Summary

AASLD/IDSA simplified HCV “test and treat” algorithm for initial and follow-up visits in treatment-naive patients without cirrhosis or other complicating conditions. Outlines point-of-care HCV RNA testing, pretreatment labs, criteria triggering specialist referral, and post-treatment SVR assessment. Patients with prior DAA treatment, HBsAg positivity, HCC, or decompensated cirrhosis require specialist referral rather than simplified treatment.

Key Recommendations

Use simplified test-and-treat pathway only for patients without prior DAA exposure, known HBsAg positivity, HCC, or decompensated cirrhosis (ascites, encephalopathy, jaundice, varices).
Refer to specialist if any exclusion criterion is present (prior DAA, HBsAg+, HCC, decompensated cirrhosis).
At initial visit, perform medication reconciliation using the HEP drug interaction checker and dispense DAA therapy.
Draw AST, ALT, platelets, and HBsAg before or at treatment initiation; engage in shared decision-making about HBV coinfection risk and start DAA while awaiting HBsAg results.
If HBsAg returns positive during DAA therapy, continue HCV treatment and initiate/refer for HBV therapy to prevent flare/reactivation.
Assess SVR with HCV RNA 4 weeks after completing therapy (quantitative PCR preferred; POC qualitative acceptable when venipuncture unavailable).
In patients with cirrhosis, confirm cure with SVR12 (HCV RNA at 12 weeks post-treatment).
After SVR in non-cirrhotic patients, no HCV-related follow-up unless ongoing reinfection risk, in which case repeat HCV RNA yearly.
If pretreatment FIB-4 >3.25, transient elastography consistent with cirrhosis, or history of decompensation, initiate cirrhosis surveillance.
Cirrhosis surveillance: HCC screening with ultrasound + AFP every 6 months and variceal screening per AASLD guidance.
Consider HCV RNA at week 4 of therapy if concern for suboptimal DAA adherence.

Thresholds & Doses

FIB-4 >3.25 — triggers cirrhosis evaluation and surveillance pathway.
HCV RNA testing 4 weeks after completion of therapy — determines SVR.
SVR12 (HCV RNA at 12 weeks post-treatment) — required to confirm cure in patients with cirrhosis.
HCC surveillance with ultrasound + AFP every 6 months in patients with cirrhosis.
Yearly HCV RNA testing in patients with ongoing reinfection risk factors after SVR.
Pretreatment AST/ALT/platelets valid if drawn within 6 months prior to treatment initiation (may be deferred if transient elastography done in prior 6 months).

Citations

Initial Visit algorithm — exclusion criteria triggering specialist referral
Initial Visit algorithm — labs (AST/ALT/PLT/HBsAg) and medication dispensing
Footnote ** — HBV coinfection risk discussion and shared decision-making on deferring vs initiating DAA
Follow-Up Visit algorithm — HCV RNA 4 weeks post-therapy for SVR determination
Footnote *** — SVR12 required in cirrhosis; POC qualitative testing acceptable in select settings
Follow-Up Visit algorithm — FIB-4 >3.25 criterion for cirrhosis monitoring pathway
Cirrhosis monitoring section — US/AFP every 6 months and endoscopic variceal surveillance
Footnote * — timing window for pretreatment labs