Hepatitis c and sex

Contents

Is Sex Safe if One Person Has Hep C?

It’s possible — albeit, rare — for hepatitis C to be spread through sex. iStock

Sign up for more FREE Everyday Health newsletters.

Hepatitis C is spread through blood-to-blood contact. Though certain sexual behaviors may increase the risk of hepatitis C, the virus is not typically sexually transmitted. So if you or your partner has been diagnosed with hepatitis C, you don’t have to swear off sex.

However, having hepatitis C doesn’t mean you should throw caution to the wind: Although treatable, hepatitis C is a serious illness that can cause liver damage — including cirrhosis, liver failure, and liver cancer — and other health complications. What’s more, it usually doesn’t cause symptoms and can go undetected for years, even decades.

“The risk comes down to whether sex results in mucosal tears in body tissues, such as to the vagina or the rectum,” says Andrew H. Talal, MD, MPH, a hepatologist and professor in the department of medicine at the Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo–State University of New York. Even the smallest tear in the skin or body tissue of both partners gives the hepatitis C virus a way to travel from one body and enter the other. “You need to always think about blood being exchanged; that’s where you need to be careful,” Dr. Talal adds.

Can Hepatitis C Be Spread During Vaginal Sex?

It’s rare for the hepatitis C virus to be transmitted through vaginal intercourse. Unless the vaginal walls aren’t lubricated or intercourse is very rough and leads to tears in the vaginal wall, there’s no opportunity for blood to be exchanged. The risk for transmission with vaginal intercourse is about 1 in 190,000, according to research published in the March 2013 issue of the journal Hepatology.

Research published in the Journal of Coagulation Disorders in March 2014 reinforces these findings, emphasizing that transmission of the hepatitis C virus by sex in monogamous heterosexual couples is rare. And the Centers for Disease Control and Prevention (CDC) states that couples in monogamous heterosexual relationships do not need to use condoms routinely, even if one partner has hepatitis C. Concerned couples, however, can discuss using a condom to lower the already very low risk of spreading the virus, says Talal.

Just how safe sex is when a partner has hepatitis C hinges on some other factors as well. For example, it’s important to use a new condom with each sexual act that has the potential to expose the uninfected partner to the infected person’s blood, even if you’re in a committed relationship, says the CDC. Some of these situations include sex when you or your partner:

  • Has an open cut or sore
  • Has another sexually transmitted infection (STI), especially one that causes sores or lesions
  • Is having her menstrual period

Keep in mind that if you have more than one sex partner, the CDC recommends always using a male latex condom. (This is especially true if you’ve been diagnosed with HIV.) If you have multiple partners, the odds increase that you’ll either infect others or become infected yourself.

What to Know About Hepatitis C During Oral and Anal Sex

Oral sex does not pose an increased risk of transmitting the hepatitis C virus, according to the American Liver Foundation, unless there are open sores or cuts in the mouth. To be safe, however, the CDC recommends using a new latex condom (or, if you’re allergic to latex, you can use polyurethane) whenever you have oral sex to reduce the risk of transmitting hepatitis and sexually transmitted infections like HIV.

Anal sex is high-risk, though, because rectal tissue is fragile and can easily tear when manipulated or pushed to expand. If the tissue tears and bleeds, there’s a chance for blood-to-blood contact. For this reason, it’s best to always use a condom during anal sex. It’s also important to liberally apply water- or silicone-based lubricant to keep anal tissue and condoms from tearing.

If you use sex toys, it may be safest to avoid sharing them. If you’re engaging in rough sex that results in skin tears, even tiny traces of infected blood that remain on a toy can pass through openings in the skin — although the risk of spreading bloodborne diseases remains very low. What’s more, the human papilloma virus (HPV) has been transmitted via sex toys, even after cleaning.

For Safer Sex, Treat Hepatitis C

If you have chronic hepatitis C, of the best strategies for preventing transmission of the virus is to get medical treatment. More than 90 percent cases of hepatitis C can be cured within 8 to 12 weeks of treatment, according to the CDC. Newer hepatitis C treatments are not only effective but generally have fewer and much less severe side effects than previous drugs.

