Abstract: Hepatitis C virus (HCV) affects an estimated 58 million people worldwide, with rising rates among women of reproductive age. This trend has important implications in pregnancy, as HCV infection can lead to adverse maternal outcomes, mother-to-child transmission, and adverse neonatal outcomes. The perinatal period is a critical time both to identify cases of HCV infection and to initiate treatment, as patients have greater access to care during this time. There has been a guideline shift from risk-based screening for HCV in pregnancy to a universal screening approach. Additionally, several clinical trials are evaluating the use of direct-acting antiviral therapy in pregnancy, with preliminary results demonstrating safety and efficacy. This article discusses the epidemiology of HCV and its implications on pregnancy outcomes, as well as the most recent guidelines on screening and treatment.
Hepatitis C virus (HCV) is a global health challenge, with an estimated 58 million people living with chronic infection and approximately 1.5 million new infections each year.1 The World Health Organization (WHO) set a goal to eliminate HCV infection as a public health threat by 2030 primarily through effective prevention strategies, expanded screening, and timely treatment.2 However, a 2024 global report on HCV elimination revealed substantial variation by region, with only a minority of countries on track to meet WHO 2030 targets.3
Identifying populations at highest risk of HCV infection and transmission patterns by region is essential to successful elimination efforts. In high-income countries, intravenous drug use (IVDU) is the leading cause of transmission, whereas in low-income countries, unsafe medical practices and unscreened blood transfusions remain major contributors.4 In the United States, the incidence of acute HCV increased 3-fold from 2009 to 2018.5 Notably, the highest rates were among reproductive-age individuals between 20 and 29 years old, coinciding with the opioid epidemic and increased unsafe IVDU practices.5,6
The increase in HCV prevalence among women of reproductive age has important implications, especially in the setting of pregnancy. Key concerns include the risk of mother-to-child transmission (MTCT) and associated outcomes, the impact of HCV infection on maternal and infant health, and the importance of determining appropriate timing of HCV treatment.7,8 In recognition of these trends, WHO classifies pregnant individuals as a priority population for elimination of HCV, highlighting pregnancy as a critical opportunity for screening and linkage to care.2 The MTCT terminology is used throughout this article, in line with terminology employed by WHO and the American Association for the Study of Liver Diseases (AASLD).2,9 This article addresses recent advances in the epidemiology and current management of HCV infection in pregnancy.
Epidemiology of Hepatitis C Virus
In 2019, an estimated 14.9 million women of reproductive age (15-49 years) were living with HCV, accounting for approximately 20% of HCV infections worldwide. China and Pakistan accounted for the greatest absolute number of women living with HCV infection, and the highest prevalence rates were seen in Mongolia and Burundi.10 Regions with low sociodemographic indexes carry the highest burden of HCV among women of reproductive age. Based on an age-period-cohort analysis of Global Burden of Disease study data, the overall global burden of HCV among women aged 15 to 49 years revealed a downward trend from 1990 to 2021. Although the age-standardized incidence and mortality rates of both acute and chronic HCV infection have declined overall, there was notable regional variability reflecting differences in health care access and socioeconomic status.11
Within the United States, rates of HCV infection have significantly increased among reproductive-age and pregnant women.5,12,13 A large retrospective cohort study using US National Center for Health Statistics birth records from 2009 to 2017 found that the prevalence of maternal HCV infection rose by 161%, increasing from 1.8 cases to 4.7 cases per 1000 live births.7 Another large cross-sectional study using the National Inpatient Sample of more than 70 million pregnancies from 1998 to 2018 found a 16-fold rise in HCV-positive pregnancies. Rates reached 5.3 cases per 1000 pregnancies, with the greatest burden in women aged 21 to 30 years.8 Although estimates vary slightly by data source, all consistently show a marked rise in HCV prevalence among pregnant individuals in the United States.
Demographic factors associated with HCV infection in pregnancy include White or American Indian/Alaska Native race, lower educational attainment (less than 4-year college degree), Medicaid insurance as primary source of payment, and being unmarried.14 Rates of maternal HCV were higher in nonurban areas compared with large central metropolitan regions, particularly in regions with high rates of IVDU, including Appalachia, Northern New England, the northern border of the Upper Midwest, and New Mexico.15,16 The uneven distribution of maternal HCV across the United States highlights the need for targeted public health strategies that account for both clinical factors, such as coinfection with HIV, and social determinants of health.
