Challenges and Controversies

I would obtain an HCV genotype prior to starting HCV treatment. The primary driver for this decision is that HCV treatment in the state I practice requires HCV genotype as a component of the prior authorization process for HCV treatment approval. Another reason to check HCV genotype is the potential to more easily define reinfection if there was recurrent HCV viremia after HCV treatment. A change in HCV genotype at the time of recurrent viremia would support reinfection as the etiology of recurrent viremia as opposed to viral relapse. In the absence of insurance requirements and high risk for HCV reinfection, HCV genotype in the setting of low-level fibrosis does not contribute to treatment outcomes as both available pan-genotypic regimens glecaprevir-pibrentasvir and sofosbuvir-velpatasvir confer equally high rates of HCV cure. The AASLD/IDSA simplified algorithm does not recommend genotye testing in treatment naive patients. If a pangenotypic regimen is not available for use, HCV genotype is indicated.

This patient qualifies for the AASLD-IDSA HCV Guidance simplified treatment approach for persons without cirrhosis, which recommends the use of pan-genotypic DAA regimens, including glecaprevir-pibrentasvir or sofosbuvir-velpatasvir. Because the recommended regimens are pan-genotypic, obtaining a genotype prior to treatment will not impact the choice or duration of DAAs and may delay initiating therapy in this highly motivated patient.

In patients with ongoing risk factors for HCV infection (e.g., active injection drug use), having a baseline genotype may be helpful in the future if one needs to decipher between persistent infection versus reinfection; however, given the excellent efficacy of DAAs, I don't routinely obtain a baseline genotype for the purposes of this hypothetical situation.