Just be aware that during treatment, transmission can still occur. And a cure doesn’t grant you protection against the virus for life. “If you continue to engage in high-risk behavior, you can get re-infected,” warns Kenneth Sherman, MD, PhD, a professor of medicine and the director of the division of digestive diseases at UC Health in Cincinnati, Ohio.

More Ways to Reduce the Risk of Infection

If you aren’t sure whether you have hepatitis C, get tested. Testing is especially important if you have sex with more than one person or if you have other risk factors for hepatitis C, including being born being 1945 and 1965, having had a blood transfusion prior to 1992, and injecting drugs (even if you’ve only done it once).

Talk to your partner about getting tested as well, for hepatitis C and other STDs, so you know the risks before having sex. “People who are at risk for hepatitis C are also at risk for HIV and other STDs,” emphasizes Talal.

Building Healthy Sexual Relationships

Rule number one for a healthy sexual relationship: Be open and honest with your partners. “I believe in transparency,” says Talal. This conversation can be difficult, but it’s important to have. Part of discussing your status is talking about what exposure you may have had to hepatitis C, even in the distant past.

It’s a good opportunity for you both to share your sexual history, as well as your experiences with other ways hepatitis C can be transmitted, such as using injection drugs or being exposed to items that may have blood on them, including needles, razors, and toothbrushes.

Sherman explains that even if you consistently use condoms during sex, other activities, such as sharing needles to inject drugs or sharing straws to snort them, increase your risk of spreading (or getting) hepatitis C. “People do not want to hear about this,” he says. “It’s difficult to get the word out about risk.”

If you and your partner find that hepatitis C is disrupting your relationship or your sex life, you might also consider working with a marriage and family therapist or a sex therapist.

Diagnosing Hepatitis C

Talk to your doctor about getting tested for Hepatitis C if you:

  • Are a current or former drug user who used needles to inject, even if you only did this one time or did it many years ago
  • Have a sex partner who has chronic Hepatitis C or have had many sex partners
  • Had your blood filtered by a machine (hemodialysis) for a long period of time because your kidneys weren’t working
  • Received a blood transfusion or organ transplant from a donor before July 1992
  • Received a blood clotting factor to treat a bleeding disorder (like hemophilia) before 1987
  • Are a healthcare worker and were exposed to blood through a needle stick or had other contact with blood or bodily fluids
  • Have HIV
  • Have evidence of liver disease, such as abnormal liver tests
  • Were born between 1945 and 1965. The Centers for Disease Control and Prevention (CDC) recommends a one-time screening for all baby boomers.

Learn more, use the Centers for Disease Control’s Hepatitis Risk Assessment tool.

What the CDC Recommends

Were you born between 1945 and 1965? If so, then you’re a member of the Hepatitis C generation. The CDC (Center for Disease Control) recently recommended that all people born between during this time have a 1-time screening test for Hepatitis C. We now have new drugs that can treat and cure Hepatitis C so you should go get tested today.

Read the CDC Hepatitis C Fact Sheet

The life you save may be your own! Please contact your local healthcare provider.

Tests to Diagnose Hepatitis C

How is Hepatitis C diagnosed?

There are two main blood tests typically used to diagnose Hepatitis C. First, you’ll have a screening test that shows if you’ve ever had Hepatitis C at some point in your life. If this test is positive, you’ll have a second test to see if you have Hepatitis C now. These blood tests are described below:

Hepatitis C antibody test

This is the screening test used by doctors to show whether or not you have ever been exposed to Hepatitis C at some time in your life, by detecting antibodies in your blood. Antibodies are substances your body makes to fight off all kinds of infections. If you were ever infected with Hepatitis C, your body would have made antibodies to fight the virus.

If the test result is:

  • Negative, it means you have not been exposed to Hepatitis C and further testing is usually not needed.
  • Positive, you have had Hepatitis C at some point. However, it does not tell you whether you have it now. You’ll need to see your doctor for another test – the Hepatitis C RNA test – to determine if the virus is still active and present in your blood.

Hepatitis C RNA Qualitative Test

This test will determine whether or not you are currently infected with Hepatitis C. It is often called the PCR test because of the process used (polymerase chain reaction – hence PCR). It looks for the genetic material (RNA) of the Hepatitis C virus in your blood.

