- Hepatitis C
- Treatment during pregnancy
- Deciding against treatment
- Long-Term Effects of Untreated Hepatitis C
- Hepatitis C Progression
- What Happens to Your Health When You Aren’t Treated for Hepatitis C
- Hepatitis C Attacks More Than Your Liver
- There’s Reason for Hope With Hepatitis C
- What is Hepatitis C?
- What Causes Hepatitis C?
- Signs and Symptoms of Hep C
- Want To Know More About Hep C?
- What Can I Expect Over Time With Hepatitis C?
- Hepatitis C
- Geographical distribution
- Testing and diagnosis
- Getting tested
- Summary of key recommendations
- WHO response
- Hepatitis C liver damage progression
Any side effects may improve with time as your body gets used to the medications. Tell your care team if any side effect is becoming particularly troublesome.
Coping with side effects can be challenging, but you should continue to take your medication as instructed. Missing doses may reduce the chances of you being cured.
Treatment during pregnancy
The medications used to treat hepatitis C, particularly ribavirin, can be harmful to unborn babies and aren’t normally used during pregnancy.
If you’re pregnant when diagnosed with the infection, treatment will usually be delayed until you have given birth. Otherwise, you’ll be advised to use contraception throughout your treatment and you may need to have regular pregnancy tests.
If you’re a man taking ribavirin, you shouldn’t have sex with a pregnant women unless you use a condom. If your partner isn’t pregnant, you should ensure contraception is used during the course of your treatment and your partner may need to have regular pregnancy tests.
Deciding against treatment
Some people with chronic hepatitis C decide against treatment. This may be because they:
- don’t have any symptoms
- are willing to live with the risk of cirrhosis at a later date
- don’t feel the potential benefits of treatment outweigh the side effects treatment can cause
Your care team can give you advice about this, but the final decision about treatment will be yours.
If you decide not to have treatment but then change your mind, you can ask to be treated at any point.
Long-Term Effects of Untreated Hepatitis C
Out of 100 people who are diagnosed with hepatitis C, 60 to 70 will develop chronic liver disease. If left untreated, this will lead to complete liver failure. In the United States alone, about 19,000 people die every year because of end-stage liver disease related to hepatitis C.
The good news is that liver failure can be detected through a blood test, CT scan, or liver biopsy. But the only current treatment for total hepatitis C–related liver failure is a liver transplant.
Scientists are quickly working to develop new treatments for liver failure, such as:
- Artificial liver support devices that can do the work a failing liver can no longer do. This helpful respite gives the liver time to regenerate itself and heal. One example is the extracorporeal liver support device (ELSD), which has seen success in trials.
- Hepatocyte transplantation involves the transplantation of a small portion of the liver’s cells. This option leaves the liver intact, allowing cells to help it regenerate.
- Xenotransplantation, which replaces the human liver with an animal liver or cells and tissues, can be used to speed up the process of receiving a human liver transplant.
Hepatitis C Progression
Being infected with hepatitis C (HCV) does not necessarily mean that liver disease will occur. What’s more, it can take several years—decades, in many cases—for hep C to cause life-threatening liver disease.
Soon after HCV enters the body, it infects cells in the liver called hepatocytes. Only a small number of people (about 25 percent) actually experience symptoms of infection, such as fatigue, decreased appetite, nausea or jaundice (yellowing of the skin and eyes). However, the majority of people infected with hepatitis C have an increase in liver enzymes—such as alanine aminotransferase (ALT)—that can be detected by a simple blood test. An increase in ALT means that some liver cells are damaged by the HCV infection.
About 15 to 25 percent of people infected with hepatitis C are able to clear the virus from their bodies, usually within six months after becoming infected. Infants and young women are more likely to clear hepatitis C spontaneously. However, the majority of people infected with HCV have “chronic” hepatitis C—an infection that can stay with them for life unless they are treated.
About 15 percent of people with chronic hepatitis C will maintain normal liver enzymes, even though HCV can be detected in their livers and in their blood. Although they usually don’t develop progressive liver disease or experience symptoms of the infection, people with normal ALT levels are still at risk for liver damage from HCV. The remainder of people with chronic hepatitis C will go on to experience some signs and symptoms of liver disease, such as fatigue, nausea, muscle aches and abdominal discomfort.
