What is the best treatment for Hepatitis C?

What is the best treatment for Hepatitis C?/Hepatitis C is a liver infection caused by the Hepatitis C virus (HCV). Hepatitis C is a blood-borne virus. Today, most people become infected with the Hepatitis C virus by sharing needles or other equipment to inject drugs. For some people, hepatitis C is a short-term illness but for 70%–85% of people who become infected with Hepatitis C, it becomes a long-term, chronic infection. Chronic Hepatitis C is a serious disease that can result in long-term health problems, even death. The majority of infected persons might not be aware of their infection because they are not clinically ill. There is no vaccine for Hepatitis C. The best way to prevent Hepatitis C is by avoiding behaviors that can spread the disease, especially injecting drugs.

Hepatitis C is a viral infection that causes liver inflammation and damage. Inflammation is swelling that occurs when tissues of the body become injured or infected. Inflammation can damage organs.

Types of Hepatitis C

  • Acute hepatitis C – Acute hepatitis C is a short-term infection. Symptoms can last up to 6 months. Sometimes your body is able to fight off the infection and the virus goes away.
  • Chronic hepatitis C – Chronic hepatitis C is a long-lasting infection. Chronic hepatitis C occurs when your body isn’t able to fight off the virus. About 75 to 85 percent of people with acute hepatitis C will develop chronic hepatitis C.

Pathophysiology

The Hepatitis C RNA virus enters the hepatocyte via endocytosis mediated by at least four co-receptor molecules. Following internalization in the cytoplasm, its positive-stranded RNA is uncoated and translated into ten mature peptides. These are then cleaved by both host proteases and virally encoded proteases known as NS3-4a serine proteases. These mature peptides then go on to reside in the endoplasmic reticulum, forming a replication complex that contains an important enzyme, the NS5B RNA dependent RNA polymerase. This enzyme catalyzes the positive RNA strand into its negative-strand intermediate which in turn serves as the template for new positive-strand synthesis. These are then packaged with core and envelop glycoprotein into mature virions which then exit the cell via exocytosis. HCV has no ability to integrate into the host’s genome. The virus can be detected in plasma within days of exposure, often 1 to 4 weeks. Viremia peaks in the first 8 to 12 weeks of infection, and then plateaus or drops to undetectable levels (viral clearance); in the majority, 50% to 85% it persists. Persistent infection appears to be due to weak CD4+ and CD8+ T-cell responses which fail to control viral replication. When the chronic infection is established, HCV does not appear to be cytopathic; it is the local inflammatory response that triggers fibrogenesis. Multiple external factors including alcohol consumption, HIV/HBV coinfections, Genotype 3 infection, insulin resistance, obesity, and non-alcoholic fatty liver disease are linked to accelerated fibrosis progression and cirrhosis. The severity of liver fibrosis is tightly correlated with the increased risk of hepatocellular carcinoma via facilitating genetic aberrations and promoting neoplastic clones.

Stages of Hepatitis C

The hepatitis C virus affects people in different ways and has several stages:

  • Incubation period – This is the time between first exposure to the start of the disease. It can last anywhere from 14 to 80 days, but the average is 45
  • Acute hepatitis C – This is a short-term illness that lasts for the first 6 months after the virus enters your body. After that, some people who have it will get rid of, or clear, the virus on their own.
  • Chronic hepatitis C – If your body doesn’t clear the virus on its own after 6 months, it becomes a long-term infection. This can lead to serious health problems like liver cancer or cirrhosis.
  • Cirrhosis – This disease leads to inflammation that, over time, replaces your healthy liver cells with scar tissue. It usually takes about 20 to 30 years for this to happen, though it can be faster if you drink alcohol or have HIV.
  • Liver cancer – Cirrhosis makes liver cancer more likely. Your doctor will make sure you get regular screenings because there are usually no symptoms in the early stages.

Causes and Transmission of Hepatitis C

The main ways you can become infected with the hepatitis C virus are described below.

