Hepatitis C Virus in Pregnancy: An Opportunity to Test and Treat

Sofosbuvir/Velpatasvir Pharmacokinetics, Safety, and Efficacy in Pregnant People With Hepatitis C Virus

BACKGROUND

Treatment of hepatitis C virus (HCV) during pregnancy can cure maternal HCV and prevent perinatal HCV transmission. The primary objective was to compare the pharmacokinetics (PK) of sofosbuvir (SOF)/velpatasvir (VEL) in pregnant versus nonpregnant people.

METHODS

Pregnant people with chronic HCV infection were enrolled between 23 and 25 weeks' gestation and were provided SOF/VEL daily for 12 weeks. PK visits were performed at 3, 6, and 9 weeks. VEL, SOF, and GS-331007 (the inactive metabolite of SOF) in plasma and the SOF active metabolite (007-TP) in peripheral blood mononuclear cells (PBMCs) and dried blood spots (DBSs) were measured and compared to historical data in nonpregnant people. Maternal adverse events, delivery outcomes, the sustained virologic response 12 weeks after therapy, infant adverse events, and HCV perinatal transmission were assessed.

RESULTS

Fourteen participants were screened, and 11 enrolled. One participant discontinued treatment due to worsening of hyperemesis. VEL area under the curve (AUC) was similar to historic data in nonpregnant people, but the AUCs of SOF and GS-331007 were 38% higher and 38% lower, respectively. Concentrations of 007-TP in PBMCs were comparable or higher, whereas 007-TP in DBSs was approximately 50% lower in pregnant versus nonpregnant people. All 10 participants who completed treatment had undetectable HCV RNA at delivery. Two participants were lost to follow-up after delivery, but 1 had an HCV RNA through clinical care. All participants with data were cured (n = 9) and none of the infants acquired HCV (n = 8).

CONCLUSIONS

SOF/VEL exposures were not clinically different in pregnancy and support further evaluation of antenatal SOF/VEL treatment.

Hepatitis C Virus Infection in Pregnant Individuals with Opioid Use Disorder and Its Association with Preterm Birth

Both hepatitis C virus (HCV) and opioid use disorder (OUD) have been associated with higher rates of preterm birth (PTB). It is unknown whether the higher prevalence of HCV in individuals with OUD may contribute to this association. The objective of this study is to evaluate the association between HCV and PTB in pregnant individuals with OUD.We conducted a retrospective cohort of pregnant individuals with OUD who participated in more than three visits in a co-located multidisciplinary program. Inclusion criteria were a diagnosis of OUD, participation in treatment/prenatal care program, and laboratory evaluation of HCV status. The primary exposure was the presence of HCV antibodies, and secondarily, a detectable viral load (viremia). The primary outcome was PTB, which was further classified as spontaneous or iatrogenic. Multivariable logistic regression was used to detect associations while adjusting for race, history of prior PTB, and tobacco use.A total of 941 individuals were included in the study, 404 with HCV and 537 without. Rates of PTB did not differ between those with compared to those without HCV (20.3 vs. 23.8%, adjusted odds ratio [aOR] = 0.75 [95% confidence interval (CI): 0.53-1.07]). There were similar rates of spontaneous PTB (13.1 vs. 16.2%, aOR = 0.79 [95% CI: 0.43-1.45]) and iatrogenic PTB (7.2 vs. 7.6%, aOR = 1.26 [95% CI: 0.69-2.30]). Comparing those with viremia to those without, there were also similar rates of overall PTB (21.6 vs. 17.9%, aOR = 0.86 [95% CI: 0.52-1.44]), spontaneous PTB (13.3 vs. 12.9%, aOR = 0.97 [95% CI: 0.52-1.87]), and iatrogenic PTB (8.3 vs. 5.0%, aOR = 1.83 [95% CI: 0.76-4.94]).HCV does not appear to be associated with spontaneous or iatrogenic PTB in pregnant persons with OUD who are engaged in treatment and prenatal care. The role of co-located multidisciplinary prenatal and addiction programs in the association between HCV and PTB warrants further investigation. · Hepatitis C antibodies are not associated with PTB in those with OUD.. · Hepatitis C viremia is not associated with PTB.. · Multidisciplinary treatment programs may contribute to these findings..

Overview of Hepatitis C in Pregnancy: Screening, Management, and Treatment

OBJECTIVE

The rising prevalence of hepatitis C infections among individuals of reproductive age further emphasizes the importance of evidence-based management of hepatitis C virus (HCV) during pregnancy to minimize perinatal transmission and to optimize maternal and fetal outcomes. In this review, we discuss the most recent recommendations on the management of HCV in pregnancy, including recommendations for screening and treatment during pregnancy and the postpartum period, as well as infant management to reduce perinatal transmission of HCV.