About 5 to 20 percent of people infected with hep C will develop cirrhosis—a scarring of the liver that results from widespread fibrosis (liver cell damage). This usually occurs over a 20-to-30-year period of HCV infection. Progression to cirrhosis may be accelerated in people who are older, obese or immune-suppressed (such as people who are coinfected with HIV*). Heavy alcohol use can also speed up liver disease, notably in men who drink more than 50 grams of alcohol a day (5 drinks) and women who consume more than 30 grams of alcohol a day (3 drinks).
Although cirrhosis is not always life-threatening, it can affect the way the liver works and it does increase the risk of liver cancer. Between 1 and 5 out of 100 hepatitis C infections will die from the consequences of chronic HCV infection, notably liver cancer or liver failure.
In other words, of every 100 people infected with the hepatitis C virus, about
- 75 to 85 people will develop chronic hepatitis C virus infection; of those,
- 60 to 70 people will go on to develop chronic liver disease,
- 5 to 20 people will go on to develop cirrhosis over a period of 20 to 30 years, and
- 1 to 5 people will die from cirrhosis or liver cancer.
Hepatitis C may increase the risk of dying early from other diseases, such as cancer and cardiovascular disease. On average, people living with hepatitis C die 15 years earlier than the general population. However, people who are cured of hep C before they reach cirrhosis, have an average life expectancy.
*HIV can worsen hepatitis C. Not only does HIV increase the risk of liver damage, it can also hasten the onset of liver damage following infection. Hepatitis C coinfection can also complicate HIV treatment, since some antiretrovirals (ARVs)—HIV medications—are less liver-friendly than others. to learn more about HIV/HCV coinfection.
Last Reviewed: March 4, 2019
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What Happens to Your Health When You Aren’t Treated for Hepatitis C
The effects of hepatitis C can take decades to appear. Thinkstock; Getty Images
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Approximately 3.2 million people in the United States are infected with the hepatitis C virus, and according to the Centers for Disease Control and Prevention (CDC), nearly half of them aren’t aware of it. If you have hepatitis C, you may feel fine for years or even decades. “Usually when someone gets infected with hepatitis C, they are initially asymptomatic until the disease gets fairly advanced,” says Hardeep Singh, MD, a gastroenterologist and hepatologist at St. Joseph Hospital in Orange, California. “The median time it takes for symptoms and end stage liver disease to develop is 30 years.”
While some people’s bodies are able to clear the hepatitis C virus on their own, most aren’t: About 75 to 85 percent go on to develop chronic hepatitis C, says the CDC.
“This leads to a low level, smoldering infection that causes few or no symptoms,” explains Kenneth E. Sherman, MD, PhD, a professor of digestive diseases at the University of Cincinnati School of Medicine in Ohio. The virus has a survival strategy, changing and adapting gradually so it can replicate throughout the body.
Over time, untreated hepatitis C can cause hardening and scarring (cirrhosis) in the liver, which slows down blood flow through this large organ — a process that’s crucial for processing both nutrients and toxins, among other things.
Liver cirrhosis and liver failure cannot be reversed; a liver transplant is the only option once advanced liver damage occurs. With hepatitis C, your risk of liver cancer also rises. According to the CDC, people with hepatitis C have a 1 to 5 percent annual risk of developing liver cancer. They also have a 3 to 6 percent annual risk of decompensation of the liver, which can cause symptoms like fluid retention in the belly, yellowing of the eyes and skin (jaundice), confusion, and internal bleeding.
Hepatitis C Attacks More Than Your Liver
In the early stages of cirrhosis, the liver can still perform most of its functions; however, as it worsens, it can affect other organs as well. Because hepatitis C symptoms go quiet for so long, people often first see their doctor for a related complication and receive a diagnosis for another health condition like rheumatoid arthritis or type 2 diabetes, explains Dr. Singh. Only later do they discover that hepatitis C played a role.