Injecting drugs

  • People who inject drugs, including illegal recreational drugs and performance-enhancing drugs such as anabolic steroids, are at the highest risk of becoming infected with hepatitis C. Almost 90% of hepatitis C cases in the UK occur in people who inject drugs or have injected them in the past. It’s estimated around half of the people in the UK who inject drugs have the infection. The infection can be spread by sharing needles and associated equipment. Injecting yourself with just one contaminated needle may be enough to become infected.
  • It’s also possible to get the infection by sharing other equipment used to prepare or take drugs – such as spoons, filters, pipes, and straws – that have been contaminated with infected blood.

Less common causes

  • Unprotected sex – Hepatitis C may be transmitted during sex without using a condom (unprotected sex), although this risk is considered very low. The risk of transmission through sex may be higher among men who have sex with men. The risk is also increased if there are genital sores or ulcers from a sexually transmitted infection, or if either person also has HIV.
  • The best way to prevent transmission of hepatitis C through sex is to use a male condom or female condom. However, as the risk is very low for couples in a long-term relationship, many choose not to use a condom. If your partner has hepatitis C, you should be tested for the condition.

Blood transfusions and treatment abroad

  • If you have a blood transfusion or medical or dental treatment overseas where medical equipment is not sterilized properly, you may become infected with hepatitis C. The virus can survive in traces of blood left on equipment.

Sharing toothbrushes, scissors, and razors

  • There’s a potential risk that hepatitis C may be passed on through sharing items such as toothbrushes, razors and scissors, as they can become contaminated with infected blood.
  • Equipment used by hairdressers, such as scissors and clippers, can pose a risk if it has been contaminated with infected blood and not sterilized or cleaned between customers. However, most salons operate to high standards, so this risk is low.

Tattooing and body piercing

  • There is a risk that hepatitis C may be passed on by using tattooing or body piercing equipment that has not been properly sterilized. However, most tattoo and body piercing parlors in the UK operate to high standards and are regulated by law, so this risk is low.

Mother to child

  • There is a small chance that a mother who is infected with the hepatitis C virus will pass the infection on to her baby. This happens in around 5% of cases. It’s not thought that the virus can be passed on by a mother to her baby in her breast milk.

Needlestick injury

  • There’s a small – approximately 1 in 30 – the risk of getting hepatitis C if your skin is accidentally punctured by a needle used by someone with hepatitis C.
  • Healthcare workers, nurses and laboratory technicians are at increased risk because they are in regular close contact with blood and bodily fluids that may contain blood.
  • Getting an accidental stick with a needle that was used on an infected person
  • Being tattooed or pierced with tools or inks that were not kept sterile—free from all viruses and other microorganisms—and were used on an infected person before they were used on you
  • Having contact with the blood or open sores of an infected person
  • Using an infected person’s razor, toothbrush, or nail clippers
  • Being born to a mother with hepatitis C
  • Having unprotected sex with an infected person

You can’t get hepatitis C from

  • Being coughed or sneezed on by an infected person
  • Drinking water or eating food
  • Hugging an infected person
  • Shaking hands or holding hands with an infected person
  • Sharing spoons, forks, and other eating utensils
  • Sitting next to an infected person

Although infrequent, HCV can also be spread through

  • Sex with an HCV-infected person (an inefficient means of transmission, although HIV-infected men who have sex with men [MSM] have increased risk of sexual transmission)
  • Sharing personal items contaminated with infectious blood, such as razors or toothbrushes (also inefficient vectors of transmission)
  • Other health care procedures that involve invasive procedures, such as injections (usually recognized in the context of outbreaks)
  • Unregulated tattooing

Hepatitis C can be transmitted from an organ donor to an organ recipient. Donors of organs are tested for hepatitis C.

  • If the donor who provides the organ is infected with hepatitis C, it is offered to a recipient who also is infected with hepatitis C.
  • For kidney transplant recipients, however, this does not seem to affect long-term outcomes after transplantation.
  • For liver transplant recipients who have hepatitis C and receive an organ from a person who is not infected with hepatitis C, the transplanted organ is expected to become infected within a few weeks. Fortunately, newer medications are allowing successful treatment of hepatitis C after transplants, and this area of medicine continues to evolve.

