What is the main indication for initiating treatment in a patient with HCV?

Initiating treatment for a patient with Hepatitis C virus (HCV) infection primarily depends on the presence of active liver disease, which is indicated by elevated alanine aminotransferase (ALT) levels and detectable HCV RNA. Elevated ALT levels suggest ongoing liver inflammation and damage, while detectable HCV RNA confirms active viral replication. Together, these factors indicate that the infection is active and could lead to progressive liver disease, making it imperative to start antiviral therapy to mitigate the risk of complications such as cirrhosis or hepatocellular carcinoma.

While other factors, like a positive HIV test or a history of intravenous drug use, may influence the management of the patient and their risk of liver disease progression, they do not serve as direct indications for starting treatment for HCV. The presence of jaundice signifies liver dysfunction, but it is more of a consequence of disease progression rather than a primary indication for initiating treatment. Instead, the focus should be on laboratory markers of active disease, specifically the elevated ALT levels and detectable HCV RNA, to guide the decision to begin antiviral therapy.