RECENT FINDINGS

Current guidelines recommend universal HCV screening during each pregnancy. With varying guidance regarding the use of direct-acting antivirals (DAAs) during pregnancy, recent studies have focused on the safety and efficacy of DAA initiation during pregnancy. Additionally, there has been an increased focus on improving treatment rates in the postpartum period through innovative linkage to care efforts, telemedicine, and additional efforts reducing barriers to care for patients.

Screening for viral hepatitis carriage

Viral hepatitis during pregnancy is common globally. In this review, we focus on the antenatal screen for hepatitis A, B, C and E, the prevention of mother-to-child transmission (MTCT) of hepatitis B and C, and the management of hepatitis A, B, C and E during pregnancy. Neonatal timely administration of hepatitis B immunoglobulin and hepatitis B vaccine is the cornerstone for preventing MTCT of hepatitis B virus (HBV), and perinatal antiviral prophylaxis with tenofovir disoproxil fumarate in mothers with positive HBeAg or HBV DNA >2 × 105 IU/ml also plays important roles in further reducing MTCT. Avoidance of risk practices in managing labor and delivery process of women with HCV infection may be useful to reduce MTCT of HCV. Early recognition of severe hepatic injury or liver failure associated with hepatitis viruses by regular liver function tests is critical to prevent maternal mortality associated with hepatitis.

Pathogenesis of viral infections during pregnancy

SUMMARYViral infections during pregnancy are associated with significant adverse perinatal and fetal outcomes. Pregnancy is a unique immunologic and physiologic state, which can influence control of virus replication, severity of disease, and vertical transmission. The placenta is the organ of the maternal-fetal interface and provides defense against microbial infection while supporting the semi-allogeneic fetus via tolerogenic immune responses. Some viruses, such as cytomegalovirus, Zika virus, and rubella virus, can breach these defenses, directly infecting the fetus and having long-lasting consequences. Even without direct placental infection, other viruses, including respiratory viruses like influenza viruses and severe acute respiratory syndrome coronavirus 2, still cause placental damage and inflammation. Concentrations of progesterone and estrogens rise during pregnancy and contribute to immunological adaptations, placentation, and placental development and play a pivotal role in creating a tolerogenic environment at the maternal-fetal interface. Animal models, including mice, nonhuman primates, rabbits, and guinea pigs, are instrumental for mechanistic insights into the pathogenesis of viral infections during pregnancy and identification of targetable treatments to improve health outcomes of pregnant individuals and offspring.

Current perspectives of viral hepatitis

Viral hepatitis represents a major danger to public health, and is a globally leading cause of death. The five liver-specific viruses: Hepatitis A virus, hepatitis B virus, hepatitis C virus, hepatitis D virus, and hepatitis E virus, each have their own unique epidemiology, structural biology, transmission, endemic patterns, risk of liver complications, and response to antiviral therapies. There remain few options for treatment, in spite of the increasing prevalence of viral-hepatitis-caused liver disease. Furthermore, chronic viral hepatitis is a leading worldwide cause of both liver-related morbidity and mortality, even though effective treatments are available that could reduce or prevent most patients' complications. In 2016, the World Health Organization released its plan to eliminate viral hepatitis as a public health threat by the year 2030, along with a discussion of current gaps and prospects for both regional and global eradication of viral hepatitis. Today, treatment is sufficiently able to prevent the disease from reaching advanced phases. However, future therapies must be extremely safe, and should ideally limit the period of treatment necessary. A better understanding of pathogenesis will prove beneficial in the development of potential treatment strategies targeting infections by viral hepatitis. This review aims to summarize the current state of knowledge on each type of viral hepatitis, together with major innovations.

Breastfeeding Initiation in People With Hepatitis C Virus Infection in the United States

OBJECTIVE

To evaluate breastfeeding initiation rates among people living with and without hepatitis C virus (HCV) infection during pregnancy and to identify characteristics associated with breastfeeding initiation.

METHODS

We conducted a cross-sectional analysis of individuals who had a live birth in the United States from 2016 to 2021 using the National Center for Health Statistics birth certificate data. We grouped participants by whether they had HCV infection during pregnancy. Using propensity-score matching, we assessed the association between breastfeeding initiation before hospital discharge , defined as neonates receiving any parental breast milk or colostrum, and HCV infection during pregnancy in a logistic regression model. We also assessed factors associated with breastfeeding initiation among those with HCV infection.

