Timing of Earliest Documented Positive Hepatitis C Laboratory Result Relative to Delivery Among Pregnant Persons With Active Infection in West Virginia, 2022–2023

ABSTRACT

Direct‐acting antiviral therapy can cure hepatitis C virus (HCV) infection; however, because treatment is not recommended during pregnancy, preconception treatment remains the primary strategy to prevent perinatal HCV exposure. West Virginia birth records from 2022 to 2023 were linked with statewide HCV laboratory surveillance data. This linked dataset was used to identify births to persons with active HCV infection and characterize the timing of the earliest documented positive HCV laboratory result relative to delivery. A total of 426 deliveries resulting in 433 HCV‐exposed live‐born infants were identified. Most pregnant persons were aged 25–34 years, White and insured by Medicaid. Overall, 38.5% had their earliest documented positive HCV laboratory result more than 5 years prior to delivery, 36.9% had their first documented positive test 1–5 years prior to delivery and 24.6% had their first documented positive test within 1 year before delivery and up to 2 weeks postpartum. These findings indicate that many pregnant persons with active HCV infection had documented longstanding infection prior to pregnancy, highlighting opportunities to strengthen linkage to care and access to curative treatment before pregnancy.

Chronic hepatitis C virus (HCV) infection can lead to progressive liver disease, including cirrhosis and hepatocellular carcinoma, making HCV elimination a global public health priority. In the United States (US), the incidence of HCV among people of reproductive age has increased substantially, largely driven by increasing injection drug use [1]. Direct‐acting antiviral (DAA) therapies achieve cure rates > 95% and are recommended for most adults with HCV infection [2]. Despite the availability of curative therapy, increasing HCV incidence among reproductive‐aged persons has resulted in a growing number of infants perinatally exposed to HCV [1].

Universal HCV screening is recommended during each pregnancy, providing an important opportunity for HCV diagnosis and linkage to care [3]. While this approach improves detection, HCV treatment during pregnancy is not currently recommended, making treatment prior to conception the primary strategy for preventing perinatal exposure [2].

Treatment uptake remains low among people of reproductive age with HCV, particularly in populations disproportionately affected by the opioid crisis [4]. Evidence suggests that prenatal screening often identifies infections that were present before pregnancy. In a multi‐jurisdictional analysis of pregnancies affected by HCV, approximately one‐fifth had a documented positive test prior to pregnancy, indicating potential missed opportunities for treatment before conception [5]. Consistent with these findings, a large retrospective cohort study found that nearly half of individuals with HCV experienced at least one potential missed opportunity for treatment before or between pregnancies and nearly one‐fifth experienced multiple missed opportunities [4]. Together, these findings suggest that many pregnant individuals with HCV have longstanding, previously identified infection, highlighting gaps in HCV treatment prior to pregnancy.

West Virginia (WV) consistently reports some of the highest incidence rates of acute HCV in the US and has clearance rates for HCV that are well below national elimination targets, underscoring challenges in achieving cure at the population level [6, 7]. Using linked statewide birth and viral hepatitis laboratory surveillance data, we identified deliveries among pregnant persons in WV with active HCV infection and characterized the timing of the earliest documented positive HCV laboratory result relative to delivery.

1. Methods

A statewide retrospective cohort analysis was conducted among WV residents who delivered a live‐born infant between January 1, 2022 and December 31, 2023. Residency was determined based on maternal address at delivery. Birth certificate records were obtained for WV residents, including those who delivered out of state. Live‐born infants with adoption indicated on the birth certificate were excluded.

Key variables obtained from the birth certificate included maternal race, insurance status at delivery, maternal age at delivery and county of residence. Race was categorized as White or Other/Unknown because of small cell counts among non‐White groups. Insurance type was categorized as Medicaid, private, or other/unknown. Maternal age was calculated at the time of delivery using the maternal date of birth and delivery date. Maternal county of residence at delivery was classified using the 2013 USDA Rural–Urban Continuum Codes (RUCC), with counties categorized as metropolitan (RUCC 1–3) or nonmetropolitan (RUCC 4–9).

