Challenges and Controversies

Although it would be ideal to have an additional undetectable HCV RNA after the patient completed treatment, I would assume this patient has reinfection with the same genotype. He had an undetectable RNA at 12 weeks and the risk of viral relapse after 12 weeks is extremely rare. Although HCV reinfection among people who inject drugs (PWID) is not as common as initial infection among the general population, continued intravenous drug use is a known risk factor for reinfection. PWID found to be HCV reinfected should be offered re-treatment along with simultaneous harm reduction strategies to minimize future infection risk. Since the patient has reinfection, and not treatment failure, I would offer him the same treatment as a naive patient. Even though the patient has taken glecaprevir-pibrentasvir before, there is no reason to suspect that the newly acquired virus has mutations, since the virus has not seen the antiviral before. Although 12 weeks of sofosbuvir-velpatasvir is also an option for a naive patient without cirrhosis with genotype 1a, I would opt to treat someone with co-occuring substance use disorder with the shortest regimen possible to promote treatment completion.