If the test result is:

  • Positive, it is reported as “detected.” This confirms that you have Hepatitis C.
  • Negative, it is reported as “not detected.” This means that even though you might have been exposed to the virus at some point, your body has cleared the infection on its own.

Hepatitis C RNA Quantitative Test

The quantitative test measures the amount of Hepatitis C virus present in your blood. This measurement is called the “viral load,” and is reported as an exact number.

This test is often used to monitor a person’s response to treatment for Hepatitis C by comparing the amount of virus in your bloodstream before, during, and after treatment. If you have lower levels of virus in your blood before starting treatment, you may have a better chance of getting rid of the virus.

Additional Tests You Might Need

Once you’ve been diagnosed with Hepatitis C, your doctor will likely order a number of tests to find out about the health of your liver and decide on a treatment plan that’s most appropriate for you.

Hepatitis C genotype

The Hepatitis C genotype refers to a specific “strain” or type of the Hepatitis C virus. There are six major types of Hepatitis C around the world: genotypes 1, 2, 3, 4, 5 and 6. In the United States, genotypes 1, 2, and 3 are common:

  • Genotype 1: Most Americans (nearly 75%) with Hepatitis C have this type
  • Genotype 2: About 10% of Americans with Hepatitis C have this type
  • Genotype 3: About 6% of Americans with Hepatitis C have this type

The genotype of Hepatitis C does not change over time, so you only need to get tested once.

Genotype tests are done before a person starts treatment. Hepatitis C treatment works differently for different genotypes, so knowing your genotype helps your doctor choose the best treatment for you.

Testing for Hepatitis A and Hepatitis B

Your doctor may test to see if your body is immune to Hepatitis A and Hepatitis B. If these tests show no prior exposure or protection, he or she will recommend that you be vaccinated against these two viruses to eliminate the chance of becoming infected.

Liver function tests (LFTs) or liver enzymes

Now that you have Hepatitis C, your liver may not work as well. Liver function tests are a group of blood tests that detect inflammation and damage to the liver. They are used to detect, evaluate, and monitor liver disease and damage.

The cells in the liver contain proteins called enzymes, which are chemicals that help your liver do its work. When liver cells are damaged or destroyed, the enzymes in the cells leak out into the blood where they can be measured by blood tests. Liver enzyme testing usually checks the blood for two main enzymes:

  • ALT (alanine aminotransferase)
  • AST (aspartate aminotransferase)

Liver function tests also include ALP (alkaline phosphatase) and total bilirubin, among other things.

If your liver is damaged due to inflammation, enzymes pass out of your liver into your bloodstream making the levels of ALT and AST higher than normal. However, it’s common for people with chronic Hepatitis C to have liver enzyme levels that go up and down over time, sometimes returning to normal for as long as a year. So even if you have Hepatitis C, it’s possible for your liver enzyme tests to come back as normal.

The ALT and AST levels do not tell you how much scarring (fibrosis) there is in your liver and they do not predict how much liver damage will develop. However, if your total bilirubin is elevated, that could be a sign of cirrhosis (advanced scarring) and needs further investigation.

Tests to measure liver scarring or fibrosis

It’s important that you get some measure of the amount of scarring in your liver. This will guide your Hepatitis C treatment, as well as the long-term management of your liver health. Your Hepatitis C provider will make a recommendation for one of the following tests:

  • Liver Biopsy

In order to determine whether the virus has caused scarring to your liver, your doctor may order a liver biopsy. During a biopsy, your doctor will insert a needle between your ribs into your liver to collect a small sample of liver tissue for laboratory testing.

  • Elastography

Instead of a liver biopsy, some providers will test for liver stiffness by using a special ultrasound machine, the most common being FibroScan. The more scarring that is present in the liver the stiffer it is. This exam, called transient elastography is painless and non-invasive. If you are scheduled for this test, do not eat or drink for two hours beforehand.

  • Serum markers

There are a number of blood tests available to estimate the amount of scarring in the liver.

