Hepatitis C (HCV)

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What Is Hepatitis?

Hepatitis is an inflammation, or swelling, of the liver. Alcohol, drugs (including street drugs, over-the-counter medications, and prescription medications), poisons, and several viruses can all cause hepatitis. Viral hepatitis is the term used for any inflammation of the liver caused by a virus.

Signs of hepatitis include:

  • Jaundice (yellowing of the skin, eyes, and lining of the mouth)
  • Dark-colored urine
  • Stool that appears pale and clay-like
  • Fatigue (extreme tiredness)
  • Loss of appetite
  • General aching
  • Nausea
  • Diarrhea

What Is Hepatitis C?

Hepatitis C is a liver disease caused by the hepatitis C virus (HCV). The US Centers for Disease Control and Prevention (CDC) estimates that there are over three million Americans living with chronic (long-lasting) HCV. The World Health Organization estimates that 150 million people are chronically infected with HCV worldwide, and that three to four million more are infected each year. HCV is particularly common in North Africa, Central Asia, and East Asia.

Approximately half of HIV-negative people clear HCV from their bodies without medical treatment within the first six months of becoming infected. For those living with HIV (HIV+), about one in five people will get rid of the virus without treatment. The majority of people do not clear HCV and go on to develop chronic infection.

Chronic HCV may not cause any symptoms for ten years or more. However, even without symptoms, it can cause serious liver damage leading to cirrhosis (scarring of the liver), liver failure, and death. In fact, HCV is one of the most common causes of liver disease and viral hepatitis is the number one reason for liver transplants in America.

How Is HCV Spread?

HCV is spread in the following ways:

  • Sharing injection needles or 'works'
  • Sharing equipment used to snort or smoke drugs (e.g., bills, straws, pipes)
  • Sharing needles or inkwells that are used to apply tattoos
  • Receiving a transfusion of blood, blood products, or organs before 1992 in the US; in some countries, HCV can still be spread through unscreened blood or blood products
  • Having unprotected sex with someone who has HCV
  • Passing the virus from an infected pregnant woman to her baby (less common)
  • Sharing personal care items that may come in contact with another person's blood, such as razors or toothbrushes (less common)

It is important to note that you can not get hepatitis C from casual contact with someone (e.g., hugging, kissing, sharing food and drink). HCV is also not spread through breast milk.

Prevention of HCV

Unfortunately there is still no vaccine to prevent you from being infected with HCV. However, there are vaccines for two other types of hepatitis: A and B. It is strongly recommended that people with HCV get hepatitis A and B vaccinations as early as possible. See The Well Project's articles on hepatitis A and hepatitis B for more information.

HCV is not commonly passed from a pregnant woman to her baby. Mother-to-child transmission (MTCT) occurs in about five out of every hundred cases. Studies have found that the risk for MTCT of HCV is three to four times higher in women living with HIV. There is currently no known treatment that will prevent the transmission of HCV from mother to child.

The best way to prevent HCV infection is to avoid being exposed to blood that is infected with HCV. Do not share equipment to use drugs and make sure tattoo artists use sterile needles and inkwells. Practicing safer sex is also a good idea; you can find tips to protect yourself in The Well Project's Safer Sex article.

Testing for HCV

Most people who are infected with HCV do not know it because they have no symptoms. Early signs of HCV can seem like the flu and often go unnoticed. The only way to know for sure if you have HCV is to get a blood test for it. Testing for HCV is usually recommended based on a person’s risk of infection or exposure to ways in which HCV is spread (see list above).

In addition, the CDC recently recommended that everyone in the US born during 1945 through 1965 (the "baby boomers") get a one-time blood test for HCV. This new recommendation has been released for a number of reasons, including improvements in treatment for hepatitis C and high rates of HCV infection among baby boomers. The Canadian Liver Foundation has made similar recommendations for testing all adults born between 1945 and 1975.

Tests for HCV include:

  • HCV antibody and nucleic acid tests

If you have HIV, it is important that you be tested for HCV. The standard HCV test is one that looks for antibodies to HCV in your blood. If your HCV antibody test is positive, your body has been infected with HCV at some point in time. However, this antibody test can not tell whether you were infected in the past and got rid of the virus, or if you are currently infected.

If your HCV antibody test is positive, you may also get a test for HCV RNA (the actual genetic material of the hepatitis C virus) called a nucleic acid test (NAT). If your NAT is positive, you are most likely currently infected with HCV. If your NAT is negative (no HCV RNA in your blood), then you were infected in the past and are not now currently infected.

If your HCV antibody test is positive, your provider may get an HCV viral load. The HCV viral load cannot tell if or when someone with HCV will develop liver damage. However, the HCV viral load can help predict how well someone will respond to HCV treatment. Generally, the lower the HCV viral load, the better the chances that treatment will work well.

  • Liver enzyme (or liver function) tests

Liver enzyme tests are blood tests that look at levels of liver enzymes. Because levels of liver enzymes can tell us how well the liver is working, liver enzyme tests are often referred to as liver function tests. Liver enzyme tests measure several things that the liver produces, including ALT, AST, bilirubin, albumin, and some indicators of your blood's ability to clot. Elevated liver enzymes may indicate liver damage. However, some people with HCV have normal liver enzymes, even in very advanced disease.

  • Genotype tests

Worldwide, there are six different types of HCV called genotypes. These genotypes differ in their regional distribution and can predict how well treatment will work. Genotype 1 is the most common globally (six out of every ten infections) and is also the most common in the US. Genotypes 2 and 3 are less common in the US. Genotype 3 is very common in Southeast Asia, while genotype 4 is found mostly in the Middle East and central Africa. Genotype 5 is located almost entirely in South Africa, and genotype 6 is found in Asia.