Implications of Hepatitis C Virus Infection on Pregnancy
HCV infection during pregnancy has important implications for both maternal and fetal health. MTCT is the leading cause of HCV infection in children.17 A 2024 meta-analysis that evaluated MTCT among 28 studies (3838 individuals) found a pooled rate of transmission of 9% in mothers with HCV viremia. The odds of transmission were higher in mothers who had HIV coinfection (odds ratio, 3.1).18 The major risk factors for MTCT described in the literature include HIV coinfection, HCV RNA greater than 106 IU/mL, antepartum vaginal bleeding, prolonged rupture of membranes (>6 hours), episiotomy, and invasive perinatal procedures such as fetal scalp monitoring.19-22 The mode of delivery (vaginal delivery vs cesarean section) does not affect risk of MTCT, and breastfeeding has not been shown to increase risk of transmission; however, caution is advised if the mother has cracked or bleeding nipples.23
The precise timing of MTCT remains incompletely understood.24 Current estimates rely on the detection of HCV RNA at delivery, such that HCV RNA positivity within 3 days of delivery is suggestive of intrauterine transmission.25 In a 2005 prospective cohort study of 54 HCV-infected children, 31% tested HCV RNA–positive within the first 3 days of life, consistent with in utero transmission, whereas 50% were initially HCV RNA–negative but tested positive by 3 months, suggesting late intrauterine or peripartum infection.26 Similarly, a prospective analysis of 1749 children found that approximately 25% of infections occur early in utero, 66% occur later in utero, and 9% occur during delivery.27 Although limited, available data suggest that the peripartum period, which refers to the period immediately before, during, and after delivery, is the highest risk window for MTCT of HCV.
Maternal HCV infection during pregnancy has been found to increase the risk of adverse outcomes for both the mother and infant (Figure).22,28 A meta-analysis of 3 studies found that the odds of developing intrahepatic cholestasis of pregnancy (ICP) is 20-fold higher in pregnant women with HCV compared with those without HCV.29 Another meta-analysis of 9 studies and more than 4 million participants found that the odds of preterm birth are nearly 2-fold higher in pregnancies with HCV,22,30 consistent with other large studies demonstrating an increased risk of premature rupture of membranes and preterm birth.31,32 These findings are further confirmed by a large retrospective cohort study in Ontario, Canada using population-based administrative health care data that found an increased risk of ICP, preterm delivery, and postpartum hemorrhage among pregnant individuals who were HCV RNA–positive compared with those with resolved infection.22 Additionally, a study using data from the 2010 to 2020 National Inpatient Sample found that rates of mortality and cirrhosis were increased among women with HCV during pregnancy.33 Untreated HCV infection can also lead to liver disease progression and increased risk for hepatocellular carcinoma.34
Additionally, HCV infection during pregnancy can lead to MTCT and potential adverse neonatal outcomes, including low birth weight (LBW) and higher rates of neonatal intensive care unit (NICU) admission. A multicenter prospective cohort study found that maternal HCV infection was associated with 2-fold increased odds of NICU admission and 3-fold increased odds of small for gestational age (SGA) birth below the 5th percentile.35 The higher rates of NICU admission are thought to be partially attributable to increased incidence of SGA. A prospective study in British Columbia, Canada from 2000 to 2003 found that mothers with HCV infection had higher rates of intrauterine fetal death and LBW infants (<2500 g) compared with the general population.32 These results are consistent with a large meta-analysis consisting of 14 studies (1950-2022) that showed that maternal HCV infection was associated with increased risk of intrauterine growth restriction and LBW.31 More recently, a retrospective analysis of US Centers for Disease Control and Prevention (CDC) and the Prevention Natality Live Birth Database (2016-2021) further demonstrated increased risk of LBW, NICU admission, congenital anomalies at birth, low 5-minute Apgar scores, neonatal sepsis requiring antibiotics, and need for immediate and prolonged ventilation.36 Although further research is needed, translational studies suggest that altered placental immune activity in HCV-exposed pregnancies may contribute to these complications.37
Screening Guidance for Hepatitis C Virus Infection in Pregnancy
Expert guidelines regarding screening for HCV have evolved from risk-based screening to universal screening over the past several years. In 2012, the CDC recommended that pregnant individuals only be tested for HCV infection if they had known risk factors.38 Risk factors that would indicate screening include IVDU, HIV-positive status, tattoos or piercings, transplant or blood transfusions prior to 1992, recipient of clotting factors prior to 1987, and long-term hemodialysis.39 However, studies showed that a risk-based screening protocol was ineffective for capturing individuals who are HCV-positive. For example, a single-center retrospective analysis of pregnant individuals found that among women with known HCV risk factors, 64.1% were not tested, and 10% of women who were found to be HCV-positive had no reported risk factors.40