Imaging tests

Your doctor may order tests that take images, or pictures, of your liver to make sure you do not have liver cancer. Different types of images can be obtained by using various types of equipment including ultrasound, a CT (computerized tomography) scan, or MRI (magnetic resonance imaging). If you have cirrhosis, these tests will be used to check for cancer as part of a screening program. Unless your Hepatitis C is very advanced, these tests will not tell you about your liver function or the overall health of your liver. Talk to your healthcare provider about why the test is being done.

Ask your doctor to explain all your test results and don’t hesitate to ask questions. This will help you have a better understanding of what’s happening in your body and why your healthcare provider is recommending a particular course of treatment.

If You’ve Got Hep C, Spitting Can Be A Felony

Last week, an Ohio man who has the hepatitis C virus was sentenced to 18 months in prison for spitting at Cleveland police and medics.

Matthew Wenzler, 27, was reportedly lying on a Cleveland street across from a downtown casino in January. When police and emergency medical technicians tried to put him on a stretcher to take him to a hospital, he spit saliva mixed with blood repeatedly at them, hitting an officer in the eye.

In Ohio, it’s a felony for people who know they have HIV, viral hepatitis or tuberculosis to intentionally expose another person to their blood, semen, urine, feces or other bodily substances such as saliva with the intent to harass or threaten the person.

Advocates for people living with diseases like hepatitis C and HIV say these laws add to the stigma that patients already face and studies suggest the laws are not effective at stopping the spread of disease.

“This person is now facing a year and a half of incarceration for something that didn’t harm anyone and didn’t pose a risk of harm to anyone,” said Kate Boulton, a staff attorney at the Center for HIV Law and Policy.

Roughly two-thirds of states, according to the Center for HIV Law and Policy, have laws that make it a crime to knowingly expose others to HIV, the virus that causes AIDS. Many of these laws were passed in the 1980s and 1990s when fear and stigma about HIV were high and contracting the disease was considered a death sentence.

In recent years, about a dozen states have added hepatitis C to the list of medical conditions for which people can face criminal prosecution if they knowingly expose others by engaging in certain activities like sex without disclosure, needle-sharing or organ donation.

Public health officials say these provisions, which are sometimes tacked on to existing HIV laws, are likely to be ineffective at stemming transmission of the disease. They may even exacerbate the problem.

“If you have to let people know that you are infected with HIV or hepatitis C before you have sex with them, why would anyone in their right mind get themselves tested and begin treatment?” said Dr. Anne Spaulding, an epidemiologist and associate professor at Emory University’s public health school. She has worked as a medical director in corrections systems and published research on hepatitis C among prisoners.

Yet, among some lawmakers there is still interest in criminalizing actions they view as spreading the disease. The increasing awareness of the opioid epidemic, which is linked to the spread of hepatitis C through the use of dirty needles, may play a role, some experts say.

“We’re seeing this massive surge in opioid addiction,” said Boulton. “Whereas hepatitis maybe wasn’t on the radar in the past, now it is.”

An estimated 3.5 million people have hepatitis C, a viral infection that causes inflammation of the liver that can lead to scarring, liver cancer and death. It is typically passed from person to person through blood. Today that happens often through sharing needles to inject drugs and, more rarely, through sex. But many older cases were caused by blood transfusions before testing for the virus existed.

The virus isn’t transmitted through urine, feces, semen or saliva, Spaulding said, noting that although there have been some cases of the disease being spread through blood hitting the eye, it is very rare and requires a great deal of blood.

In the case of semen, there are concerns about transmission of hepatitis C. “We are not aware of a study that ‘explicitly demonstrates’ transmission through semen/sexual contact,” the Centers for Disease Control and Prevention said in an email. “However, there has been considerable epidemiological evidence of sexual transmission of the hepatitis C virus (HCV), primarily among HIV-positive men who have sex with men. There has also been laboratory evidence of HCV viral levels in semen being high enough to cause transmission.”

In 2016, the most recent figures available, nearly 3,000 cases were reported to the federal Centers for Disease Control and Prevention, a 22 percent increase from the previous year. But many cases go unreported, in part because people don’t realize they carry the virus. The CDC estimates that the full number of new cases in 2016 was 41,200.