Hepatitis C cannot be transmitted by

  • Kissing
  • Sharing food, cups or cutlery
  • Shaking hands or day-to-day physical contact


Symptoms of Hepatitis C

Symptoms of acute HCV infection

The incubation period for hepatitis C ranges from 2 weeks to 6 months. Following initial infection, approximately 80% of people do not exhibit any symptoms.

Symptoms of Advanced Hepatitis C

You could notice acute symptoms along with:

  • Fluid buildup in the abdominal cavity (ascites) or the legs (edema)
  • Gallstones
  • Your brain doesn’t work as well (encephalopathy)
  • Kidney failure
  • Easy bleeding and bruising
  • Intense itching
  • Muscle loss
  • Problems with memory and concentration
  • Spider-like veins in the skin
  • Vomiting blood due to bleeding in the lower esophagus (esophageal varices)
  • Weight loss
  • Liver cirrhosis may lead to portal hypertension, ascites (accumulation of fluid in the abdomen), easy bruising or bleeding, varices (enlarged veins, especially in the stomach and esophagus), jaundice, and a syndrome of cognitive impairment known as hepatic encephalopathy.[rx] Ascites occurs at some stage in more than half of those who have a chronic infection.[rx]
  • Approximately 20%–30% of those newly infected with HCV experience fatigue, abdominal pain, poor appetite, or jaundice [rx].

Diagnosis of Hepatitis C

CDC recommends HCV testing for

  • Current or former injection drug users, including those who injected only once many years ago
  • Everyone born from 1945 through 1965 [rx]
  • Recipients of clotting factor concentrates made before 1987 when less advanced methods for manufacturing those products were used
  • Recipients of blood transfusions or solid organ transplants prior to July 1992, before better testing of blood donations, became available
  • Chronic hemodialysis patients
  • People with known exposures to HCV, such as health care workers after needlesticks involving HCV-positive blood recipients of blood or organs from a donor who tested HCV-positive
  • People with HIV infection
  • Children born to HCV-positive mothers

U.S. Preventive Services Task Force (USPSTF) also recommends HCV testing external icon for

  • Incarcerated persons
  • People who use intranasal drugs,
  • People who get an unregulated tattoo

Several blood tests are performed to test for HCV infection, including

  • Magnetic resonance elastography (MRE) – A noninvasive alternative to a liver biopsy (see below), MRE combines magnetic resonance imaging technology with patterns formed by sound waves bouncing off the liver to create a visual map showing gradients of stiffness throughout the liver. Stiff liver tissue indicates the presence of scarring of the liver (fibrosis) as a result of chronic hepatitis C.
  • Transient elastography – Another noninvasive test, transient elastography is a type of ultrasound that transmits vibrations into the liver and measures the speed of their dispersal through liver tissue to estimate its stiffness.
  • Liver biopsy – Typically done using ultrasound guidance, this test involves inserting a thin needle through the abdominal wall to remove a small sample of liver tissue for laboratory testing.
  • Blood tests – A series of blood tests can indicate the extent of fibrosis in your liver.
  • Transient elastography – A member of the care team performs transient elastography — a painless alternative to liver biopsy — to assess liver damage.
  • The hepatitis C PCR test – is recommended for anyone who has positive hepatitis C antibodies unless they have recently completed hepatitis C treatment. If you have had treatment, antibodies will persist whether you have cleared the hepatitis C virus or not.

Screening Tests

Anti–HCV antibody testing followed by polymerase chain reaction testing for viremia is accurate for identifying patients with chronic HCV infection. Various noninvasive tests with good diagnostic accuracy are possible alternatives to liver biopsy for diagnosing fibrosis or cirrhosis.

  • Screening tests for antibody to HCV (anti-HCV) and enzyme immunoassay (EIA), enhanced chemiluminescence immunoassay (CIA)
  • Qualitative tests to detect the presence or absence of virus (HCV RNA polymerase chain reaction [PCR])
  • Quantitative tests to detect amount (titer) of virus (HCV RNA PCR)

Biopsy – Liver biopsies are used to determine the degree of liver damage present; however, there are risks from the procedure.[rx] The typical changes seen are lymphocytes within the parenchyma, lymphoid follicles in portal triad, and changes to the bile ducts.[rx] There are a number of blood tests available that try to determine the degree of hepatic fibrosis and alleviate the need for biopsy.[rx]

Genotype test – Your doctor can use this test to find out what strain, or form, of hepatitis C virus you have. At least six specific strains—called genotypes—of hepatitis C exist. Genotype 1 is the most common hepatitis C genotype in the United States.1 Your doctor will recommend treatment based on which hepatitis C genotype you have.

