Gaps in the hepatitis C prenatal and postpartum care cascade: rationale for treatment in pregnancy

Background — Hepatitis C virus (HCV) infections have increased among younger populations, including pregnant people. While universal screening guidelines have improved case-finding, studies suggest low postpartum linkage-to-care rates. Better understanding of the peripartum HCV care cascade at the population level is needed to inform optimal management, including the role of treatment in pregnancy.

Methods — A retrospective cohort study linking pregnant individuals with HCV test records to health administrative data in Ontario, Canada. We examined the HCV care continuum, including during subsequent pregnancies. We used Andersen-Gill models to examine predictors of missed opportunities for treatment, defined as pregnancies occurring before/in absence of treatment, and initiating treatment.

Results — From 2003 to 2021, we identified 42 797 pregnancies in 16 888 people who tested HCV antibody-positive between 1999 and 2021. Of antibody-positive individuals, 14 538 (86.1%) had RNA testing and 7457 (51.3%) tested RNA-positive. Treatment uptake was 1.1%, 2.5%, and 5.2% at 1, 2, and 5 years after RNA positivity. Ultimately, 3861 (51.8%) initiated treatment and 2277 (30.5%) demonstrated sustained virologic response. Among those with confirmed chronic HCV, 47.5% (n = 3025) experienced a missed opportunity for treatment, with 19.2% (n = 1221) having multiple missed opportunities. Numbers of pregnancies and diagnosis year pre-2012 were associated with higher likelihood of a missed opportunity for treatment, while diagnoses of substance use disorder, HIV, and chronic disease were associated with lower likelihood.

Conclusions — Despite diagnosis, <10% initiated treatment within 5 years of RNA positivity and multiple pregnancies occurred before treatment, resulting in repeated exposures. Additional efforts will be required to ensure linkage-to-care and treatment either during pregnancy or postpartum.