opioïdes aux différentes étapes de la vie des femmes : Grossesse et allaitement

OBJECTIF

Présenter aux professionnels de la santé les données probantes concernant l'utilisation des opioïdes et la santé des femmes. Les domaines d'intérêt sont la grossesse et les soins post-partum.

POPULATION CIBLE

Toutes les femmes qui utilisent des opioïdes. RéSULTATS: Un dialogue ouvert et éclairé sur l'utilisation des opioïdes améliorera les soins aux patientes. BéNéFICES, RISQUES ET COûTS: L'exploration de l'utilisation d'opioïdes par une approche tenant compte des traumatismes antérieurs donne au professionnel de la santé et à la patiente l'occasion de bâtir une alliance solide, collaborative et thérapeutique. Cette alliance permet aux femmes de faire des choix éclairés. Elle favorise le diagnostic et le traitement possible du trouble lié à l'utilisation d'opioïdes. L'utilisation ne doit pas être stigmatisée, puisque la stigmatisation affaiblit le partenariat (le partenariat entre patiente et professionnel de la santé). Les professionnels de la santé ceus-ci doivent comprendre l'effet potentiel des opioïdes sur la santé les femmes enceintes et les aider à prendre des décisions éclairées sur leur santé. DONNéES PROBANTES: Une recherche a été conçue puis effectuée dans les bases de données PubMed et Cochrane Library pour la période d'août 2018 à mars 2023 des termes MeSH et mots clés suivants (et variantes) : opioids, opioid agonist therapy, illicit drugs, fertility, pregnancy, fetal development, neonatal abstinence syndrome et breastfeeding. MéTHODES DE VALIDATION: Les auteurs ont évalué la qualité des données probantes et la force des recommandations en utilisant le cadre méthodologique GRADE (Grading of Recommendations, Assessment, Development, and Evaluation). Voir l'annexe A en ligne (tableau A1 pour les définitions et tableau A2 pour l'interprétation des recommandations fortes et conditionnelles [faibles]). PROFESSIONNELS CONCERNéS: Tous les professionnels de la santé qui prodiguent des soins aux femmes et aux nouveaux-nés. RéSUMé POUR TWITTER: La consommation d'opioïdes pendant la grossesse coïncide souvent avec des problèmes de santé mentale et est associée à des conséquences néfastes pour la mère, le fœtus et le nouveau-né ; le traitement des troubles liés à la consommation d'opioïdes par agonistes peut être sûr pendant la grossesse lorsque les risques sont plus nombreux que les avantages. DÉCLARATIONS SOMMAIRES: RECOMMANDATIONS.

Hepatitis C Virus Cascade of Care Among Perinatal Patients in Maine Diagnosed With Opioid Use Disorder, 2015-2020

OBJECTIVE

This is a quality improvement project to determine the best process to identify and address gaps in care for perinatal patients in receiving appropriate hepatitis C virus (HCV) testing and treatment across the largest health system in Maine.

STUDY DESIGN

We reviewed electronic medical record data between October 1, 2015, and February 1, 2020, to investigate rates of HCV testing and treatment among 916 perinatal patients with opioid use disorder across 8 hospitals using a "cascade of care" framework, a model used previously to identify gaps in care and treatment of chronic diseases.

MAIN OUTCOME MEASURE

We examined HCV testing and treatment rates along the cascade of care and patient characteristics associated with HCV antibody testing and treatment, separately, using log binomial regression models. Models were adjusted for age, residential distance to medical center, psychiatric diagnosis, and opioid agonist therapy at delivery.

RESULTS

Of pregnant patients eligible for screening, 64% (582/916) received HCV antibody testing. Of 136 patients with active HCV infection, 32% (n = 43) received a referral for treatment, 21% (n = 28) were treated, and 13% (n = 18) achieved sustained virologic response. In the adjusted regression models, only opioid agonist therapy was associated with HCV antibody testing (adjusted risk ratio, 1.31; 95% confidence interval, 1.18-1.46), and no factors were significantly associated with receipt of treatment among HCV viremic patients.

CONCLUSION

Low referral and treatment rates signify the need for quality improvement interventions to improve coordination of care between multiple disciplines and practice settings to increase access to HCV treatment.

Women in the 2019 hepatitis C cascade of care: findings from the British Columbia Hepatitis Testers cohort study

BACKGROUND

Women living with hepatitis C virus (HCV) are rarely addressed in research and may be overrepresented within key populations requiring additional support to access HCV care and treatment. We constructed the HCV care cascade among people diagnosed with HCV in British Columbia, Canada, as of 2019 to compare progress in care and treatment and to assess sex/gender gaps in HCV treatment access.