HCV RNA – It measures the number of viral RNA (genetic material from the hepatitis virus) particles in your blood. They usually show up 1-2 weeks after you’re infected. The results can be:

  • Negative: You don’t have hep C.
  • Positive: You currently have hep C.

Liver function tests – They measure proteins and enzyme levels, which usually rise 7 to 8 weeks after you’re infected. As your liver gets damaged, enzymes leak into your bloodstream. But you can have normal enzyme levels and still have hepatitis C.

Anti-HCV antibodies – These are proteins your body makes when it finds the hep C virus in your blood. They usually show up about 12 weeks after infection. It usually takes a few days to a week to get results, though a rapid test is available in some places. The results can be

  • Nonreactive, or negative
      • That may mean you don’t have hep C.
      • If you’ve been exposed in the last 6 months, you’ll need to be retested.
  • Reactive, or positive
      • That means you have hep C antibodies and you’ve been infected at some point.
      • You’ll need another test to make sure.


Treatment of Hepatitis C

  • Get plenty of rest
  • Maintain a cool, well-ventilated environment, wear loose clothing, and avoid hot baths or showers if itching is a problem
  • Those with chronic hepatitis C – are advised to avoid alcohol and medications toxic to the liver.[rx] They should also be vaccinated against hepatitis A and hepatitis B due to the increased risk if also infected.[rx]
  • The use of acetaminophen – is generally considered safe at reduced doses.[rx]
  • Nonsteroidal anti-inflammatory drugs (NSAIDs) – are not recommended in those with advanced liver disease due to an increased risk of bleeding.[rx] Take over-the-counter painkillers, such as paracetamol or ibuprofen, for tummy pain. 
  • Ultrasound surveillance for hepatocellular carcinoma – is recommended in those with accompanying cirrhosis.[rx] Coffee consumption has been associated with a slower rate of liver scarring in those infected with HCV.[rx]

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Genotype 1 Approved Regimens: Treatment-Naïve and Noncirrhotic Patients

Medications Dosing Duration Contraindications or Warnings
Sofosbuvir/ledipasvir* 400/90 mg once daily 12 weeks Sofosbuvir: Avoid use with amiodarone, rosuvastatin, known CYP 450 inducers; ledipasvir levels may be altered by agents that suppress gastric acid.
Sofosbuvir/simeprevir 400/150 mg once daily 12 weeks Simeprevir: Screen patients for Q80K mutation in GT 1a; possible increase in bilirubin levels; increased risk of rash or photosensitivity in East Asian patients.
Sofosbuvir/daclatasvir 400/60 mg once daily 12 weeks Avoid use with strong CYP3A4-inducing or -inhibiting agents.
Sofosbuvir/velpatasvir* 400/100 mg once daily 12 weeks Avoid use with strong CYP3A4-inducing or -inhibiting agents; medications that increase gastric pH may lower concentrations of velpatasvir.
Elbasvir/grazoprevir* 50/100 mg once daily 12 weeks Avoid use in the presence of CTP stage B or C, inhibitors of organic anion transporting polypeptide, strong CYP3A4 inducers.
Paritaprevir/ritonavir/ombitasvir/dasabuvir, plus ribavirin 150/100/25/250 mg, plus weight-based ribavirin 12 weeks Avoid use in strong CYP3A4- or CYP2C8-inducing or inhibiting agents; avoid use in the presence of CTP stage B or C; monitor closely for elevations in ALT and discontinue if > 10 times ULN; many potential drug–drug interactions secondary to ritonavir component.
*Indicates single-tablet combinations

Guide for HCV Infection Management in Both Initial Treatment and Treatment-Experienced Failures