“Hepatitis C is still a very dangerous disease to contract,” said South Dakota Republican state Sen. Stace Nelson, who sponsored a bill this year that would have made it a felony for people who have been diagnosed with hepatitis C to expose someone else to the disease. “These circumstances where someone knows that they have it and intentionally or negligently infects someone else … it’s a threat to society.”

Advocates have been working to reform state laws that make it a crime to expose people to HIV. In the process, they are increasingly working to head off efforts to criminalize hepatitis C, including supporting local advocates to help stop a bill in Michigan in recent years, said Sean Strub, who in 1994 founded POZ magazine, which is dedicated to issues about HIV. He is also executive director of the Sero Project, an education and advocacy group that, among other things, is working to end criminal penalties for exposing others to HIV.

“Now we have this very robust and active movement combating HIV criminalization,” Strub said. “But we’re really combating a whole range of conditions.”

Sometimes, however, HIV reform has had negative consequences for people living with hepatitis C.

Take, for example, Iowa, which passed a law in 1998 that said people who were found guilty of knowingly exposing others to HIV faced up to 25 years in prison and had to register as sex offenders, even if they used a condom and didn’t infect anyone. The burden of proof was on the accused to show that they had disclosed their HIV status to their partner.

Advocates successfully pushed to replace that with a law reducing the penalties and eliminating the sex offender registration requirement. But one of their goals also was to reduce stigma by no longer singling out HIV.

So they added hepatitis, meningococcal disease and tuberculosis to the medical conditions that people could be prosecuted for if they exposed others to it.

People who worked for the replacement law say they realized from the start that it wasn’t an ideal solution.

But outright repeal wasn’t an option politically, said Tami Haught, a community organizer in Iowa who works as the training and organizing coordinator for the Sero Project.

“It was a tough decision that had to be made,” said Haught, who is HIV-positive. She noted that in some states without disease-specific exposure laws, prosecutors have found a way to charge people under other general criminal laws in any case.

On balance, she said, she believes it was the right way to go.

Related Topics

Insuring Your Health Public Health States Hepatitis HIV/AIDS

Hepatitis C symptoms & treatment

FAST FACTS

• Hepatitis C is found in infected blood (it’s very unlikely, but not impossible, that it can be passed on in semen).

• Hepatitis C is mainly passed on through using contaminated needles and syringes or sharing other items with infected blood on them. It’s also a sexually transmitted infection (STI) that can be passed on through unprotected sex, although this is less common.

• Hepatitis C can be prevented by never sharing needles and syringes; practising safer sex including using male and female condoms, dental dams and latex gloves; and avoiding unlicensed tattoo parlours and acupuncturists.

• A simple blood test carried out by a healthcare professional will show whether you have hepatitis C.

• Most people don’t need treatment for acute hepatitis C. If it develops into chronic hepatitis C, treatment is available to reduce the risk of further complications such as liver damage.

If you’ve had unprotected sex, or you’re worried about hepatitis C or other STIs, get tested as soon as possible – even if you don’t have symptoms.

What is hepatitis C?

Hepatitis C – hep C or HCV – is part of a group of hepatitis viruses that causes inflammation of the liver – which is when your liver becomes swollen and painful.

Is hepatitis C serious?

Hepatitis C can be serious and, without appropriate treatment and care, can cause liver disease and liver cancer leading to death.

How do you get hepatitis C?

Hepatitis C can be passed on easily and you can get it if you:

  • share contaminated needles and syringes during recreational drug use
  • are exposed to unsterilised tattoo, body-piercing or medical/dental equipment (occasionally you can get it from sharing a towel, razor blades or a toothbrush if there is infected blood on them)
  • have unprotected sex (sex without a condom or dental dam), including vaginal, anal and oral sex with someone who has hepatitis C (even if they don’t have symptoms)
  • share sex toys that aren’t washed or covered with a new condom each time they are used
  • practise anal sex, rimming, fingering or fisting without condoms, dental dams or latex gloves
  • receive a transfusion of unscreened blood and blood products
  • are a pregnant woman with hepatitis C you can pass the virus on to your unborn baby.