Between 2018 and 2023, guidelines for HCV screening in pregnancy shifted from risk-based to universal screening, beginning with a recommendation from AASLD and the Infectious Diseases Society of America (IDSA).41 Other organizations, including the US Preventive Services Task Force, CDC, American College of Obstetricians and Gynecologists (ACOG), Society for Maternal-Fetal Medicine (SMFM), WHO, and European Association for the Study of the Liver (EASL), followed suit with updated recommendations for broader screening (Table 1).2,19,41-46 Current guidelines suggest that all pregnant individuals should undergo an HCV antibody (anti-HCV) test, and those who test positive should also undergo a nucleic acid amplification test for HCV RNA.47 Ideally, this screening should occur at the first prenatal visit.48
The shift to universal screening in pregnancy creates an opportunity to identify cases of HCV infection during a time when people have high contact with the health care system. A universal screening protocol has the potential to improve outcomes for individuals with HCV, reduce pregnancy complications, and identify infants exposed to HCV.49 Additionally, a study evaluating the cost of testing for HCV with an anti-HCV and an HCV RNA test shows that universal screening of HCV during pregnancy is highly cost-effective, with an incremental cost-effectiveness ratio of less than $3000 per quality-adjusted life years gained. Even in states where the prevalence of HCV is very low, the model of universal screening remains cost-effective.50 Another model similarly found that universal screening was cost-effective and increased identification of infants exposed to HCV at birth from 44% to 92%.49
Although there has been a significant increase in the percent of women who are tested for HCV following the implementation of universal screening recommendations, screening is still falling short of universal levels.51 A recent study that evaluated screening for HCV using data from TriNetX—an electronic health data source from 68 US health care organizations—found that after the change in guidelines, screening increased from 141 to 253 per 1000 person-years. By December 2022, approximately 39% of pregnant individuals had ever been tested for HCV, compared with 90% of pregnant individuals who had ever been tested for HIV.52 Additionally, individuals with Medicaid are less likely to get tested than those with commercial insurance.51 Likewise, a 2024 study surveyed physicians who provide prenatal care in the United States and found that among 224 providers, less than half (43%) reported regular use of the ACOG HCV screening recommendation. Physicians who reported that they had general knowledge about HCV and those who reported that screening is easily implemented in their practice were more likely to complete appropriate screening.53 Further evaluating knowledge gaps among providers, insurance coverage for testing, and integrating HCV testing into the workflow of the first prenatal visit may be helpful for increasing adherence to the updated guidelines.
For children born to mothers with HCV, AASLD guidance has shifted from recommending testing at age 18 months to testing between 2 and 6 months.41 Earlier testing has been shown to improve health outcomes by facilitating timely diagnosis and follow-up.54,55 Additionally, earlier testing has the potential to decrease loss to follow-up while reducing anxiety among families who want to know their child’s HCV status. Of note, infants should not be tested before they are 2 months of age owing to the risk of false-negative results. As such, the most up-to-date CDC guidelines recommend HCV RNA testing between age 2 and 6 months. Infants with undetectable HCV RNA at or after age 2 months do not require further follow-up, whereas those with detectable HCV RNA should be referred to a specialist for evaluation and treatment.47 Direct-acting antivirals (DAAs) are currently recommended for all children age 3 years and older with HCV infection, with available options including glecaprevir/pibrentasvir (GLE/PIB; Mavyret, AbbVie), sofosbuvir/velpatasvir (SOF/VEL; Epclusa, Gilead), and ledipasvir/sofosbuvir (LDV/SOF; Harvoni, Gilead) based on their age and weight.9,47
Pregnancy is a critical opportunity to diagnose and link individuals to HCV treatment. This is largely because pregnancy often represents the primary point of contact with the health care system for many individuals, particularly for uninsured or medically underserved populations.56 As a result, prenatal care often represents the primary entry point for addressing both pregnancy-related and general health care needs.57 Screening for and identifying HCV in pregnancy allows for counseling about associated pregnancy-related complications, implementation of measures to reduce the risk of MTCT, and linkage to care.