In WV, hepatitis C is a reportable condition, and all positive laboratory results, including those from antibody, RNA and genotype testing, must be reported to the WV Department of Health. To identify deliveries affected by active HCV infection, laboratory records were restricted to females and individuals reported as having an unknown sex who were of childbearing age (13–50 years) at the time of specimen collection. Using probabilistic data linkage software (Link Plus), HCV RNA‐positive and genotype laboratory reports were matched to birth certificate records using maternal first name, last name and date of birth. All potential matches were manually reviewed and verified using additional identifying information, including address, Social Security number and maiden name, when available. When multiple laboratory reports corresponded to a single pregnancy, records were consolidated into a single record. Analyses were conducted at the pregnancy level. Some pregnant persons contributed more than one delivery during the study period, and some deliveries resulted in multiple gestations, resulting in differences in the counts of pregnant persons, deliveries and infants.

Active HCV infection during pregnancy was defined as a positive laboratory result indicating detectable HCV RNA or a genotype result collected from 1 year before delivery through 2 weeks postpartum. Positive antibody results alone were not considered sufficient evidence of active infection. For pregnancies meeting this definition, all available HCV laboratory reports were reviewed to identify the earliest documented positive result. Because the date of conception was not available, the timing of the first positive HCV laboratory result was assessed relative to delivery rather than pregnancy onset. To characterize the timing of the earliest documented positive HCV laboratory result relative to delivery, the interval between the test result and delivery was calculated and categorized as ≤ 1 year before delivery to 2 weeks postpartum, > 1 year to ≤ 5 years before delivery and > 5 years before delivery.

Descriptive analyses were conducted for all study variables. Frequencies and percentages were calculated for categorical variables. All analyses were performed using SAS version 9.4. The West Virginia University Institutional Review Board determined that this study did not constitute human subjects research.

2. Results

A total of 426 deliveries, resulting in 433 live‐born infants exposed to HCV, were identified among WV residents between January 1, 2022 and December 31, 2023 (Table 1). Ten pregnant persons contributed more than one delivery, and seven deliveries resulted in multiple gestations. Most deliveries occurred among pregnant persons aged 25–34 years (65.7%), and the majority were White (95.1%) and insured by Medicaid at delivery (81.5%). Most pregnant persons resided in metropolitan counties (70.2%).

TABLE 1.

Characteristics of pregnant persons with active HCV infection and timing of the earliest documented positive HCV laboratory result relative to delivery ^a , West Virginia, 2022–2023 (N = 426).

Characteristic	n (%)
Maternal age group at delivery, years
< 25	52 (12.2%)
25–29	130 (30.5%)
30–34	150 (35.2%)
≥ 35	94 (22.1%)
Race
White	405 (95.1%)
Other/Unknown	21 (4.9%)
Insurance at delivery
Any Medicaid	347 (81.5%)
Private Insurance	68 (16.0%)
Other/Unknown	11 (2.6%)
Rural residence at delivery b
Metropolitan	299 (70.2%)
Nonmetropolitan	127 (29.8%)
Timing of earliest documented positive HCV laboratory result relative to delivery
≤ 1 year before delivery to 2 weeks postpartum	105 (24.6%)
> 1 year to ≤ 5 years before delivery	157 (36.9%)
> 5 years before delivery	164 (38.5%)

Abbreviation: HCV, hepatitis C virus.

^a Each delivery was counted separately. Ten pregnant persons contributed more than one delivery during the 2‐year study period, and seven deliveries resulted in multiple gestations.

^b Rural residence at delivery was classified using the 2013 USDA Rural–Urban Continuum Codes (RUCC).

Overall, approximately three‐quarters (75.4%) had their earliest documented positive HCV laboratory result more than 1 year prior to delivery, including 38.5% whose first positive test occurred more than 5 years prior to delivery, and 36.9% whose first positive test occurred one to 5 years before delivery. The remaining 24.6% had their earliest documented positive HCV laboratory result within 1 year before delivery and up to 2 weeks postpartum.