METHODS

The BC Hepatitis Testers Cohort includes 1.7 million people who tested for HCV, HIV, reported cases of hepatitis B, and active tuberculosis in BC from 2000 to 2019. Test results were linked to medical visits, hospitalizations, cancers, prescription drugs, and mortality data. Six HCV care cascade stages were identified: (1) antibody diagnosed; (2) RNA tested; (3) RNA positive; (4) genotyped; (5) initiated treatment; and (6) achieved sustained virologic response (SVR). HCV care cascade results were assessed for women, and an 'inverse' cascade was created to assess gaps, including not being RNA tested, genotyped, or treatment initiated, stratified by sex.

RESULTS

In 2019, 52,638 people with known sex were anti-HCV positive in BC; 37% (19,522) were women. Confirmatory RNA tests were received by 86% (16,797/19,522) of anti-HCV positive women and 83% (27,353/33,116) of men. Among people who had been genotyped, 68% (6756/10,008) of women and 67% (12,640/18,828) of men initiated treatment, with 94% (5023/5364) of women and 92% (9147/9897) of men achieving SVR. Among the 3252 women and 6188 men not yet treated, higher proportions of women compared to men were born after 1975 (30% vs. 21%), had a mental health diagnosis (42% vs. 34%) and had used injection drugs (50% vs. 45%). Among 1619 women and 2780 men who had used injection drugs and were not yet treated, higher proportions of women than men used stimulants (64% vs. 57%), and opiates (67% vs. 60%).

CONCLUSIONS

Women and men appear to be equally engaged into the HCV care cascade; however, women with concurrent social and health conditions are being left behind. Treatment access may be improved with approaches that meet the needs of younger women, those with mental health diagnoses, and women who use drugs.

Enhancing Linkage to Hepatitis C Virus Treatment Following Pregnancy in Women Identified During Perinatal Care

Amid the current US opioid crisis, hepatitis C virus (HCV) infection rates continue to rise in young adults, including among pregnant women, yet few studies describe linkage to care and treatment in pregnant or postpartum women with HCV infection. We used electronic health record data to estimate HCV treatment rates for postpartum women before (January 2014-September 2016) and during (October 2016-March 2018) implementation of a maternal-infant HCV linkage program in combination with a multidisciplinary clinic to colocate mother and infant care. Using Poisson regression models, we compared HCV treatment initiation rates, adjusting for demographics, substance use, and treatment. From January 2014 through March 2018, 343 women who were HCV seropositive delivered at our institution. Of these, 95% completed HCV nucleic acid testing and 255 women had chronic HCV infection. Mean age was 30 years, 96% were publicly insured, and 94% had documented substance use. HCV treatment initiation increased from 28/164 (17.1%) women with chronic HCV infection in the preintervention period to 16/66 (24.2%) with the linkage-only intervention and 13/25 (52.0%) with the linkage intervention and colocated care. Adjusted analyses demonstrated that women delivering during the intervention period initiated HCV treatment at 2.40 times (95% confidence interval [CI], 1.10-5.25; linkage only) and 3.36 times (95% CI, 1.57-7.17; linkage and colocated care) the rate of women delivering preintervention. Women on buprenorphine had higher HCV treatment initiation rates compared with those on methadone (rate ratio, 2.10; 95% CI, 1.05-4.21). Conclusion: HCV linkage to care and treatment rates improved in the setting of mother-infant linkage and colocated care interventions. Perinatal care may represent a critical venue to identify, link, and treat women for HCV infection to improve their own health and prevent transmission to subsequent pregnancies.

Prenatal hepatitis C screening, diagnoses, and follow-up testing in British Columbia, 2008-2019

OBJECTIVE

Current guidelines in British Columbia recommend prenatal screening for hepatitis C antibodies (anti-HCV) if risk factors are present. We aimed to estimate frequency of prenatal anti-HCV testing, new diagnoses, repeated and follow-up testing among BC women.

METHODS

BC Centre for Disease Control Public Health Laboratory data estimated the number of BC women (assigned female at birth or unknown sex) aged 13-49 who received routine prenatal serological screening (HIV, hepatitis B, syphilis and rubella) from 2008-2019. Anti-HCV tests ordered the same day as routine prenatal screens were considered prenatal anti-HCV tests. Assessment of follow-up was based on HCV RNA and/or genotype testing within one year of new prenatal anti-HCV diagnoses.