Treatment Considerations
Guidance from various medical associations should be considered when determining treatment for HCV during pregnancy. According to joint AASLD-IDSA guidance, treatment of HCV infection with DAAs is recommended prior to pregnancy to reduce risk of transmission to the fetus.48 Those who become pregnant while taking DAAs should be counseled about the risks and benefits of continuing with treatment during pregnancy. The lack of robust safety and efficacy data for DAA use during pregnancy has posed a barrier to consensus on treatment guidelines. AASLD and IDSA advise that treatment can be considered on an individual basis through shared decision-making and discussion of the potential risks and benefits to treatment.48 Likewise, EASL suggests that, if necessary, DAAs can be considered after a thorough discussion among an interdisciplinary team.45 However, SMFM recommends that DAA therapy only be initiated in the setting of a clinical trial in pregnant individuals.19,44
Although there are no US Food and Drug Administration–approved DAAs for the treatment of HCV in pregnancy, emerging data from 2 published phase 1 clinical trials have begun to explore their safety and efficacy (Table 2). The trials studied SOF/VEL in 10 individuals and LDV/SOF in 9 individuals initiated between 23 and 25 weeks of gestation for a 12-week course. Both trials reported a 100% cure rate among participants, no transmission to infants, and no significant safety concerns.58,59 Among the 10 individuals in the SOF/VEL trial, 1 (8%) participant experienced a grade 3 adverse effect (vomiting) from the medications that led to discontinuation from the trial.58
Additionally, the STORC trial is an ongoing multicenter, phase 4 single-arm study of SOF/VEL for treatment of chronic HCV infection during pregnancy.60 Interim results of the study reveal that 100% of participants (35) had a sustained virologic response at 12 weeks (SVR12). There was no transmission to the fetus, and no significant safety concerns were identified. The most common adverse events attributable to SOF/VEL were nausea and vomiting, fatigue, headache, and gastric reflux.61 In addition, site selection was completed for the IMPAACT trial, which will be a phase 1/2 trial evaluating the pharmacokinetics and safety of GLE/PIB.62 Estimated enrollment in this trial is 30 participants at a gestational age of 14 to 32 weeks who will be followed for 12 weeks postpartum.63 Furthermore, the Treatment in Pregnancy for Hepatitis C (TiP-HepC) registry was established in 2022 to collect real-world data on mother-infant outcomes following DAA exposure during pregnancy.64 As of June 2025, there have been a total of 37 reported cases of DAA exposure during pregnancy from the United States, Canada, Australia, and Mexico (including 16 cases that were previously not described in published literature).65 Although obtaining complete data for all cases remains a limitation of the TiP-HepC registry, this platform serves as a centralized repository for safety and efficacy data that can help inform treatment decision-making.
The potential benefits and harms must be carefully weighed when considering DAA use during pregnancy. The greatest limitation is the lack of robust data on DAA use during pregnancy and breastfeeding, highlighting the need for larger studies evaluating safety and efficacy. Additionally, there is still a need for more research on the cost-effectiveness of treatment during pregnancy and achievement of timely access to treatment. Nonetheless, the potential benefits of DAA use during pregnancy should not be underestimated. Treatment can result in maternal cure of HCV, leading to reduced community transmission, perinatal transmission, and HCV-associated complications. Pregnancy may also serve as an opportunity to initiate treatment while individuals with HCV have increased engagement with the health care system and insurance coverage.66 In a retrospective cohort study of Medicaid-enrolled pregnant individuals with opioid use disorder and HCV, less than 6% of participants had any follow-up visits within 6 months of delivery.67 These results highlight loss to follow-up among women at risk for HCV and the opportunity to initiate care during the antenatal period.
Despite limited data on DAA use during pregnancy, studies show that individuals with HCV are open to treatment. In a survey of 141 women residing in the San Francisco Bay Area with a history of HCV, 60% reported that they would take antepartum DAAs if such treatment lowered the risk of perinatal transmission. However, only 21% of respondents said that they would take DAAs during pregnancy for the purpose of self-cure, and 20% reported that they would like to see more data on DAAs during pregnancy.68 These themes have also been observed in lower-income countries with a high burden of HCV. A study of women in Egypt, Pakistan, and Ukraine found that 544 (88%) would take DAAs during pregnancy, with most reporting they would do so to prevent vertical transmission.69
A qualitative analysis of patient and provider attitudes toward DAAs reported that both groups recognized pregnancy as a window of opportunity to initiate treatment given increased insurance coverage and motivation for behavioral change during this period. However, concerns about limited safety data, medication side effects, and cost of the medications were cited as barriers, underscoring the need for more robust studies on the use of DAAs in pregnancy. Obstetricians identified insufficient training, infrequent exposure to HCV in pregnancy, and lack of professional guidelines as additional barriers they face regarding treatment.70 Real-world data highlight these challenges as well. In a cohort of 23 pregnant individuals with HCV, most were interested in pursuing treatment with DAAs; however, treatment was often delayed owing to insurance approval processes, and many people were lost to follow-up. Although therapy was well tolerated, adherence remained a challenge, as 80% of individuals with HCV completed their course of DAAs, and only 58% presented at their SVR12 visit.71 These findings emphasize the potential for the use of DAAs during pregnancy while revealing the need for system-level support, such as programs to maximize compliance and improve insurance coverage.
In cases where individuals with HCV are not treated before or during pregnancy, the postpartum period represents another window of opportunity to initiate therapy. Beginning treatment in the postpartum period helps prevent risk of future HCV complications, decrease MTCT in future pregnancies, and reduce risk of further community transmission of the virus. Despite reassuring data on the safety of DAAs during breastfeeding, practice guidance from AASLD and ACOG still discourage the initiation of treatment in breastfeeding individuals.72,73 A recent study examined the pharmacokinetics of SOF/VEL in 4 breastfeeding individuals and found that the estimated infant dose of these medications was less than 1% of the weight-adjusted daily dose for children.74 These early results are encouraging and support further study of DAAs in breastfeeding individuals, as this period may be another important opportunity to initiate therapy.