All told, almost 40 percent of people with hepatitis C develop at least one other health complication in addition to liver damage, according to research in the June 2014 issue of the World Journal of Gastroenterology.
This may include:
Harm to blood vessels and joints The most common non-liver-related problem in people with chronic hepatitis C is a condition called cryoglobulinemia, say the authors of an article published in PLoS One in June 2013. With this condition, abnormal proteins in the blood solidify in cold conditions. The result: damage to blood vessels, as well as nerve damage, skin sores, stroke, and heart attack.
Rheumatoid arthritis (RA) This inflammatory type of arthritis develops in some people with hepatitis C and can cause pain, fatigue, swelling, and joint stiffness. The American College of Rheumatology says signs and symptoms of RA related to hepatitis C can appear before people realize they have the virus. The good news is that RA symptoms often improve when the hepatitis C is treated. But the doctor treating your hepatitis C should work with your rheumatologist, since hepatitis medication can sometimes worsen RA symptoms.
Psychiatric and neurological problems Research published in April 2016 in the World Journal of Hepatology shows how the hepatitis C virus can contribute to imbalances, inflammation, and other reactions that affect your nervous system and mental state. As a result, peripheral neuropathy (nerve damage in the hands and feet) and cognitive problems can develop. In addition, cirrhosis can eventually make the liver so ineffective that toxins build up in the brain, causing a condition called hepatic encephalopathy, which leads to confusion, sleepiness, and disorientation.
Many of these psychiatric and neurological problems improve with antiviral medication, and corticosteroids may be used temporarily to help relieve inflammation.
Damage to kidney function “Any chronic liver disease that leads to cirrhosis can affect the kidneys and lead to kidney failure,” says Singh. In fact, hepatitis C is common among people undergoing kidney dialysis and kidney transplantation, according to research published in the journal Blood Purification in January 2017. And the combination of hepatitis C and chronic kidney disease is linked to increased rates of sickness and even death.
Hepatitis C itself may lead to kidney issues in several ways. Some people with hepatitis C develop glomerulonephritis, a condition that affects the part of the kidney that filters waste from the bloodstream. If left untreated, this can cause the kidneys to shut down.
Hepatitis C may also increase the risk of end-stage renal (kidney) disease, according to a study published in the June 2014 issue of the World Journal of Gastroenterology. The researchers point out that involvement of the kidney in hepatitis C shows just how broad and damaging the viral infection can be.
Type 2 diabetes With hepatitis C, you’re more likely to have problems controlling your blood sugar. According to a review published in September 2015 in Frontiers in Endocrinology, up to 33 percent of people with chronic hepatitis C also have type 2 diabetes. The review also describes a two-way street between the conditions: The virus may trigger diabetes, and having diabetes can in turn worsen hepatitis C, including increasing the risk of cirrhosis and liver cancer.
It’s important to ask your hepatitis C and diabetes doctors to coordinate closely regarding your treatment plan so you can manage both conditions. You should also make necessary lifestyle changes to keep your blood sugar levels stable, such as eating small, frequent meals and snacks that are low in fat and refined carbs.
Rare bone disease A bone condition called osteosclerosis can develop with hepatitis C, though it’s very rare. The illness involves extremely fast bone turnover, which leads to severe, deep bone pain. Only people with hepatitis C develop this condition, and just 19 cases have been identified since 1992, according to a case study published in November 2016 in the journal Endocrinology, Diabetes & Metabolism Case Reports.
There’s Reason for Hope With Hepatitis C
Even when people are diagnosed with hepatitis C, many don’t do anything about it. According to a report published in May 2013 in the New England Journal of Medicine, only about a third of people with hepatitis C receive medical care for their condition.
Yet “new treatments for hepatitis C have been revolutionary,” explains Singh. “Over 95 percent of patients can be cured with three months of treatment.” Newer antiviral drugs can clear the virus even in people who have had no luck on earlier medications. They also generally take less time to start working, cause fewer side effects, and can treat and even eliminate illnesses caused by hepatitis C.
Singh says he’s seeing more people with hepatitis C than ever before, as patients are finding out that new treatment options often work well.