RESULTS

There were 96,896 reported cases (0.5%) of HCV infection among 19.0 million births that met inclusion criteria during the study period. Using propensity-score matching, we matched 87,761 individuals with HCV infection during pregnancy with 87,761 individuals without HCV infection. People with HCV infection during pregnancy were less likely to initiate breastfeeding compared with those without HCV infection (51.5% vs 64.2%, respectively; odds ratio 0.59, 95% CI, 0.58-0.60, P <.001). Characteristics associated with higher rates of breastfeeding initiation among individuals with HCV infection included a college degree (adjusted odds ratio [aOR] 1.22, 95% CI, 1.21-1.24); self-identified race or ethnicity as Native Hawaiian or Pacific Islander (aOR 1.22, 95% CI, 1.06-1.40), Asian (aOR 1.09, 95% CI, 1.06-1.13), or Hispanic (aOR 1.09, 95% CI, 1.08-1.11); private insurance (aOR 1.07, 95% CI, 1.06-1.08); nulliparity (aOR 1.09, 95% CI, 1.08-1.10), and being married (aOR 1.08, 95% CI, 1.07-1.09). Characteristics associated with not breastfeeding before hospital discharge included receiving no prenatal care (aOR 0.81, 95% CI, 0.79-0.82), smoking during pregnancy (aOR 0.88, 95% CI, 0.88-0.89), and neonatal intensive care unit admission (aOR 0.92, 95% CI, 0.91-0.93).

CONCLUSION

Despite leading health organizations' support for people living with HCV infection to breastfeed, our study demonstrates low breastfeeding initiation rates in this population. Our findings highlight the need for tailored breastfeeding support for people with HCV infection and for understanding the additional effects of human immunodeficiency virus (HIV) co-infection, HCV treatment, and concurrent substance use disorders on breastfeeding initiation.

Hepatitis C infection seroprevalence in pregnant women worldwide: a systematic review and meta-analysis

Background

Monitoring progress towards the WHO global target to eliminate hepatitis C virus (HCV) infection by 2030, entails reliable prevalence estimates for HCV infection in different populations. Little is known about the global burden of HCV infection in pregnant women. Here, for the first time to our knowledge, we estimated the global and regional seroprevalence of HCV antibody (Ab) and determinants in pregnant women.

Methods

In this systematic review and meta-analysis study, we searched PubMed/MEDLINE, Web of Science, Embase, Scopus, and SciELO databases for peer-reviewed observational studies between January 1, 2000 and April 1, 2023, without language or geographical restrictions. Pooled global seroprevalence (and 95% confidence interval, CI) were estimated using random-effects meta-analysis and seroprevalences were categorised according to World Health Organization regions and subregions, publishing year, countries' income and human development index (HDI) levels. We used sensitivity analysis to assess the effect of four large sample size studies on pooled global prevalence through the "leave-one-out" method. We also investigated the association of potential risk factors with HCV seropositivity in pregnant women by subgroup and meta-regression analyses. The Protocol was registered in PROSPERO CRD42023423259.

Findings

We included 192 eligible studies (208 datasets), with data for 148,509,760 pregnant women from 53 countries. The global seroprevalence of HCV Ab in pregnant women was 1.80% (95% CI, 1.72-1.89%) and 3.29% (3.01-3.57%) in overall and sensitivity analyses, respectively. The seroprevalence was highest in the Eastern Mediterranean region (6.21%, 4.39-8.29%) and lowest in the Western Pacific region (0.75%, 0.38-1.22%). Subgroup analysis indicated that the seroprevalence of HCV Ab among pregnant women was significantly higher for those with opioid use disorder (51.94%, 95% CI: 37.32-66.39) and HIV infection (4.34%, 95% CI: 2.21-7.06%) than for the general population of pregnant women (1.08%, 95% CI: 1.02-1.15%), as confirmed by multivariable meta-regression (p < 0.001). A significant decreasing trend was observed with increasing human development index levels. Other important risk factors for HCV seropositivity included older age, lower educational levels, poly sexual activity, history of blood transfusion, hospitalization, surgery, abortion and sexual transmitted diseases, having scarification/tattoo or piercing, and testing hepatitis B positive.

Interpretation

This meta-analysis showed relatively high burden of exposure to HCV infection (2.2-5.3 million) in pregnant women globally. However, due to substantial heterogeneity between studies, our estimates might be different than the true seroprevalence. Our findings highlighted the need to expand HCV screening for women of reproductive age or during pregnancy, particularly in countries with high prevalence; as well as for more studies that assess safety of existing therapeutic drugs during pregnancy or potentially support development of drugs for pregnant women.

Funding

There was no funding source for this study.