Hepatitis C, HIV and sexual health

  • Having an STI, including hepatitis C, increases your risk of getting HIV. This is because most STIs cause sores or lesions that make it easier for HIV to enter the body.
  • Because they are passed on in similar ways, some people have both viruses, which is known as co-infection.
  • If you’re living with HIV and also have hepatitis C, your viral load is likely to increase because your immune system is weaker. This will make you more likely to pass on HIV if you have sex without a condom.
  • Hepatitis C is rarely passed on during heterosexual sex – it’s more common for it to be spread sexually among men who have sex with men who are living with HIV.
  • If you’re taking antiretrovirals, it’s important to discuss with your doctor how treatment for hepatitis c may interact with your HIV drugs.

If you’re worried about HIV infection, find out everything you need to know in our HIV Transmission and Prevention section

How do you protect yourself against hepatitis C?

  • Never share needles and syringes or other items that may be contaminated with infected blood, such as razors, toothbrushes, towels or manicure tools (even old or dried blood can contain the virus).
  • Only have tattoos, body piercings or acupuncture in a professional setting, and ensure that new, sterile needles are used.
  • Practise safer sex:
    • Know the status of any sexual partner.
    • Male (or external) or female (or internal) condoms and/or dental dams aren’t usually necessary to prevent hepatitis C for long-term heterosexual couples, but it’s a good idea to use them when having anal sex (in case there is minor bleeding), or if blood such as menstrual blood is present; or for sex with a new partner.
    • for men who have sex with men – use condoms, dental dams and latex gloves for anal sex, rimming, fingering and fisting.
  • There is no vaccine for hepatitis C.

Note – apart from condoms – other types of contraception such as the contraceptive pill offer no protection against sexually transmitted infections.

Ask your healthcare professional if you need further advice on how to protect yourself and your partner(s) from HIV and other STIs.

What do hepatitis C symptoms look like?

Hepatitis C infection can go through two stages: acute and chronic. In the early – acute –stage most people don’t have any symptoms and don’t know they have it until the liver has been significantly damaged.

For women and men acute (or short-term) symptoms include:

  • flu-like symptoms, including tiredness, fever and aches and pains
  • feeling and/or being sick
  • loss of weight/appetite
  • itchy skin
  • tummy (abdominal) pain
  • mental confusion (often called ‘brain fog’) and depression – these are specific to hepatitis C.

Acute hepatitis C infection doesn’t always become chronic, but if it does, you often don’t notice any symptoms until the virus has damaged the liver enough to cause the signs and symptoms of liver disease including:

  • bleeding and/or bruising easily
  • tiredness
  • loss of weight/appetite
  • jaundice, meaning your skin and the whites of your eyes turn yellow
  • dark urine (pee)
  • Itchy skin
  • fluid build-up in your tummy (abdomen)
  • swollen legs
  • confusion, drowsiness and slurred speech
  • spider-like blood vessels on your skin.

Can I get tested for hepatitis C?

Yes – a simple blood test carried out by a healthcare professional will show whether you have the virus. You may also be given an extra test to see if your liver is damaged.

If you’ve got hepatitis C you should be tested for other STIs. It’s important that you tell your recent sexual partner/s so they can also get tested and treated. Many people who have hepatitis C do not notice anything wrong, and by telling them you can help to stop the virus being passed on; and it can also stop you from getting the infection again.

How is hepatitis C treated?

The majority of people with hepatitis C don’t need treatment. However, you will need regular check-ups for three months to see if your body is fighting the virus.

For people who develop a chronic infection, there is treatment, and people with chronic infection do not necessarily develop liver damage.

If you’ve already got hepatitis C, it’s advisable to have the vaccination against hepatitis A and B to protect your liver from further damage.

Whether you have symptoms or not, don’t have sex until your healthcare professional says you can.

It’s usually possible to cure hepatitis C, but you’re not immune to future infections – which means you can get it again. You can also still get other types of hepatitis, and having hepatitis C together with another type is more serious.

Complications of hepatitis C

  • As with most STIs, hepatitis C puts you at risk of other STIs, including HIV.
  • Without treatment a pregnant woman with hepatitis C can pass it on to her unborn baby.
  • Without treatment, chronic hepatitis C can cause scarring of the liver (cirrhosis), which can cause the liver to stop working properly. A small number of people with cirrhosis develop liver cancer and these complications can lead to death. Other than a liver transplant, there’s no cure for cirrhosis. However, treatments can help relieve some of the symptoms.