Talk to your doctor about your risk of hepatitis and whether you should get tested. The CDC recommends that Americans born between 1945 and 1965 — the baby boomers — get screened at least once. Other risk factors include if you’ve ever shared a needle to inject drugs (even just once); had unprotected sex; or had a needlestick injury, such as in a healthcare setting.
If you do test positive and get treated, keep in mind that damage from liver cirrhosis usually can’t be reversed, Singh says. You’ll have to be monitored closely for liver cancer and other health problems.
In the end, knowing what can happen to your health if you aren’t treated (or even remain undiagnosed) may be the best preventative medicine of all.
What is Hepatitis C?
What Causes Hepatitis C?
In this video, we introduce you to what Hepatitis C is, how you can get it, the symptoms, as well as the tests and cures available so you can live hep C free. There’s never been a better time for a C change!
Hep C is an easily cured viral infection. It is passed on when blood from someone who has hep C gets into the bloodstream of someone else. Around 199,000 Australians have hep C, many through:
- sharing of equipment for Injecting drugs
- contaminated medical procedures, prior to 1990
- medical procedures overseas (migrants from countries with high levels of hep C).
Signs and Symptoms of Hep C
Liver cells get damaged when the hep C virus reproduces itself. This doesn’t always make people feel sick. When people do feel sick, they might experience the following symptoms:
- Flu-like symptoms
- Muscle aches
- Abdominal pain
- Joint aches
- Dark urine
- Jaundice (yellowing of the eyes)
If hep C is not treated, it can result in liver cirrhosis (after many years). It can also turn into chronic hep C, which is why it’s important to get tested for hep C as soon as possible if you feel you may have contracted it.
Want To Know More About Hep C?
If you feel you may have hep C, or have tested positive and aren’t sure what to do next, you may like to give our free Hepatitis Infoline a call.
Alternatively you can find the answers to many frequently asked questions here, or browse our free online resources for further information.
What Can I Expect Over Time With Hepatitis C?
Very understandably, almost everyone diagnosed with the hepatitis C virus asks the same question: “What’s going to happen to me?”
Unfortunately, with HCV infection, it’s very hard for doctors to offer an answer. More than with most diseases, the course of HCV infection varies widely from person to person. In about 15 to 25 percent of people infected with the virus, their immune systems attack the virus and eliminate it, and they never know they were exposed. At the other extreme are people who develop chronic infections and eventually serious liver disease. In between are people who carry the virus but never show signs of trouble, and others who have mild symptoms and some liver damage, but never develop serious illness.
Many factors affect the course of HCV infection
How can one virus act so differently in different people? Researchers don’t know all the answers. They do know that men are more likely to develop serious liver problems than women. One study published found that 13 to 46 percent of men developed cirrhosis (scarring of the liver) over a 30-year period of being infected with HCV. Only 1 to 29 percent of women developed the disease during the same period.
The age when infection occurs also makes a difference in the course of the disease. The earlier in life people are infected, the lower the risk of serious complications from hepatitis C infection.
Other health problems and HCV infection
Co-infections with other viruses can worsen the prognosis for HCV. Many people are co-infected with hepatitis C and HIV/AIDS. Both viruses are spread through sharing needles. In a large European study, 33 percent of HIV-positive patients were shown to be infected with HCV as well. When experts looked just at known injection-drug users, they found that 75 percent of HIV-positive patients also had hepatitis C virus. Being infected with these two viruses appears to increase the risk of cirrhosis. In 2008, researchers found that after 20 years of infection, the risk of developing cirrhosis was 21 percent in people who carried both HCV and HIV and 16 percent for those infected only with HCV.
Certain lifestyle aspects also shape the course of HCV infection. People who are infected and who consume alcohol are more likely to develop liver problems than are nondrinkers. Alcoholics are at the highest risk. A study by University of Pennsylvania researchers found that alcohol actually causes the hepatitis C virus to multiply faster. Alcohol also lessens the effectiveness of alpha interferon, which is used to treat serious HCV infections. In one report, Italian researchers showed that alcohol increases oxidative stress in the liver, generating unstable free radicals that can damage liver cells. The scientists speculate that “oxidative injury might be one of the mechanisms by which alcohol contributes to the progression of chronic hepatitis C.”