RESULTS

In 2019, 55,202 routine prenatal screens were carried out for 50,392 BC women. Prenatal anti-HCV tests increased significantly, from 19.6% (9,704/49,515) in 2008 to 54.6% (27,516/50,392) in 2019 (p<0.001). New prenatal anti-HCV diagnoses (HCV positive diagnoses at first test or seroconversions) declined from 14.3% in 2008 to 10.1% in 2019. The proportion of women with new prenatal anti-HCV diagnoses that were a result of a first HCV test declined from 0.3% (29/9,701) in 2008 to 0.03% (8/27,500) in 2019. For women known to be anti-HCV positive at the time of prenatal screening, the proportion who had a prenatal anti-HCV test increased from 35.6% in 2008 to 50.8% in 2019.

CONCLUSION

Prenatal anti-HCV testing increased substantially over the study period. However, new HCV diagnoses remained relatively stable, suggesting that a considerable proportion of BC women with low or no risk are being screened as part of prenatal care. The vast majority of women with new HCV diagnoses receive appropriate follow-up HCV RNA and genotype testing, which may indicate interest in HCV treatment. These findings contribute to the discussion around potential for prenatal anti-HCV screening in an effort to eliminate HCV.

The MATernaL and Infant NetworK to Understand Outcomes Associated with Treatment of Opioid Use Disorder During Pregnancy (MAT-LINK): Surveillance Opportunity

Pregnant women with opioid use disorder (OUD) are at risk of overdose, infectious diseases, and inadequate prenatal care. Additional risks include adverse pregnancy and infant outcomes, such as preterm birth and neonatal abstinence syndrome. Management and treatment of OUD during pregnancy are associated with improved maternal and infant outcomes. Professional organizations, including the American College of Obstetricians and Gynecologists, recommend offering opioid agonist pharmacotherapy (i.e., methadone or buprenorphine) combined with behavioral therapy as standard treatment for pregnant women with OUD. Other medications and herbal supplements have also been used by pregnant women for OUD. Determining which OUD treatments optimize maternal and infant outcomes is challenging given the host of potential factors that affect these outcomes. The Centers for Disease Control and Prevention initiated the MATernaL and Infant NetworK to Understand Outcomes Associated with Treatment of Opioid Use Disorder during Pregnancy (MAT-LINK) to monitor more than 2000 mothers and their infants, using data collected from geographically diverse clinical sites. Information learned from MAT-LINK will inform the future management and treatment of pregnant women with OUD.

Estimates of Prenatal HIV, Hepatitis B Virus, and Hepatitis C Virus Testing Among Pregnant People Enrolled in Wisconsin Medicaid, 2011-2015

BACKGROUND

The opioid epidemic and rising rates of injection drug use are increasing the risk of human immunodeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) infections among pregnant people. According to national clinical guidelines, pregnant people should be universally tested for HIV and HBV, and risk-based tested for HCV. The aim of this study was to determine the proportion and characteristics of prenatal HIV, HBV, and HCV testing and diagnosis among pregnant people with Wisconsin Medicaid coverage between 2011 and 2015.

METHODS

Wisconsin birth certificates and Medicaid enrollment data were used to identify the sample. Standard billing and diagnosis codes were used to assess study variables. Data for each pregnancy were analyzed to describe the proportion of pregnancies that had evidence of testing, diagnoses, and yearly trends.

RESULTS

Of the 78,917 pregnancies, prenatal testing estimates were 67% for HIV, 73% for HBV, and 6% for HCV. The estimated rate of infections during the study period was 1.82 for HIV, 2.09 for HBV, and 3.52 for HCV per 1000 pregnancies. Compared to the other race/ethnicity groups, pregnant people who were Black were most likely to be tested for HIV (78%) and HBV (80%), and pregnant people who were White were most likely to be tested for HCV (7%).

CONCLUSIONS

Clinical testing guidelines have not been effectively translated to practice. Additionally, compared to HIV and HBV, HCV infections during pregnancy are becoming more prevalent, yet current national HCV screening guidelines are the least comprehensive.

Clinical characteristics and efficacy evaluation of antiviral therapy in pregnant women with chronic hepatitis B virus infection

BACKGROUND

During pregnancy, decreased maternal liver blood supply and increased load metabolism make woman susceptible to hepatitis attack. Severe cases often develop liver failure, leading to coagulation mechanism abnormality, bleeding and infection, fetal distress, premature delivery, stillbirth, etc. Therefore, high attention to the treatment and management of pregnant women with chronic hepatitis B virus (HBV) infection is the key to reducing the mother-to-child transmission of HBV, representing an important issue of concern for clinical medical personnel. Therefore, the early diagnosis and treatment of hepatitis attack during pregnancy are particularly important.

