Post‑Treatment Follow‑Up for Hepatitis C

Confirmation of Sustained Virologic Response (SVR)

Perform HCV RNA testing at 12 weeks after completing direct‑acting antiviral therapy to confirm SVR; a routine repeat test at 48 weeks is also advised. This dual‑time‑point confirmation is endorsed by the American Gastroenterological Association. 1
The 12‑week HCV RNA test (SVR12) has replaced the older 24‑week benchmark from the interferon era as the standard cure‑confirmation method. 2
A 24‑week post‑treatment HCV RNA test may be used selectively; it is not required for all patients. 3
After 48 weeks, routine virologic testing is unnecessary because late relapse occurs in < 1 % of patients who have achieved SVR. 4
Patients with ongoing risk factors for reinfection (e.g., active injection‑drug use) should undergo indefinite periodic HCV RNA testing. 5

Indefinite semi‑annual surveillance with liver ultrasound ± α‑fetoprotein (AFP) is mandatory for all patients with stage F3 fibrosis or cirrhosis, even after SVR. 6
Do not intensify the surveillance interval immediately after SVR; maintain the six‑month schedule. [@7@]
Continue surveillance indefinitely because the risk of HCC persists despite viral clearance. [@8@]

HCC surveillance is not recommended for patients with fibrosis stages F0‑F2 after achieving SVR. [@9@]

All patients with cirrhosis should receive an initial upper endoscopy regardless of SVR status. [@10@]
If the initial endoscopy shows no varices or only small varices, repeat endoscopy in 2–3 years is advised. [@11@]
Endoscopic surveillance may be discontinued on an individual basis when no varices are detected on the 2–3‑year follow‑up and no additional risk factors for disease progression exist. [@12@]

Hepatic elastography or non‑invasive scores (FIB‑4, APRI) can be considered case‑by‑case to evaluate fibrosis progression or regression. [@13@]
Early reductions in elastography or FIB‑4 values after SVR mainly reflect decreased necro‑inflammation rather than true fibrosis regression. [@14@]
Late reductions are more likely to represent genuine fibrosis regression, although further evidence is required. [@15@]
Improvements in fibrosis metrics should not alter the current HCC surveillance frequency. [@16@]

Educate patients about other liver‑injuring factors—such as alcohol use, hepatic steatosis, and hepatotoxic medications—that can contribute to fibrosis progression. [@17@]
If liver enzymes remain elevated after SVR, investigate alternative causes of hepatic injury. [@18@]

The European Association for the Study of the Liver (EASL) 2024 guidelines emphasize that proper risk stratification using elastography or non‑invasive scores before initiating therapy is essential for planning appropriate post‑treatment follow‑up. [@19@]