Other researchers have found a connection between hepatitis C infection and type 2 diabetes and obesity. In 2009, scientists from the Center for Liver Diseases at Inova Fairfax Hospital analyzed health data from almost 16,000 people, including some with hepatitis C. According to the study results, obesity and type 2 diabetes were associated with a higher mortality rate in patients with hepatitis C. This finding suggests that making lifestyle changes to ward off obesity and diabetes should be an important consideration for people with hepatitis C.
Surprisingly, the level of virus in the blood, called viral load, doesn’t help predict the course of hepatitis C. Some people with high viral levels do well. Others, with low levels of virus, develop liver problems. Doctors use the test to gauge how well treatment is working, but not to make a prognosis. Elevated levels of aminotransferase, a liver enzyme, are a sign that the disease is causing liver damage. But even this marker isn’t a perfect predictor. As many as 30 percent of patients with liver damage have normal levels of aminotranferase.
A look at the numbers
When patients ask, “What will happen to me?” the best answer doctors can give is to explain how the disease progresses in an average group of patients. Of every 100 people infected with HCV:
75 to 85 may develop long-term infection; of those:
- 60 to 70 may develop chronic liver disease
- 5 to 20 may develop cirrhosis (scarring of the liver) over a period of 20-30 years
- 1 to 5 are likely to die of the consequences of long-term infection, either from liver cancer or cirrhosis.
As those numbers show, most people infected with hepatitis develop chronic infections. Among them, most have some signs of liver damage. But the numbers are also reassuring. Fewer than 7 percent of those with chronic hepatitis C die of complications from the virus. That means that for a large majority of people, the virus isn’t fatal. In many, it causes nothing more than mild symptoms such as fatigue.
The changing picture of HCV infection
There’s more good news coming out of clinical trials and pharmaceutical laboratories. The combination treatment used today is more effective than anything doctors were able to offer when the disease emerged in 1989. Combination therapy can eliminate the virus in about half of all patients. Some combination treatments can do even better. One 2007 study of nearly 1,000 hepatitis C patients showed a cure rate of 99 percent after treatment with peginterferon and ribavirin — with a number of patients remaining disease-free for as long as seven years. The prognosis for people infected with HCV is brighter than ever. And it’s likely to get even brighter as doctors learn more effective combinations of existing drugs and as new drugs are developed.
Younossi ZM, McCullough AJ. Metabolic syndrome, non-alcoholic fatty liver disease and hepatitis C virus: impact on disease progression and treatment response. Liver International. 2009 Apr;29(4):617.
Thein HH, Yi Q, Dore GJ, Krahn MD. Estimation of stage-specific fibrosis progression rates in chronic hepatitis c virus infection: A meta-analysis and meta-regression. Hepatology. August 2008; 48(2): 418-431.
Lauer, GL, et al. Hepatitis C virus infection, New England Journal of Medicine, July 5, 2001, pp 41-52
Ho, W et al. Alcohol increases hepatitis C virus in human cells, Hepatology, July 2003, pp 57-65
Pessione, F et al. Five-year survival predictive factors in patients with excessive alcohol intake and cirrhosis. Effect of alcoholic hepatitis, smoking, and abstinence, Liver International, Feb 2003, pp 45-53
Seeff et al, The National Institutes of Health Consensus Development Conference management of hepatitis C 2002, Clinical Liver Disease, Feb 2003, pp 261-87
Thomas DL et al, The natural history of hepatitis C virus infection: host, viral and environmental factors, Journal of the American Medical Association, July 26, 2000, pp. 450-6
Quaglio GL et al, Hepatitis C virus infection: prevalence, predictor variables and prevention opportunities among drug users in Italy, Journal of Viral Hepatitis, Sep 2003, pp 394-400
Hisada et al, Increased hepatitis C virus load among injection drug users infected with HIV and HTLV2, Journal of Infectious Diseases, Sept 15, 2003, pp 891-7 Sanchez-Quijano et al, Influence of human immunodeficiency virus type 1 infection on the natural course of chronic parenterally acquired hepatitis C, European Journal of Clinical Microbiology and Infectious Disease.