AIM

To observe the clinical characteristics of HBV in pregnant women and evaluate the efficacy of antiviral therapy.

METHODS

A total of 180 pregnant women with chronic HBV infection who visited Yuyao Maternal and Child Health Center of Zhejiang Province from February 2017 to June 2019 were selected as study subjects. Liver function was tested every 4 to 12 wk during pregnancy, and HBV serum markers were checked to determine whether there was hepatitis attack during pregnancy. For those with a definite diagnosis, tibivudine was given orally at a dose of 600 mg once per day. The clinical characteristics, alanine aminotransferase (ALT), HBV serum markers, and HBV DNA changes in pregnant women with chronic HBV infection were recorded. ALT recovery rate, HBV DNA and hepatitis B e antigen (HBeAg) negative conversion rate, and HBeAg seroconversion rate after antiviral treatment at different time points during pregnancy were also recorded.

RESULTS

Of the 180 pregnant women with chronic HBV infection included in this study, 48 (26.67%) had hepatitis attacks during pregnancy. The average age was 32.3 ± 2.4 years. The duration of hepatitis attacks ranged from 6 to 34 wk, with an average of 20.3 ± 7.8 wk. The mean value of ALT was 224.95 ± 19.6 U/L. Compared with pregnant women without hepatitis attack during pregnancy, ALT and HBV DNA changes were significant (P < 0.05), and hepatitis B surface antigen and HBeAg quantification were significantly reduced (P < 0.05). For hepatitis attacks during pregnancy, with the extension of treatment time, ALT recovery rate, HBV DNA negative conversion rate, HBeAg negative conversion rate, and HBeAg seroconversion rate had varying degrees of rise. Especially at 36 wk after treatment, the ALT recovery rate was 100.0%, HBV DNA negative conversion rate was 72.92%, HBeAg negative conversion rate was 41.67%, and HBeAg seroconversion rate was 37.5%, which were significantly higher than those at 6 wk, 12 wk, and 24 wk of treatment (P < 0.05).

CONCLUSION

Hepatitis attacks in pregnant women with chronic HBV infection usually occur in the second trimester.

Syndemic profiles of people living with hepatitis C virus using population-level latent class analysis to optimize health services

BACKGROUND

Hepatitis C (HCV) affects diverse populations such as people who inject drugs (PWID), 'baby boomers,' gay/bisexual men who have sex with men (gbMSM), and people from HCV endemic regions. Assessing HCV syndemics (i.e.relationships with mental health/chronic diseases) among subpopulations using Latent Class Analysis (LCA) may facilitate targeted program planning.

METHODS

The BC Hepatitis Testers Cohort(BC-HTC) includes all HCV cases identified in BC between 1990 and 2015, integrated with medical administrative data. LCA grouped all BC-HTC HCV diagnosed people(n = 73,665) by socio-demographic/clinical indicators previously determined to be relevant for HCV outcomes. The final model was chosen based on fit statistics, epidemiological meaningfulness, and posterior probability. Classes were named by most defining characteristics.

RESULTS

The six-class model was the best fit and had the following names and characteristics: 'Younger PWID'(n =11,563): recent IDU (67%), people born >1974 (48%), mental illness (62%), material deprivation (59%). 'Older PWID'(n =15,266): past IDU (78%), HIV (17%), HBV (17%) coinfections, alcohol misuse(68%). 'Other Middle-Aged People'(n = 9019): gbMSM (26%), material privilege (31%), people born between 1965-1974 (47%). 'People of Asian backgrounds' (n = 4718): East/South Asians (92%), no alcohol misuse (97%) or mental illness (93%), people born <1945 (26%), social privilege (66%). 'Rural baby boomers' (n = 20,401): rural dwellers (32%), baby boomers (79%), heterosexuals (99%), no HIV (100%). 'Urban socially deprived baby boomers' (n = 12,698): urban dwellers (99%), no IDU (100%), liver disease (22%), social deprivation (94%).

CONCLUSIONS

Differences between classes suggest variability in patients' service needs. Further analysis of health service utilization patterns may inform optimal service layout.