Conclusion
HCV infection during pregnancy presents unique challenges in management and opportunities for intervention and establishment of care. The rising prevalence of HCV among reproductive-age women and potential
implications on perinatal outcomes highlight the importance of universal screening in pregnancy. Pregnancy and the postpartum period represent critical periods to identify infection, provide counseling, and initiate treatment, ultimately improving outcomes for individuals with HCV and contributing to population-level HCV elimination goals. Although there are currently no large-scale trials on the use of DAAs during pregnancy, early-phase clinical trials and ongoing studies show promising safety and efficacy. Future directions in this field should focus on establishing the safety and efficacy of DAAs during pregnancy and breastfeeding, as well as optimizing strategies for screening and treatment uptake.
Disclosures
Ms Slobin and Dr Aliasi-Sinai have no relevant conflicts of interest to disclose. Dr Kushner has research support from Gilead, Mirum, and Ipsen; has advisory roles to Gilead, Madrigal, Ipsen, Mirum, GSK, Vir, and Bluejay Therapeutics; and is supported by the NIH K23 HL163486 grant.
References
1. Polaris Observatory HCV Collaborators. Global change in hepatitis C virus prevalence and cascade of care between 2015 and 2020: a modelling study. Lancet Gastroenterol Hepatol. 2022;7(5):396-415.
2. Global Health Sector Strategies on, Respectively, HIV, Viral Hepatitis and Sexually Transmitted Infections for the Period 2022-2030. Geneva, Switzerland: World Health Organization; 2022.
3. Hiebert-Suwondo L, Manning J, Tohme RA, et al; National Hepatitis Elimination Profile Collaborators. A 2024 global report on national policies, programmes, and progress towards hepatitis C elimination: findings from 33 hepatitis elimination profiles. Lancet Gastroenterol Hepatol. 2025;10(7):685-700.
4. Stroffolini T, Stroffolini G. Prevalence and modes of transmission of hepatitis C virus infection: a historical worldwide review. Viruses. 2024;16(7):1115.
5. Ryerson AB, Schillie S, Barker LK, Kupronis BA, Wester C. Vital signs: newly reported acute and chronic hepatitis C cases—United States, 2009-2018. MMWR Morb Mortal Wkly Rep. 2020;69(14):399-404.
6. Suryaprasad AG, White JZ, Xu F, et al. Emerging epidemic of hepatitis C virus infections among young nonurban persons who inject drugs in the United States, 2006-2012. Clin Infect Dis. 2014;59(10):1411-1419.
7. Rossi RM, Wolfe C, Brokamp R, et al. Reported prevalence of maternal hepatitis C virus infection in the United States. Obstet Gynecol. 2020;135(2):387-395.
8. Chen PH, Johnson L, Limketkai BN, et al. Trends in the prevalence of hepatitis C infection during pregnancy and maternal-infant outcomes in the US, 1998 to 2018. JAMA Netw Open. 2023;6(7):e2324770.
9. Ghany MG, Morgan TR; AASLD-IDSA Hepatitis C Guidance Panel. Hepatitis C guidance 2019 update: American Association for the Study of Liver Diseases-Infectious Diseases Society of America recommendations for testing, managing, and treating hepatitis C virus infection. Hepatology. 2020;71(2):686-721.
10. Dugan E, Blach S, Biondi M, et al. Global prevalence of hepatitis C virus in women of childbearing age in 2019: a modelling study. Lancet Gastroenterol Hepatol. 2021;6(3):169-184.
11. Ying Z, Jing Y, Tong W, Chaoyan Y. Spatiotemporal evolution of HCV burden among women of reproductive age: a multinational age-period-cohort analysis. Virol J. 2025;22(1):265.
12. Ly KN, Jiles RB, Teshale EH, Foster MA, Pesano RL, Holmberg SD. Hepatitis C virus infection among reproductive-aged women and children in the United States, 2006 to 2014. Ann Intern Med. 2017;166(11):775-782.
13. Ely DM, Gregory ECW. Trends and characteristics in maternal hepatitis C virus infection rates during pregnancy: United States, 2016-2021. National Vital Statistics Reports. 2023;72(3):1-11. https://www.cdc.gov/nchs/data/nvsr/nvsr72/nvsr72-03.pdf. Accessed September 25, 2025.
14. Patrick SW, Dupont WD, McNeer E, et al. Association of individual and community factors with hepatitis C infections among pregnant people and newborns. JAMA Health Forum. 2021;2(10):e213470.