Because different genotypes of HCV respond differently to different treatments, it is important to have a genotype test before you begin treatment. This will help you and your health care provider make decisions about which treatments to use and how long to use them.

  • Liver biopsy

A liver biopsy (inserting a needle through the skin and into the liver to obtain a small sample that is examined under a microscope) is the most reliable way to determine how much damage has been done to your liver. It can also help you and your health care provider figure out when to start HCV treatment.

  •  FibroSURE™ (or FibroTest) 

FibroSURE™ is a blood test that looks at six markers of liver activity to measure liver damage. It is often used as a non-invasive alternative to liver biopsy. This test is good at identifying either no liver damage or advanced liver damage. However, if the damage is somewhere between none and advanced, it does not give very helpful information. A liver biopsy gives more detailed information about all levels of liver damage.

  • FibroScan™

FibroScan is a relatively new non-invasive test that is currently approved for use in 70 countries. In April of 2013, the US Food and Drug Administration (FDA) approved its use in the US. It is similar to an ultrasound, and is done in the office or clinic by your provider. The scan uses a dull probe that is pressed against the skin over the liver. FibroScan is used to measure liver damage and determine the amount of liver cirrhosis. Because the sound waves it uses to measure liver damage must pass through body fat, it is not a good test for those who are obese, since its results are likely to be unreliable.

Women and Hepatitis C

Women who are infected with HCV are different from HCV-infected men in a few important ways. First, the good news: women are more likely to clear HCV than men are. This means that when women become infected with HCV, their bodies are more successful at fighting it off. Women who develop chronic HCV infections are also more likely to get rid of HCV with treatment. Lastly, liver disease tends to progress more slowly in pre-menopausal women than in men.

However, women with HCV face a few extra challenges compared with HCV-infected men. First, women's livers are more sensitive to alcohol and are therefore more likely to be damaged by it in smaller amounts. The amount of alcohol women without HCV can drink without damaging their livers is smaller than men's. For women living with HCV, it is best to avoid alcohol altogether. For HCV-positive women who do drink, however, it is recommended that they not have more than one drink per day.

Secondly, women tend to be more likely to experience side effects when taking the drugs that have been the standard backbone of treatment of hepatitis C – pegylated interferon and ribavirin. Specifically, depression and anemia are more common in women taking these drugs than in men. The good news is that several new HCV drugs in the development process now provide more effective treatment without having to take either interferon or ribavirin and so provide alternatives without these side effects.

It is also important for women to know that excess body weight can lead to fat in the liver. Fat in the liver increases inflammation and liver damage, and increases the risk of cirrhosis (scarring of the liver) in women living with HCV. Being overweight and having fat in the liver also lowers the chance of being able to get rid of HCV with treatment.

HIV and HCV Co-Infection

Because both HIV and HCV can be spread by contact with infected blood, many people are infected with both viruses. This is called co-infection. It is estimated that 12 million people worldwide are co-infected with HIV and HCV - that's about one in three HIV+ people living with HCV. In the US, about one in four people living with HIV are co-infected with HCV. Co-infection is even more common among HIV+ injection drug users, of whom about eight out of ten also have HCV.

HCV can progress more rapidly and lead to serious liver damage more often in people living with HIV. According to the CDC, having HIV more than triples the risk of liver disease, liver failure, and liver-related death due to HCV. Pregnant women with HCV who are also living with HIV are two to seven times more likely to pass HCV on to their babies than HIV-negative women. Co-infection with HCV may also make HIV treatment more challenging.

For these reasons, it is important for people living with HIV to know whether they have HCV. The CDC recommends that all people living with HIV be screened for both hepatitis B and hepatitis C. Some experts recommend that HIV+ people at risk for HCV be screened every year.

Treatment of HCV/HIV Co-Infection

Treatment of HIV/HCV co-infection is complicated. It is important to have a health care provider who is familiar with HIV and HCV to get the best treatment for both diseases. The good news is that HCV can be treated successfully, even in people living with HIV, and that there are several new and effective HCV drugs.

Recent research shows that waiting to treat HCV until a person has serious liver disease decreases the effectiveness of treatment and leads to poor health outcomes and higher likelihood of death. Moreover, we now know that HIV+ people are more likely to develop HCV-related liver damage and develop it faster than HIV-negative people. At CROI 2015, researchers showed that those people living with HIV and HCV who delay HCV treatment remain at risk for scarring of the liver (cirrhosis), liver cancer, and liver-related death, even after being cured of HCV. They also showed that the longer HCV treatment was put off, the worse the outcome.

In the past, when HCV treatment was based on taking interferon, experts often advised waiting, since treatment involved a long course of poorly-tolerated medication that often did not produce a cure. Now, however, there are several interferon-free treatment regimens with much higher success rates, even for people co-infected with HIV and HCV. These regimens are often referred to as DAAs, or direct-acting antiviral agents. 

For more information about HCV treatment, see The Well Project's article Treatment of Hepatitis C.

Taking Care of Yourself

Because there is no vaccine for HCV, the best way to avoid getting it is to understand how it is spread and protect yourself through safer sex and using clean needles when injecting. You can also keep your liver healthy by:

See The Well Project's article Caring for Your Liver for more information.

Additional Resources

Select the links below for additional material related to hepatitis C.

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