Hepatitis C treatment during pregnancy: time for a practice change

Hepatitis C virus (HCV) infection has become a public health crisis in the last few decades, with a significant impact on individuals of reproductive age. Direct-acting antivirals (DAAs) were introduced in 2011 and are highly effective at eradicating HCV infection through 8- to 12-week treatment courses, making them the mainstay of treatment for nonpregnant adults. Obstetric guidelines have not recommended treatment of HCV infection during pregnancy due to more limited data on DAA use during pregnancy. The risk of perinatal transmission of HCV is up to 9%, with at least one-third of transmissions occurring antenatally. Infant follow-up after perinatal exposure to HCV infection has been poor due to loss to care and a long latency to recommended testing. In recent years, there has been a growing body of evidence that DAAs are safe and effective in pregnancy, with similar cure rates as nonpregnant adults. Pregnancy represents a time when individuals are continuously engaged in care, providing an optimal window for treatment of HCV infection. Obstetrician/gynecologists should employ shared decision-making surrounding treatment of HCV infection during pregnancy, acknowledging the benefits and efficacy of treatment versus the available data on DAA exposure in pregnancy. Therapy should be initiated during the second or third trimesters, with limited but reassuring data on DAA exposure through breastmilk. Ledipasvir/sofosbuvir and sofosbuvir/velpatasvir currently have the most data available in pregnancy and should be included in conversations regarding HCV treatment in pregnancy. Multidisciplinary care between maternal-fetal medicine, infectious disease, and hepatology can help promote access to HCV treatment in pregnancy. El resumen está disponible en Español al final del artículo.