3. Discussion

This statewide analysis characterized the timing of the earliest documented positive HCV laboratory result relative to delivery among pregnant persons with evidence of active infection in WV. More than three‐quarters (75.4%) of pregnant persons had their earliest documented positive HCV laboratory result more than 1 year before delivery, including 38.5% whose earliest documented positive HCV laboratory result occurred more than 5 years before delivery, indicating that infection was frequently longstanding. These results are consistent with prior research showing that infections identified during pregnancy are often documented before conception and may reflect potential opportunities to strengthen linkage to care and treatment among reproductive‐aged persons [4, 5]. The high proportion of White individuals in this cohort is consistent with the demographic composition of West Virginia. A large proportion of this cohort was insured by Medicaid at delivery, underscoring the importance of strengthening HCV care among publicly insured populations. Interpretation of these findings should consider that access to HCV treatment may be influenced by multiple factors, including linkage to care, provider availability, insurance coverage and treatment eligibility requirements. Although HCV treatment delivery has increasingly expanded beyond specialty care settings, Medicaid coverage policies and treatment eligibility criteria for DAAs have varied over time and may have limited access to treatment for some individuals before pregnancy. Supporting timely linkage to HCV care and access to curative treatment prior to conception may reduce the number of individuals entering pregnancy with HCV infection, thereby improving maternal health outcomes and reducing perinatal exposure.

Because treatment during pregnancy is not currently recommended, prevention of perinatal transmission depends largely on treatment prior to pregnancy [2]. Identification of HCV infection during pregnancy may support postpartum linkage to care; however, many pregnant persons are lost to follow‐up during the postpartum period [4]. Infants exposed to HCV require follow‐up testing to determine infection status and, if infected, evaluation for treatment; however, many do not receive recommended testing or treatment, further emphasizing the importance of preventing perinatal exposure [1, 8].

Limitations of this study should be considered. Surveillance and linked vital records data likely did not capture all individuals with active HCV infection during pregnancy, particularly individuals tested outside WV, those affected by name changes, or birth records involving adoption. Individuals who did not receive prenatal care or HCV testing during pregnancy may likewise not have been identified. As a result, the number of pregnancies affected by active HCV infection was likely underestimated. Because the date of conception was unknown, the timing of the first documented HCV laboratory result was assessed relative to delivery rather than conception, which may have limited precision in classifying when infection was first identified in relation to pregnancy. Possible incomplete capture of prior testing conducted outside WV may also have resulted in underestimation of the interval between the first documented HCV laboratory result and delivery. Additionally, because HCV treatment data were unavailable, we could not determine the proportion of individuals who may have previously received successful HCV treatment before pregnancy. Some individuals may have represented reinfection rather than ongoing infection. Despite these limitations, this study used population‐based linked surveillance and vital records data to evaluate the timing of the earliest documented positive HCV laboratory result among pregnant persons with laboratory‐confirmed active infection, identifying potential opportunities to strengthen HCV care, linkage to treatment and treatment access before pregnancy.

4. Conclusions

Many pregnant persons with active HCV infection during pregnancy in WV had evidence of previously documented HCV infection, often years before delivery. These findings support strengthening HCV linkage to care and treatment among reproductive‐aged individuals to promote timely access to curative treatment before future pregnancies, reduce perinatal HCV exposure, improve maternal health and advance progress towards HCV elimination goals.

Funding

This work was supported by Cooperative Agreement NU51CK000347 (M.Y.) funded by the Centers for Disease Control and Prevention (CDC) of the US Department of Health and Human Services (HHS) and the West Virginia (WV) Department of Health. The contents are those of the authors and do not necessarily represent the official views of, nor an endorsement, by CDC/HHS, the U.S. Government, or the West Virginia Department of Health.

Consent

This study was based on data collected as part of routine public health surveillance activities conducted under a legally authorized public health authority. As such, it does not include factors necessitating patient consent.

Conflicts of Interest

A.G.H. reports funding from the CDA Foundation through the Relink programme, unrelated to the present work. All other authors report no potential conflicts of interest.

Data Availability Statement

The data used in this study are not publicly available because they are confidential state public health surveillance data subject to privacy and data‐use restrictions.