Thein HH, Yi Q, Dore GJ, Krahn MD. Natural history of hepatitis C virus infection in HIV-infected individuals and the impact of HIV in the era of antiretroviral therapy: a meta-analysis. AIDS. October 1, 2008; 22(15).
Centers for Disease Control and Prevention. Hepatitis C FAQs for the Public. http://www.cdc.gov/hepatitis/C/cFAQ.htm
Hepatitis C virus causes both acute and chronic infection. New HCV infections are usually asymptomatic. Some persons get acute hepatitis which does not lead to a life-threatening disease. Around 30% (15–45%) of infected persons spontaneously clear the virus within 6 months of infection without any treatment.
The remaining 70% (55–85%) of persons will develop chronic HCV infection. Of those with chronic HCV infection, the risk of cirrhosis ranges between 15% and 30% within 20 years.
Hepatitis C is found worldwide. The most affected regions are the WHO Eastern Mediterranean Region and the WHO European Region, with an estimated prevalence in 2015 of 2.3% and 1.5% respectively. Prevalence of HCV infection in other WHO regions varies from 0.5% to 1.0%. Depending on the country, hepatitis C virus infection can be concentrated in certain populations. For example, 23% of new HCV infections and 33% of HCV mortality is attributable to injecting drug use. Yet, people who inject drugs and people in prisons are not often included in national responses.
In countries where infection control practices are or were historically insufficient, HCV infection is often widely distributed in the general population. There are multiple strains (or genotypes) of the HCV virus and their distribution varies by region. However, in many countries, the genotype distribution remains unknown.
The hepatitis C virus is a bloodborne virus. It is most commonly transmitted through:
- injecting drug use through the sharing of injection equipment;
- the reuse or inadequate sterilization of medical equipment, especially syringes and needles in healthcare settings;
- the transfusion of unscreened blood and blood products;
- sexual practices that lead to exposure to blood (for example, among men who have sex with men, particularly those with HIV infection or those taking pre-exposure prophylaxis against HIV infection).
HCV can also be transmitted sexually and can be passed from an infected mother to her baby; however, these modes of transmission are less common.
Hepatitis C is not spread through breast milk, food, water or casual contact such as hugging, kissing and sharing food or drinks with an infected person.
WHO estimates that in 2015, there were 1.75 million new HCV infections in the world (23.7 new HCV infections per 100 000 people).
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. Those who are acutely symptomatic may exhibit fever, fatigue, decreased appetite, nausea, vomiting, abdominal pain, dark urine, grey-coloured faeces, joint pain and jaundice (yellowing of skin and the whites of the eyes).
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:
- Testing for anti-HCV antibodies with a serological test identifies people who have been infected with the virus.
- 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.
Early diagnosis can prevent health problems that may result from infection and prevent transmission of the virus. WHO recommends testing people who may be at increased risk of infection.
Populations at increased risk of HCV infection include:
- people who inject drugs;
- people in prisons and other closed settings;
- people who use drugs through other routes of administration (non-injecting);
- people who use intranasal drugs;
- recipients of infected blood products or invasive procedures in health-care facilities with inadequate infection control practices ;
- children born to mothers infected with HCV ;
- people with sexual partners who are HCV-infected;
- people with HIV infection;
- prisoners or previously incarcerated persons; and
- people who have had tattoos or piercings.
In settings with high HCV antibody seroprevalence in the general population (defined as >2% or >5% HCV antibody seroprevalence), WHO recommends that all adults have access to and be offered HCV testing with linkage to prevention, care and treatment services.
About 2.3 million people (6.2%) of the estimated 3.7 million living with HIV globally have serological evidence of past or present HCV infection. Chronic liver disease represents a major cause of morbidity and mortality among persons living with HIV globally.
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.
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.
For people infected with the hepatitis C virus, WHO recommends:
- education and counselling 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 gudelines. These include country programme managers and health-care prividers responsible for planning and implementing hepatitis care and treatment programmes, particularly in low- and middle-income countries.