15. Ahrens KA, Rossen LM, Burgess AR, Palmsten KK, Ziller EC. Rural-urban residence and maternal hepatitis C infection, U.S.: 2010-2018. Am J Prev Med. 2021;60(6):820-830.
16. Van Handel MM, Rose CE, Hallisey EJ, et al. County-level vulnerability assessment for rapid dissemination of HIV or HCV infections among persons who inject drugs, United States. J Acquir Immune Defic Syndr. 2016;73(3):323-331.
17. Nwaohiri A, Schillie S, Bulterys M, Kourtis AP. Hepatitis C virus infection in children: how do we prevent it and how do we treat it? Expert Rev Anti Infect Ther. 2018;16(9):689-694.
18. Quek JWE, Loo JH, Lim EQ, et al. Global epidemiology, natural history, maternal-to-child transmission, and treatment with DAA of pregnant women with HCV: a systematic review and meta-analysis. EClinicalMedicine. 2024;74:102727.
19. Dotters-Katz SK, Kuller JA, Hughes BL; Society for Maternal-Fetal Medicine (SMFM). Society for Maternal-Fetal Medicine Consult Series #56: hepatitis C in pregnancy-updated guidelines: replaces consult number 43, November 2017. Am J Obstet Gynecol. 2021;225(3):B8-B18.
20. Prasad M, Saade GR, Clifton RG, et al; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Risk factors for perinatal transmission of hepatitis C Virus. Obstet Gynecol. 2023;142(3):449-456.
21. Mast EE, Hwang LY, Seto DSY, et al. Risk factors for perinatal transmission of hepatitis C virus (HCV) and the natural history of HCV infection acquired in infancy. J Infect Dis. 2005;192(11):1880-1889.
22. Kushner T, Djerboua M, Biondi MJ, Feld JJ, Terrault N, Flemming JA. Influence of hepatitis C viral parameters on pregnancy complications and risk of mother-to-child transmission. J Hepatol. 2022;77(5):1256-1264.
23. Cottrell EB, Chou R, Wasson N, Rahman B, Guise JM. Reducing risk for mother-to-infant transmission of hepatitis C virus: a systematic review for the U.S. Preventive Services Task Force. Ann Intern Med. 2013;158(2):109-113.
24. European Paediatric Hepatitis C Virus Network. Three broad modalities in the natural history of vertically acquired hepatitis C virus infection. Clin Infect Dis. 2005;41(1):45-51.
25. Prasad MR, Honegger JR. Hepatitis C virus in pregnancy. Am J Perinatol. 2013;30(2):149-159.
26. Mok J, Pembrey L, Tovo PA, Newell ML; European Paediatric Hepatitis C Virus Network. When does mother to child transmission of hepatitis C virus occur? Arch Dis Child Fetal Neonatal Ed. 2005;90(2):F156-F160.
27. Ades AE, Gordon F, Scott K, et al. Overall vertical transmission of hepatitis C virus, transmission net of clearance, and timing of transmission. Clin Infect Dis. 2023;76(5):905-912.
28. Goins EC, Wein LE, Watkins VY, et al. Maternal and neonatal outcomes in patients with hepatitis C and intrahepatic cholestasis of pregnancy: the sum of the parts. PLoS One. 2023;18(10):e0293030.
29. Wijarnpreecha K, Thongprayoon C, Sanguankeo A, Upala S, Ungprasert P, Cheungpasitporn W. Hepatitis C infection and intrahepatic cholestasis of pregnancy: a systematic review and meta-analysis. Clin Res Hepatol Gastroenterol. 2017;41(1):39-45.
30. Huang QT, Huang Q, Zhong M, et al. Chronic hepatitis C virus infection is associated with increased risk of preterm birth: a meta-analysis of observational studies. J Viral Hepat. 2015;22(12):1033-1042.
31. Shen GF, Ge CH, Shen W, Liu YH, Huang XY. Association between hepatitis C infection during pregnancy with maternal and neonatal outcomes: a systematic review and meta-analysis. Eur Rev Med Pharmacol Sci. 2023;27(8):3475-3488.
32. Money D, Boucoiran I, Wagner E, et al. Obstetrical and neonatal outcomes among women infected with hepatitis C and their infants. J Obstet Gynaecol Can. 2014;36(9):785-794.
33. Wasuwanich P, Rajborirug S, Egerman RS, Wen TS, Karnsakul W. Hepatitis C prevalence and birth outcomes among pregnant women in the United States: a 2010-2020 population study. Pathogens. 2024;13(4):321.
34. Fiehn F, Beisel C, Binder M. Hepatitis C virus and hepatocellular carcinoma: carcinogenesis in the era of direct-acting antivirals. Curr Opin Virol. 2024;67:101423.