Genotype Available Regimens
Sofosbuvir/velpatasvir: 12 weeks of treatment

  • For decompensated cirrhosis, add ribavirin

  • For decompensated cirrhosis and for sofosbuvir or NS5A failure, add ribavirin: 24 weeks treatment
Elbasvir/grazoprevir: 12 weeks of treatment

  • In genotype 1a, check RAVs to NS5A; if positive: 16 weeks treatment

  • For NS3/protease inhibitor+pegylated interferon/ribavirin-experienced patients, add ribavirin; if +RAVs to NS5A: 16 weeks treatment

  • Not for post-liver transplant or decompensated cirrhosis
Sofosbuvir/ledipasvir: 12 weeks of treatment

  • Naive, noncirrhotic, non–African American, and <106 copies: 8 weeks treatment

  • For decompensated cirrhosis, NS3A/protease inhibitor+pegylated interferon/ribavirin-experienced with cirrhosis, or a post-liver transplant, add ribavirin

  • If sofosbuvir/ribavirin-experienced, add ribavirin: 12 weeks treatment; if cirrhotic,b add ribavirin: 24 weeks treatment
Paritaprevir/ritonavir/ombitasvir+dasabuvir: 12 weeks of treatment

  • If genotype 1a or 1, add ribavirin

  • If cirrhotic, caution (per FDA) genotype 1b: 12 weeks treatment; genotype 1a or 1, add ribavirin: 24 weeks treatment
Sofosbuvir/simeprevir: 12 weeks of treatment

  • If NS5A-experienced, avoid in genotype 1a if +NS3 Q80K
Sofosbuvir/daclatasvir: 12 weeks of treatment

  • If cirrhotic or NS3/protease inhibitor+pegylated interferon/ribavirin-experienced, ± ribavirin: 24 weeks treatment

  • For decompensated cirrhosis, add ribavirin
Sofosbuvir/velpatasvir: 12 weeks of treatment

  • For decompensated cirrhosis, add ribavirin
Sofosbuvir/daclatasvir: 12 weeks of treatment

  • If cirrhotic, 16-24 weeks treatment

  • For decompensated cirrhosis, add ribavirin: 12 weeks treatment

  • If sofosbuvir/ribavirin-experienced, ± ribavirin: 24 weeks treatment
Sofosbuvir/velpatasvir: 12 weeks of treatment

  • For decompensated cirrhosis, pegylated interferon/ribavirin-experienced, or sofosbuvir/ribavirin-experienced, add ribavirin
Sofosbuvir/elbasvir/grazoprevir: 12 weeks of treatment

  • If cirrhotic and/or treatment-experienced, ± ribavirin: 12 weeks treatment
Sofosbuvir/daclatasvir: 12 weeks of treatment

  • If cirrhotic ± ribavirin: 24 weeks treatment

  • If sofosbuvir/ribavirin-experienced, add ribavirin: 24 weeks treatment

  • For decompensated cirrhosis, add ribavirin: 12 weeks treatment
Sofosbuvir/velpatasvir: 12 weeks of treatment

  • For decompensated cirrhosis, add ribavirin

  • If sofosbuvir/NS5A-experienced, add ribavirin: 24 weeks treatment
Sofosbuvir/ledipasvir: 12 weeks of treatment

  • For decompensated cirrhosis, add ribavirin

  • If pegylated interferon/ribavirin-experienced and cirrhotic, add ribavirin

  • If sofosbuvir-experienced, add ribavirin
Elbasvir/grazoprevir: 12 weeks of treatment

  • For treatment-experienced, if failure to suppress virus on prior treatment, add ribavirin: 16 weeks treatment

  • Not for post-liver transplant or decompensated cirrhosis
Paritaprevir/ritonavir/ombitasvir+ribavirin: 12 weeks of treatment

  • If cirrhotic, caution (per FDA), add ribavirin

  • If pegylated interferon/ribavirin-experienced, add ribavirin
Sofosbuvir/velpatasvir: 12 weeks of treatment
Sofosbuvir/ledipasvir: 12 weeks of treatment

  • If sofosbuvir-experienced or post-liver transplant, add ribavirin
Sofosbuvir/velpatasvir: 12 weeks of treatment
Sofosbuvir/ledipasvir: 12 weeks of treatment