- Guidelines for the care and treatment of persons diagnosed with chronic hepatitis C virus infection
Summary of key recommendations
1. Screening for alcohol use and counselling to reduce moderate and high levels of alcohol intake
An alcohol intake assessment is recommended for all persons with HCV virus infection followed by the offer of a behavioural alcohol reduction intervention for persons with moderate-to-high alcohol intake.
2. Assessing degree of liver fibrosis and cirrhosis
In resource-limited settings, the aminotransferase/platelet ratio index (APRI) or FIB4 tests should be used for the assessment of hepatic fibrosis rather than other non-invasive tests that require more resources such as elastography or fibrotest.
Recommendations on hepatitis C treatment
3. Assessing for treatment
All adults and children with chronic HCV infection should be assessed for antiviral treatment.
WHO recommends offering treatment to all individuals diagnosed with HCV infection who are 12 years of age or older, irrespective of disease stage.
WHO recommends the use of pan-genotypic DAA regimens for the treatment of persons with chronic HCV infection aged 18 years and above.
In adolescents aged 12-17 years or weighing at least 36 kg with chronic HCV infection, WHO recommends:
• sofosbuvir/ledipasvir for 12 weeks in genotypes 1, 4, 5 and 6
• sofosbuvir/ribavirin for 12 weeks in genotype 2
• sofosbuvir/ribavirin for 24 weeks in genotype 3.
In children aged less than 12 years with chronic HCV infection, WHO recommends:
• deferring treatment until 12 years of age
• treatment with interferon-based regimens should no longer be used.
New highly effective short-course oral pan-genotypic DAA regimens are likely to become available for children under 12 years of age in late 2019 or 2020. This will provide an opportunity to advance treatment access and cure to a vulnerable group that will benefit from early treatment.
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 a 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 has 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.
Hepatitis C liver damage progression
How the disease progresses varies significantly from person to person. After many years some people will have minimal liver damage with no scarring while others can progress to cirrhosis (extensive scarring of the liver) within less than ten years. On average it takes about twenty years for significant liver scarring to develop. The symptoms experienced and the damage done to the liver vary dramatically from person to person. Some people will have few, if any, symptoms for many years. While for others the symptoms can have quite noticeable effects on their health.
The period immediately following infection is called the ‘acute phase’. This lasts about six months. If the immune system does not manage to clear the virus in this time, the disease is considered to have moved into a long-term or ‘chronic phase’.
- You can read about possible symptoms during the acute phase here.
After six months 70% to 85% of those infected will have failed to clear the virus spontaneously. After this period the hepatitis C virus enters what is known as the ‘chronic phase’. This is when hepatitis C becomes a chronic or long-term infection. The diagnosis is confirmed when over a six month period hepatitis C RNA viral presence is detectable on at least two occasions.
A diagnosis of chronic hepatitis C means the battle between the virus and the immune system that occurs during the acute stage has finally been won by the virus. It is now highly unlikely that the virus can be cleared without treatment.
The liver damage due to the virus begins with fibrosis, the build-up of scar tissue in the liver which can then go onto lead to cirrhosis, where areas of the liver cease to function. The liver can only compensate for so much of the liver ceasing to function. This leads to decompensated cirrhosis also called end stage liver disease (ESLD) when the liver ceases to function.
You can read about cirrhosis here.
Within the NHS the extent of liver damage is measured by a Fibroscan, a non-invasive test similar to an ultrasound that measures the stiffness of the liver.
- You can read more about how the liver is damaged in people living with hepatitis C here.
Extent of liver damage
2.5 – 7
No liver damage up to very mild liver damage.
7 – 9.5
Scarring has built up around the blood supply to the liver.
9.5 – 11.5
The scars around different blood vessels in the liver are joined but liver function is unaffected.
11.5 – 29
The scarring is beginning to build up in the tissues of the liver and it’s function is impaired. The higher the Fibroscan score the less well the liver will be able to function.
30 and above
The liver can no longer maintain its function due to the extent of the scarring.