Testing for Hepatitis C in Pregnancy: the Time has Come for Routine Rather than Risk-based

Purpose of review

The purpose of this review is to discuss the reasons for HCV testing during pregnancy and to review what is known about antiviral treatment during pregnancy.

Recent findings

Hepatitis C virus affects over 3 million persons in the United States and is one of the leading infectious causes of death. While HCV is most commonly transmitted via parenteral exposures, thus affecting people who inject drugs, it is also transmitted from mother-to-child. Due to an expanding opioid crisis, an increasing number of women of childbearing age are now infected, resulting in transmission to infants. Risk-based screening has never been proven effective and thus universal screening of pregnant women for HCV infection has been recommended.

Summary

Obstetricians may play a key role in the U.S. by implementing universal testing for HCV in pregnant women, thereby enhancing the health of mothers and identifying children at risk.

Hepatitis C virus among pregnant women and children in the USA: an emerging epidemic

Hepatitis C virus (HCV) infection is increasing among pregnant women, resulting in an increased prevalence of perinatal exposure and pediatric infection. While antiviral medications have been effective at preventing perinatal transmission of viral infections, such as HIV, there are currently no interventions to prevent the perinatal transmission of HCV. In this review, the epidemiology of HCV, current HCV screening recommendations during pregnancy and existing knowledge gaps for the use of directly acting antivirals (DAAs) medications in pregnancy will be discussed. To address the rapidly changing epidemiology of HCV, consideration should be given to universal screening for HCV during pregnancy and future studies should explore when directly acting antivirals should be used for maternal treatment during pregnancy to prevent perinatal transmission.

Perinatal Transmission of Hepatitis C Virus: Defining the Cascade of Care

OBJECTIVES

The US National Viral Hepatitis Action Plan calls for major efforts to expand hepatitis C virus (HCV) diagnosis and treatment; prenatal care settings are potential venues for expanding HCV testing. We aimed to characterize the HCV diagnostic cascade for women and infants and investigate factors associated with linkage and follow-up.

STUDY DESIGN

We used electronic health records for a 10-year cohort of 879 women with opioid use disorder from an obstetric clinic serving women with substance use disorders.

RESULTS

Altogether, 744 women (85%) were screened for HCV; 510 (68%) were seropositive, of whom 369 (72%) had nucleic acid testing performed and of these 261 (71%) were viremic. Of 404 infants born to HCV-seropositive women, 273 (68%) were tested at least once for HCV, 180 (45%) completed the American Academy of Pediatrics-recommended perinatal HCV screening, and 5 (2.8%) were diagnosed with HCV infection and linked to care. More recent delivery date (2014-2015) was associated with maternal linkage to care (aOR, 2.5; 95% CI, 1.4-4.7). Maternal coinfection with HIV (aOR, 9.0; 95% CI, 1.1-72.8) and methadone maintenance therapy, compared with buprenorphine (aOR, 1.5; 95% CI, 0.9-2.5), were associated with higher rates of infant HCV testing.

CONCLUSIONS

HCV prevalence among pregnant women with opioid use is high and infant HCV screening is imperfect. Programmatic changes to improve both mother and infant follow-up may help to bridge identified gaps in the cascade to cure.

Sexually acquired acute hepatitis C infection diagnosed during pregnancy: a case report of successful postpartum treatment

BACKGROUND

Infection with the hepatitis C virus (HCV) during pregnancy has emerged as an increasingly recognized and prevalent condition among women of reproductive age in the United States. While screening recommendations exist for pregnant women at high risk of HCV infection, pregnant women with HCV are often under-screened, not diagnosed, or do not receive adequate follow-up, thereby increasing the risk of suboptimal maternal and infant outcomes (including in future pregnancies).

CASE

A pregnant woman living with HIV presented with intrahepatic cholestasis of pregnancy. She had tested negative for HCV earlier in pregnancy as part of routine screening recommended for women living with HIV. She was found to have sexually acquired a new HCV infection from her partner during pregnancy. She successfully completed treatment postpartum.

CONCLUSION

With the rise in HCV infection among pregnant patients, physicians should be diligent in assessing pregnant women and their partners for HCV risk factors, testing for HCV when risk is identified, and arranging follow-up testing and treatment for HCV-positive mothers and their infants.

Opioid Use Disorders and Pregnancy

Opioid use disorder presents an increased risk of complications in pregnancy, particularly when untreated. To optimize outcomes, medication-assisted treatment using methadone or buprenorphine as a part of a comprehensive care model is recommended. Neonatal abstinence syndrome and poor fetal growth remain significant complications of this disorder despite maternal treatment.