  • If sofosbuvir-experienced or post-liver transplant, add ribavirin

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No Prior Treatment

  • HCV genotype 1a (no cirrhosis) – 8 weeks of glecaprevir/pibrentasvir or ledipasvir/sofosbuvir (the latter for people who do not have HIV/AIDS, are not African-American, and have less than 6 million HCV viral copies per milliliter of blood) or 12 weeks of elbasvir/grazoprevir, ledipasvir/sofosbuvir, or sofosbuvir/velpatasvir.[rx] Sofosbuvir with either daclatasvir or simeprevir may also be used.[rx]
  • HCV genotype 1a (with compensated cirrhosis) – 12 weeks of elbasvir/grazoprevir, glecaprevir/pibrentasvir, ledipasvir/sofosbuvir, or sofosbuvir/velpatasvir. An alternative treatment regimen of elbasvir/grazoprevir with weight-based ribavirin for 16 weeks can be used if the HCV is found to have antiviral resistance mutations against NS5A protease inhibitors.[rx]
  • HCV genotype 1b (no cirrhosis) – 8 weeks of glecaprevir/pibrentasvir or ledipasvir/sofosbuvir (with the aforementioned limitations for the latter as above) or 12 weeks of elbasvir/grazoprevir, ledipasvir/sofosbuvir, or sofosbuvir/velpatasvir. Alternative regimens include 12 weeks of ombitasvir/paritaprevir/ritonavir with dasabuvir or 12 weeks of sofosbuvir with either daclatasvir or simeprevir.[rx]
  • HCV genotype 1b (with compensated cirrhosis) – 12 weeks of elbasvir/grazoprevir, glecaprevir/pibrentasvir, ledipasvir/sofosbuvir, or sofosbuvir/velpatasvir. A 12-week course of paritaprevir/ritonavir/ombitasvir with dasabuvir may also be used.[rx]
  • HCV genotype 2 (no cirrhosis) – 8 weeks of glecaprevir/pibrentasvir or 12 weeks of sofosbuvir/velpatasvir. Alternatively, 12 weeks of sofosbuvir/daclatasvir can be used.[rx]
  • HCV genotype 2 (with compensated cirrhosis) – 12 weeks of sofosbuvir/velpatasvir or glecaprevir/pibrentasvir. An alternative regimen of sofosbuvir/daclatasvir can be used for 16–24 weeks.[rx]
  • HCV genotype 3 (no cirrhosis) – 8 weeks of glecaprevir/pibrentasvir or 12 weeks of sofosbuvir/velpatasvir or sofosbuvir and daclatasvir.[rx]
  • HCV genotype 3 (with compensated cirrhosis) – 12 weeks of glecaprevir/pibrentasvir, sofosbuvir/velpatasvir, or if certain antiviral mutations are present, 12 weeks of sofosbuvir/velpatasvir/voxilaprevir (when certain antiviral mutations are present), or 24 weeks of sofosbuvir and daclatasvir.[rx]
  • HCV genotype 4 (no cirrhosis) – 8 weeks of glecaprevir/pibrentasvir or 12 weeks of sofosbuvir/velpatasvir, elbasvir/grazoprevir, or ledipasvir/sofosbuvir. A 12-week regimen of ombitasvir/paritaprevir/ritonavir is also acceptable in combination with weight-based ribavirin.[rx]
  • HCV genotype 4 (with compensated cirrhosis) – A 12-week regimen of sofosbuvir/velpatasvir, glecaprevir/pibrentasavir, elbasvir/grazoprevir, or ledipasvir/sofosbuvir is recommended. A 12-week course of ombitasvir/paritaprevir/ritonavir with weight-based ribavirin is an acceptable alternative.[rx]
  • HCV genotype 5 or 6 (with or without compensated cirrhosis) – If no cirrhosis is present, then 8 weeks of glecaprevir/pibrentasvir is recommended. If cirrhosis is present, then a 12-week course of glecaprevir/pibrentasvir, sofosbuvir/velpatasvir, or ledipasvir/sofosbuvir is warranted.[rx]

