Hepatitis C

Long-term infection with the hepatitis C virus is known as chronic hepatitis C. Chronic hepatitis C is usually a "silent" infection for many years, until the virus damages the liver enough to cause the signs and symptoms of liver disease.

Signs and symptoms include:

• Bleeding easily
• Bruising easily
• Fatigue
• Poor appetite
• Yellow discoloration of the skin and eyes (jaundice)
• Dark-colored urine
• Itchy skin
• Fluid buildup in your abdomen (ascites)
• Swelling in your legs
• Weight loss
• Confusion, drowsiness and slurred speech (hepatic encephalopathy)
• Spiderlike blood vessels on your skin (spider angiomas)

Every chronic hepatitis C infection starts with an acute phase. Acute hepatitis C usually goes undiagnosed because it rarely causes symptoms. When signs and symptoms are present, they may include jaundice, along with fatigue, nausea, fever and muscle aches. Acute symptoms appear one to three months after exposure to the virus and last two weeks to three months.

Acute hepatitis C infection doesn't always become chronic. Some people clear HCV from their bodies after the acute phase, an outcome known as spontaneous viral clearance. In studies of people diagnosed with acute HCV, rates of spontaneous viral clearance have varied from 15% to 25%. Acute hepatitis C also responds well to antiviral therapy.

Screening for hepatitis C

The U.S. Preventive Services Task Force recommends that all adults ages 18 to 79 years be screened for hepatitis C, even those without symptoms or known liver disease. Screening for HCV is especially important if you're at high risk of exposure, including:

• Anyone who has ever injected or inhaled illicit drugs
• Anyone who has abnormal liver function test results with no identified cause
• Babies born to mothers with hepatitis C
• Health care and emergency workers who have been exposed to blood or accidental needle sticks
• People with hemophilia who were treated with clotting factors before 1987
• People who have undergone long-term hemodialysis treatments
• People who received blood transfusions or organ transplants before 1992
• Sexual partners of anyone diagnosed with hepatitis C infection
• People with HIV infection
• Anyone born from 1945 to 1965
• Anyone who has been in prison

Other blood tests

If an initial blood test shows that you have hepatitis C, additional blood tests will:

• Measure the quantity of the hepatitis C virus in your blood (viral load)
• Identify the genotype of the virus

Antiviral medications:

Hepatitis C infection is treated with antiviral medications intended to clear the virus from your body. The goal of treatment is to have no hepatitis C virus detected in your body at least 12 weeks after your complete treatment.

Researchers have recently made significant advances in treatment for hepatitis C using new, "direct-acting" antiviral medications, sometimes in combination with existing ones. As a result, people experience better outcomes, fewer side effects and shorter treatment times — some as short as eight weeks. The choice of medications and length of treatment depend on the hepatitis C genotype, presence of existing liver damage, other medical conditions and prior treatments.

Due to the pace of research, recommendations for medications and treatment regimens are changing rapidly. It is therefore best to discuss your treatment options with a specialist.

Throughout treatment your care team will monitor your response to medications.

Liver transplantation:

If you have developed serious complications from chronic hepatitis C infection, liver transplantation may be an option. During liver transplantation, the surgeon removes your damaged liver and replaces it with a healthy liver. Most transplanted livers come from deceased donors, though a small number come from living donors who donate a portion of their livers.

In most cases, a liver transplant alone doesn't cure hepatitis C. The infection is likely to return, requiring treatment with antiviral medication to prevent damage to the transplanted liver. Several studies have demonstrated that new, direct-acting antiviral medication regimens are effective at curing post-transplant hepatitis C. At the same time, treatment with direct-acting antivirals can be achieved in appropriately selected patients before liver transplantation.

Vaccinations:

Although there is no vaccine for hepatitis C, your doctor will likely recommend that you receive vaccines against the hepatitis A and B viruses. These are separate viruses that also can cause liver damage and complicate the course of chronic hepatitis C.

Testing and diagnosis

Because new HCV infections are usually asymptomatic, few people are diagnosed when the infection is recent. In those people who go on to develop chronic HCV infection, the infection is also often undiagnosed because it remains asymptomatic until decades after infection when symptoms develop secondary to serious liver damage.

HCV infection is diagnosed in 2 steps:

1. Testing for anti-HCV antibodies with a serological test identifies people who have been infected with the virus.
2. If the test is positive for anti-HCV antibodies, a nucleic acid test for HCV ribonucleic acid (RNA) is needed to confirm chronic infection because about 30% of people infected with HCV spontaneously clear the infection by a strong immune response without the need for treatment. Although no longer infected, they will still test positive for anti-HCV antibodies.

After a person has been diagnosed with chronic HCV infection, they should have an assessment of the degree of liver damage (fibrosis and cirrhosis). This can be done by liver biopsy or through a variety of non-invasive tests.

The degree of liver damage is used to guide treatment decisions and management of the disease.

A new infection with HCV does not always require treatment, as the immune response in some people will clear the infection. However, when HCV infection becomes chronic, treatment is necessary. The goal of hepatitis C treatment is cure.

WHO’s updated 2018 guidelines recommend therapy with pan-genotypic direct-acting antivirals (DAAs). DAAs can cure most persons with HCV infection, and treatment duration is short (usually 12 to 24 weeks), depending on the absence or presence of cirrhosis.

WHO recommends treating all persons with chronic HCV infection over the age of 12. Pan-genotypic DAAs remain expensive in many high- and upper-middle-income countries. However, prices have dropped dramatically in many countries (primarily low-income and lower middle-income countries), due to the introduction of generic versions of these medicines.

Access to HCV treatment is improving but remains too limited. In 2017, of the 71 million persons living with HCV infection globally, an estimated 19% (13.1 million) knew their diagnosis, and of those diagnosed with chronic HCV infection, around 5 million persons had been treated with DAAs by the end of 2017. Much more needs to be done in order for the world to achieve the 80% HCV treatment target by 2030.