HELP US HELP OTHERS

Avert.org is helping to prevent the spread of HIV and improve sexual health by giving people trusted, up-to date information.

We provide all this for FREE, but it takes time and money to keep Avert.org going.

Can you support us and protect our future?

Every contribution helps, no matter how small.

Photo credit: ©iStock.com/xrender

What Are the Chances of Getting Hep C Sexually?

Doctor’s Response

Sexual transmission of hepatitis C occurs, but this is quite infrequent. The frequency of sexual transmission increases if there is anal intercourse, or if intercourse takes place during menstruation. Transmission through kissing, especially if there are sores in the mouth, is theoretically possible, but has not been scientifically proven. Saliva is not infectious unless it contains blood. Sharing personal hygiene items such as toothbrushes and razors also can potentially transmit the infection.

Hepatitis C is only contracted through contact with another person who is infected with the hepatitis C virus (HCV). It is not acquired through contact with animals or insects.

Hepatitis C is present primarily in the blood, and to a lesser degree in specific other body fluids, of an infected person. Today, it is passed most commonly through sharing of used needles by injection drug users. Prior to 1990, it was commonly passed through blood transfusions. However, since 1990, all donated blood is tested for hepatitis C virus, so it is extremely rare for hepatitis C to be acquired through a blood transfusion.

Transmission of hepatitis C occasionally occurs in healthcare settings, such as hospitals and clinics, when established infection control protocols are not followed. Healthcare workers who do not follow these protocols can become infected if they sustain a needle stick from a patient who carries hepatitis C virus.
An uncommon, but real mode of transmission is through organ transplantation when the donated organ comes from a person who carries the hepatitis C virus. The use of HCV-positive organs is currently reserved for the most serious cases requiring transplantation.

Transmission of hepatitis C from an infected mother to a newborn does occur, but it is most common if the mother has measurable HCV in her blood. (See hepatitis C diagnosis section). Transmission is infrequent if the mother has no detectable hepatitis C virus in her blood. Breastfeeding has not been documented as a way to transmit hepatitis C.

Hepatitis C is associated with hemodialysis, a technique used to “clean” the blood in patients with end-stage kidney disease. Careful attention to sterilization of equipment and carefully following infection control procedures should reduce or eliminate dialysis-associated transmission of hepatitis C. Likewise, hepatitis C has rarely been transmitted by the use of other incorrectly sanitized medical equipment, which is preventable using correct infection control techniques.

Tattooing and body piercing have been documented to transmit the hepatitis C virus when recommended sterilization and infection control procedures are not followed.

Hepatitis C and sexual transmission

Introduction

Hepatitis C (also called hep C) is not classified as an STI (sexually transmissible infection) although people, unable to identify any other risk factors, may believe they may have contracted hep C sexually.

General transmission of hep C

Hep C is most commonly transmitted through blood-to-blood contact, i.e. when the blood of someone with the virus enters the bloodstream of someone else. This can occur through:

  • Sharing needles or syringes or any other drug injecting equipment
  • Unsafe tattooing or body piercing
  • Less common means are from mother to baby at birth (vertical transmission), household transmissions (e.g. sharing razors and toothbrushes) and occupational transmission (e.g. through needle-stick or sharps injuries).
  • There is no documented evidence that breastfeeding spreads hep C. If a nursing mother’s nipples are cracked and bleeding, she should stop nursing temporarily until her nipples are healed.
  • Before hep C tests were introduced in Australia (in 1990), some people received contaminated blood transfusions or blood products. All blood donations in Australia are now screened for hepatitis C.
  • Being hep C positive (also called “having chronic hep C”) means that you have tested positive with the hep C PCR blood test. Antibody tests can’t confirm whether or not you actually have hep C.

HCV transmission during sex: is it possible?

Some research suggests that a small percentage of people do contract hep C through blood-to-blood contact that may occur during sexual contact. Thus, transmission of hep C during sex is seen as possible but is believed to be rare.