Chronic infection can be cured in more than 90% of people with medications.[rx] Getting access to these treatments however can be expensive.[rx] The combination of sofosbuvir, velpatasvir, and voxilaprevir may be used in those who have previously been treated with sofosbuvir or other drugs that inhibit NS5A and were not cured.[rx]

Surgery

  • Cirrhosis due to hepatitis C is a common reason for liver transplantation though the virus usually (80–90% of cases) recurs afterward. Infection of the graft leads to 10–30% of people developing cirrhosis within five years. Treatment with pegylated interferon and ribavirin post-transplant decreases the risk of recurrence to 70%.[rx] A 2013 review found unclear evidence regarding if the antiviral medication was useful if the graft became reinfected.[rx]

Alternative medicine

  • Several alternative therapies are claimed by their proponents to be helpful for hepatitis C including milk thistle, ginseng, and colloidal silver.[rx] However, no alternative therapy has been shown to improve outcomes in hepatitis C, and no evidence exists that alternative therapies have any effect on the virus at all.[rx][rx]


Counseling Patients

What topics should be discussed with patients who have HCV infection?

  • First and foremost, patients should be informed about the effectiveness and benefits of new direct acting antivirals (DAAs) and referred for prompt assessment and treatment, if indicated.
  • Patients should be informed about the low but present risk for transmission with sex partners.
  • Sharing personal items that might have blood on them, such as toothbrushes or razors, can pose a risk to others.
  • Cuts and sores on the skin should be covered to keep from spreading infectious blood or secretions.
  • Donating blood, organs, tissue, or semen can spread HCV to others.
  • HCV is not spread by sneezing, hugging, holding hands, coughing, sharing eating utensils or drinking glasses, or through food or water.

What should HCV-infected persons be advised to do to protect their livers from further harm?

  • Patients should be informed about the effectiveness and benefits of new direct-acting antivirals (DAAs) and referred for prompt assessment and treatment if indicated.
  • HCV-positive patients should be advised to avoid alcohol because it can accelerate cirrhosis and end-stage liver disease.
  • Viral hepatitis patients should also check with a health professional before taking any new prescription pills, over-the-counter drugs (such as non-aspirin pain relievers), or supplements, like these, can potentially damage the liver.
  • Clinicians may wish to consider vaccinating HCV-positive patients against hepatitis A and hepatitis B even in the absence of liver disease.

Prevention

Primary prevention

  • There is no effective vaccine against hepatitis C, therefore prevention of HCV infection depends upon reducing the risk of exposure to the virus in health-care settings and in higher-risk populations, for example, people who inject drugs and men who have sex with men, particularly those infected with HIV or those who are taking pre-exposure prophylaxis against HIV.

The following list provides a limited example of primary prevention interventions recommended by WHO

  • Safe and appropriate use of health care injections;
  • Safe handling and disposal of sharps and waste;
  • Provision of comprehensive harm-reduction services to people who inject drugs including sterile injecting equipment and effective treatment of dependence;
  • Testing of donated blood for HBV and HCV (as well as HIV and syphilis);
  • Training of health personnel;
  • Prevention of exposure to blood during sex;
  • Hand hygiene, including surgical hand preparation, hand washing and use of gloves; and
  • Promotion of correct and consistent use of condoms.

Secondary prevention

For people infected with the hepatitis C virus, WHO recommends:

  • Education and counseling on options for care and treatment;
  • Immunization with the hepatitis A and B vaccines to prevent coinfection from these hepatitis viruses and to protect their liver;
  • Early and appropriate medical management including antiviral therapy; and
  • Regular monitoring for early diagnosis of chronic liver disease.

Screening, care, and treatment of persons with hepatitis C infection

In July 2018, WHO updated its “Guidelines for the care and treatment of persons diagnosed with chronic hepatitis C virus infection“.

These guidelines are intended for government officials to use as the basis for developing national hepatitis policies, plans, and treatment guidelines. These include country program managers and health-care providers responsible for planning and implementing hepatitis care and treatment programs, particularly in low- and middle-income countries.