35. Hughes BL, Sandoval GJ, Saade GR, et al; for the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD) Maternal-Fetal Medicine Units (MFMU) Network. Pregnancy outcomes in patients with hepatitis C virus infection. Obstet Gynecol. 2024;144(4):501-506.
36. Gulersen M, Lenchner E, Grunebaum A, Chervenak FA, Bornstein E. Risk factors and adverse outcomes associated with hepatitis C virus in pregnancy. J Perinat Med. 2025;53(7):821-826.
37. Hurtado CW, Golden-Mason L, Brocato M, Krull M, Narkewicz MR, Rosen HR. Innate immune function in placenta and cord blood of hepatitis C—seropositive mother-infant dyads. PLoS One. 2010;5(8):e12232.
38. Smith BD, Morgan RL, Beckett GA, et al; Centers for Disease Control and Prevention. Recommendations for the identification of chronic hepatitis C virus infection among persons born during 1945-1965. MMWR Recomm Rep. 2012;61(RR-4):1-32.
39. El-Kamary SS, Hashem M, Saleh DA, et al. Reliability of risk-based screening for hepatitis C virus infection among pregnant women in Egypt. J Infect. 2015;70(5):512-519.
40. Boudova S, Mark K, El-Kamary SS. Risk-based hepatitis C screening in pregnancy is less reliable than universal screening: a retrospective chart review. Open Forum Infect Dis. 2018;5(3):ofy043.
41. AASLD-IDSA HCV Guidance Panel. Hepatitis C guidance 2018 update: AASLD-IDSA recommendations for testing, managing, and treating hepatitis C virus infection. Clin Infect Dis. 2018;67(10):1477-1492.
42. Owens DK, Davidson KW, Krist AH, et al; US Preventive Services Task Force. Screening for hepatitis C virus infection in adolescents and adults: US Preventive Services Task Force Recommendation Statement. JAMA. 2020;323(10):970-975.
43. Test for hepatitis C during every pregnancy. Centers for Disease Control and Prevention. https://archive.cdc.gov/www_cdc_gov/knowmorehepatitis/hcp/Test-For-HepC-During-Pregnancy.htm. Published March 10, 2023. Accessed September 15, 2025.
44. HCV screening during pregnancy recommended by ACOG: Am Coll. of Obstetricians & Gynecologists. NATAP. https://www.natap.org/2021/HCV/051921_03.htm. Accessed September 15, 2025.
45. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of liver diseases in pregnancy. J Hepatol. 2023;79(3):768-828.
46. Call to action: now is the time to eliminate hepatitis in Asia. GlobalHep.org. https://www.globalhep.org/sites/default/files/content/page/files/2024-03/APASL%20Call%20to%20Action_2024.pdf. Published March 28, 2024. Accessed September 29, 2025.
47. Panagiotakopoulos L, Sandul AL, Conners EE, Foster MA, Nelson NP, Wester C. CDC recommendations for hepatitis C testing among perinatally exposed infants and children—United States, 2023. MMWR Recomm Rep. 2023;72(4):1-21.
48. HCV in pregnancy. HCVGuidelines.org. https://www.hcvguidelines.org/unique-populations/pregnancy. Accessed September 15, 2025.
49. Tasillo A, Eftekhari Yazdi G, Nolen S, et al. Short-term effects and long-term cost-effectiveness of universal hepatitis C testing in prenatal care. Obstet Gynecol. 2019;133(2):289-300.
50. Chaillon A, Rand EB, Reau N, Martin NK. Cost-effectiveness of universal hepatitis C virus screening of pregnant women in the United States. Clin Infect Dis. 2019;69(11):1888-1895.
51. Kaufman HW, Osinubi A, Meyer WA III, et al. Hepatitis C virus testing during pregnancy after universal screening recommendations. Obstet Gynecol. 2022;140(1):99-101.
52. Singh RP, Biondi B, Gordon SH, Linas BP, Epstein RL. Hepatitis C virus screening in pregnant and nonpregnant women after universal screening guidelines. JAMA. 2025;333(15):1356-1358.
53. Moore JD, Nguyen UDT, Ojha RP, Griner SB, Thompson EL. Physician-level determinants of HCV screening during pregnancy in a U.S. sample. Arch Gynecol Obstet. 2024;309(6):2491-2498.
54. Hall EW, Panagiotakopoulos L, Wester C, Nelson N, Sandul AL. Cost-effectiveness of strategies to identify children with perinatally acquired hepatitis C infection. J Pediatr. 2023;258:113409.
55. Kuncio DE, Waterman EJ, Robison SZG, Roberts A. Factors associated with perinatal hepatitis C screening among exposed children: 2016-2020. Pediatrics. 2024;154(1):e2023064745.
