The Hepatitis C Cascade of Care in Pregnancy: Identifying Barriers to Treatment

Introduction: Over the past decade, hepatitis C virus (HCV) infections have increased in young adults, including pregnant women, and screening for HCV during each pregnancy is now recommended. Pregnancy presents a unique opportunity for diagnosis, though data on subsequent linkage to care, treatment for HCV, and barriers experienced during this process are limited. This study aimed to assess the HCV care cascade in women diagnosed during pregnancy. Methods: Adults ≥18 with a first positive HCV RNA between 1/1/2017-12/31/2022 at our center were identified. Obstetrics and gynecology encounters with associated +RNA were reviewed to confirm pregnancy status, assess timing of HCV diagnosis, and identify any barriers to care for HCV. Progression through the HCV cascade was compared between pregnant and non-pregnant patients, and characteristics associated with successful linkage to care (visit in specialty clinic or treatment) and treatment among pregnant women were evaluated. Comparisons were performed using chi-square tests or Fisher exact tests. Results: A total of 98 pregnant and 3,905 non-pregnant patients with first positive HCV RNA tests were identified. Most pregnant women with HCV were insured by Medicaid (85%), and a high proportion had opioid use disorder (56%). Overall, 40% were newly diagnosed during pregnancy, including 9% at delivery. After diagnosis, 47% were linked to care for HCV, and 20% were prescribed treatment, both lower compared to non-pregnant patients (Figure 1). Only 12% had documented negative RNA 12 weeks after treatment. Pregnant women who were diagnosed at delivery or a non-outpatient encounter were less likely to be linked to care (Table 1). A high proportion received a specialty referral (74%), though only 50% had a subsequent clinic visit. The most common reason for lack of treatment was a canceled or no-show appointment following referral (32%, n = 24). Other barriers included lack of referral (21%), lack of scheduled appointment after referral (17%), or loss to follow-up (22%). None were not treated due to substance use. Conclusion: At our institution, only 20% of women diagnosed with HCV during pregnancy received treatment, significantly lower than non-pregnant patients. Most pregnant patients were referred for treatment but experienced barriers in subsequently attending appointments. Collaborative efforts are needed to ensure appropriate linkage to care and navigation of the healthcare system to improve postnatal HCV treatment rates.Figure 1.: HCV Care Cascade in Pregnant Patients Compared to Non-Pregnant Patients. Table 1. - Characteristics Associated with Linkage to Care After HCV Diagnosis in Pregnancy Linkage to Care (n = 46) No Linkage to Care (n = 52) P-value Treatment (n = 20) No Treatment (n = 78) P-value Insurance 0.62 0.80 Commercial 66.7 (6) 33.3 (3) 22.2 (2) 77.8 (7) Medicare 50.0 (1) 50.0 (1) 0 100 (2) Medicaid 45.8 (38) 54.2 (45) 20.5 (17) 79.5 (66) Other 50.0 (1) 50.0 (1) 50.0 (1) 50.0 (1) Self-Pay 0 100 (2) 0 100 (2) Comorbidities Depression 45.8 (22) 54.2 (26) 0.83 18.8 (9) 81.2 (39) 0.69 Opioid use disorder 45.4 (25) 54.6 (30) 0.74 20.0 (11) 80.0 (44) 0.91 Diagnosis Location 0.001 0.41 Outpatient 60.0 (39) 40.0 (26) 24.6 (16) 75.4 (49) Inpatient 23.3 (7) 76.7 (23) 13.3 (4) 86.7 (26) Emergency department 0 100 (3) 0 100 (3) Diagnosis Period 0.004 0.05 Pregnancy, pre-delivery 60.0 (18) 40.0 (12) 33.3 (10) 66.7 (20) At delivery 0 100 (9) 0 100 (9) Pre-existing diagnosis 47.5 (28) 52.5 (31) 17.0 (10) 83.0 (49)