WHO Response

In May 2016, The World Health Assembly adopted the first “Global Health Sector Strategy on Viral Hepatitis, 2016-2021”. The strategy highlights the critical role of universal health coverage and sets targets that align with those of the Sustainable Development Goals. The strategy has the vision to eliminate viral hepatitis as a public health problem. This is encapsulated in the global targets to reduce new viral hepatitis infections by 90% and reduce deaths due to viral hepatitis by 65% by 2030. Actions to be taken by countries and the WHO Secretariat to reach these targets are outlined in the strategy.

WHO is working in the following areas to support countries in moving towards achieving the global hepatitis goals under the Sustainable Development Agenda 2030:

  • Raising awareness, promoting partnerships and mobilizing resources;
  • Formulating evidence-based policy and data for action;
  • Preventing transmission; and
  • Scaling up screening, care and treatment services.

Since 2011, together with national governments, civil society and partners, WHO have organized annual World Hepatitis Day campaigns (as 1 of its 9 flagship annual health campaigns) to increase awareness and understanding of viral hepatitis. The date of 28 July was chosen because it is the birthday of Nobel-prize winning scientist Dr Baruch Bloomberg, who discovered the hepatitis B virus and developed a diagnostic test and vaccine for the virus.

For World Hepatitis Day 2019, WHO is focusing on the theme “Invest in eliminating hepatitis” to highlight the need for increased domestic and international funding to scale up hepatitis prevention, testing and treatment services, in order to achieve the 2030 elimination targets.

Complications of Undiagnosed Hepatitis C

  • Hepatitis C is known to be associated with two skin conditions, lichen planus, and porphyriacutanea tarda.
  • Diabetes, heart disease, and arterial blockage are more common among patients with chronic hepatitis C infection than in the general population. It may be that liver damage and chronic inflammation caused by hepatitis C may affect the levels of blood fats (lipids) and blood sugar.
  • Low platelet counts may occur as a result of the destruction of platelets by antibodies.
  • Hepatitis C also is associated with B-cell lymphoma, a cancer of the blood.

End-stage liver disease

Over several years or decades, chronic inflammation may cause the death of liver cells and cirrhosis (scarring, fibrosis). When the liver becomes cirrhotic, it becomes stiff, and it cannot perform its normal functions of clearing waste products from the blood. As fibrosis worsens, symptoms of liver failure begin to appear. This is called “decompensated cirrhosis” or “end-stage liver disease.

Symptoms of end-stage liver disease include

  • Small spider veins begin to appear on the skin as the stiff, scarred liver obstructs the forward flow of blood.
  • Body fluids back up and accumulate in the abdomen (ascites).
  • The spleen enlarges because of back-pressure.
  • Yellowing of eyes and skin (jaundice) occurs because the liver is not clearing bilirubin (a yellow pigment from the breakdown of red blood cells) from the blood.
  • A serious complication is severe bleeding from varicose veins that develop in the swallowing tube or esophagus (esophageal varices).

Cirrhosis-associated immune dysfunction syndrome

The liver and spleen have an important function of clearing bacteria from the bloodstream. Cirrhosis affects many areas of immune function, including the attraction of white blood cells to bacteria, reduced killing of bacteria, reduced the production of proteins involved in immune defenses, and decreased the life span of white blood cells involved in immune defenses. This may be referred to as having cirrhosis-associated immune dysfunction syndrome or CAIDS.

  • Fluid in the abdomen often becomes infected (spontaneous bacterial peritonitis), and preventive antibiotics may be given for this type of infection.
  • Bacteria also may enter the bloodstream easily (bacterial translocation), referred to as sepsis, especially when esophageal variceal bleed.
  • Individuals may succumb to many types of bacterial infections more easily than normal, but some are specific to liver disease. People with chronic hepatitis C and fibrosis should avoid being exposed to these bacteria.
    • Vibrio species of bacteria are a serious risk from eating raw oysters or exposure to seawater. Vibrio vulnificus may cause sepsis, cellulitis, and necrotizing fasciitis, a “flesh-eating” infection.
    • Listeria species may cause sepsis and meningitis, and are a risk from unpasteurized dairy products and salty processed meats.
    • Yersinia species may be picked up from raw or undercooked pork, especially intestines(chitterlings).


References

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