56. Kushner T, Chappell CA, Kim AY. Testing for hepatitis C in pregnancy: the time has come for routine rather than risk-based. Curr Hepatol Rep. 2019;18(2):206-215.
57. Ehrenreich K, Kimport K. Prenatal care as a gateway to other health care: a qualitative study. Womens Health Issues. 2022;32(6):602-606.
58. Chappell CA, Kiser JJ, Brooks KM, et al. Sofosbuvir/velpatasvir pharmacokinetics, safety, and efficacy in pregnant people with hepatitis C virus. Clin Infect Dis. 2025;80(4):744-751.
59. Chappell CA, Scarsi KK, Kirby BJ, et al. Ledipasvir plus sofosbuvir in pregnant women with hepatitis C virus infection: a phase 1 pharmacokinetic study. Lancet Microbe. 2020;1(5):e200-e208.
60. ClinicalTrials.gov. Sofosbuvir/velpatasvir treatment of chronic hepatitis C during pregnancy (STORC). https://clinicaltrials.gov/study/NCT05140941. Identifier: NCT05140941. Accessed August 25, 2025.
61. Chappell CA. Safety, tolerability, and outcomes of sofosbuvir/velpatasvir in treatment of chronic hepatitis C virus during pregnancy: interim results from the STORC study. Conference Reports for NATAP. AASLD 2024 The Liver Meeting; November 15-19, 2024; San Diego, CA. https://www.natap.org/2024/AASLD/AASLD_14.htm. Accessed August 25, 2025.
62. IMPAACT Study Group. Phase I/II study of the pharmacokinetics and safety of glecaprevir/pibrentasvir initiated in pregnancy in women with hepatitis C with and without HIV. IMPAACT Network. https://www.impaactnetwork.org/studies/impaact2041. Accessed September 15, 2025.
63. ClinicalTrials.gov. Study of the pharmacokinetics and safety of glecaprevir/pibrentasvir initiated in pregnancy in women with hepatitis C with and without HIV. https://clinicaltrials.gov/study/NCT07040319. Identifier: NCT07040319. Accessed September 18, 2025.
64. Treatment in pregnancy for hepatitis C. GlobalHep.org. https://www.globalhep.org/projects-research/treatment-pregnancy-hepatitis-c. Published September 9, 2025. Accessed September 25, 2025.
65. Coalition for Global Hepatitis Elimination. Hepatitis C Treatment Exposure In Pregnancy Registry (TiP-HepC Registry). Evidence brief no. 4. Interim update: June 2025. GlobalHep.org. https://www.globalhep.org/sites/default/files/content/page/files/2025-09/TiP-HepC%20Registry%20Evidence%20Brief%20No.%204.pdf. Accessed September 25, 2025.
66. Kushner T, Reau N. Changing epidemiology, implications, and recommendations for hepatitis C in women of childbearing age and during pregnancy. J Hepatol. 2021;74(3):734-741.
67. Jarlenski M, Chen Q, Ahrens KA, et al; Medicaid Outcomes Distributed Research Network (MODRN). Postpartum follow-up care for pregnant persons with opioid use disorder and hepatitis C virus infection. Obstet Gynecol. 2022;139(5):916-918.
68. Kushner T, Cohen J, Tien PC, Terrault NA. Evaluating women’s preferences for hepatitis C treatment during pregnancy. Hepatol Commun. 2018;2(11):1306-1310.
69. Scott K, Chappell E, Mostafa A, et al. Acceptability of hepatitis C screening and treatment during pregnancy in pregnant women in Egypt, Pakistan, and Ukraine: a cross-sectional survey. Clin Liver Dis (Hoboken). 2024;23(1):e0140.
70. Yee LM, Shah SK, Grobman WA, Labellarte PZ, Barrera L, Jhaveri R. Identifying barriers and facilitators of the inclusion of pregnant individuals in hepatitis C treatment programs in the United States. PLoS One. 2022;17(11):e0277987.
71. Kushner T, Lange M, Sperling R, Dieterich D. Treatment of women with hepatitis C diagnosed in pregnancy: a co-located treatment approach. Gastroenterology. 2022;163(5):1454-1456.e1.
72. Viral hepatitis in pregnancy: ACOG Clinical Practice Guideline No. 6. Obstet Gynecol. 2023;142(3):745-759.
73. Sarkar M, Brady CW, Fleckenstein J, et al. Reproductive health and liver disease: practice guidance by the American Association for the Study of Liver Diseases. Hepatology. 2021;73(1):318-365.
74. Chappell CA, Brooks KM, Kiser JJ, et al. Sofosbuvir/velpatasvir concentrations in the breastmilk of postpartum women with opioid use disorder receiving treatment for hepatitis C virus: a pharmacokinetic study [published online August 7, 2025]. Clin Infect Dis. doi:10.1093/cid/ciaf443.