If hep C is transmitted during sex, it is likely to be through blood-to-blood contact. This emphasises the need for safe sex practices where there is a risk of blood-to-blood contact, e.g. sex when you have cuts or lesions on or close to the genitals, during anal sex (because the anus lining is easily broken), during menstruation, and during sexual practices that may involve bleeding or broken skin.

Some studies suggest a slightly increased rate of hep C transmission in people with multiple sexual partners and high levels of sexual activity. These studies, though, have usually found it difficult to exclude other possible routes of transmission, e.g. injecting drug use.

Research increasingly suggests the risk of transmission of hep C through sexual contact among heterosexual people is minimal.

Sex and relationships

Because hep C is not classified as an STI, people with chronic hep C do not need to consider making dramatic changes within their sexual relationships.

It is currently believed that a decision to use safe sex practices depends on the nature of the sexual relationship.

With new or casual sexual partners, or any instances where there may be blood-to-blood contact during sex, safe sex practices should always be used to protect against the wide range of STIs.

Within monogamous sexual relationships where one or both partners is hep C positive and there is little risk of blood-to-blood contact, there is no need to adopt safe sex practices.

Safe sex and sexually transmitted diseases

All sexually active people should consider safe sex because of the risk of contracting a sexually transmissible infection. STIs include conditions such as genital herpes, HIV, hepatitis B, gonorrhoea, syphilis, chlamydia, crabs and genital warts.

If you have any condition that involves scratching, sores or blisters (especially when these may come into contact during sexual activity) the possibility of blood-to-blood contact and transmission of STIs is increased.

Men who have sex with men

In a nutshell, there is an increased risk of sexual transmission for men who have sex with men (if one or more partners has HIV).

It is estimated that up to 5 per cent of gay men and men who have sex with other men have hep C, compared with 1 per cent of the general population. Around 13 per cent of people with HIV in Australia also have hep C.

Among men who have sex with men, the risk of hep C being transmitted is higher if one or more partners has HIV, or if the sex involves blood-to-blood contact, of if they have other STIs, or if recreational drugs are used.

To reduce the risks:

  • use condoms and lots of lube for anal sex
  • wear gloves and use lots of lube for fisting
  • use condoms on toys and change them between partners, or wash toys with hot soapy water and dry them between partners
  • if affected by alcohol or recreational drugs, your judgement around risks will be impaired and you’ll have decreased inhibitions so take special care to avoid blood-to-blood contact.

Some men choose not to use condoms when having sex with other men who believe they have the same HIV status. This is called sero-sorting and can further increase people’s risk of contracting hep C.

For more information about anything in this factsheet, phone the Hepatitis Infoline on 1800 803 990.

This factsheet was developed by Hepatitis NSW. It was produced with assistance from NSW Health, Drs Ingrid van Beek, Alex Wodak and Leena Gupta, and Profs Geoff McCaughan, Geoff Farrell, Michael Kidd, Sue Kippax and Bob Batey. “Men who have sex with men and hep C transmission” section based on information provided by Positive Life NSW.

Hepatitis C: An In-Depth Guide

This FAQ answers some questions you may have about privacy, hepatitis C infection and the law. As a general rule, people have a right to keep their health information private, including information about their hepatitis C virus infection or disease. Generally, they do not have to disclose health information to other people unless they choose to do so.

Also, healthcare professionals and staff cannot tell other people about someone’s health information unless they are given permission (known as “consent”) to disclose the information.

But there are exceptions to these general rules, such as situations where there may be a legal duty for a person to disclose his or her HCV infection, or where someone else may have the legal power to disclose such information.

Read the entire FAQ below, or click on a link to skip to a specific situation:

  • Public Health
  • At home
  • At work
  • Accessing healthcare
  • Insurance
  • Having sex
  • Sharing drugs and drug equipment
  • Exposure by accident or during a crime
  • Disclaimer / For more information and advice

a) Public Health:

Hepatitis C is a reportable disease. This means that when a person is diagnosed with HCV his or her name (and likely other information) is given to local, provincial or territorial Public Health. Public Health officials have a responsibility to monitor cases of infectious diseases, including hepatitis C. Public health laws require certain health professionals (and sometimes labs and other people) to report cases of HCV infection to Public Health.

Public Health may keep a record or database of people who have been infected with infectious diseases such as hepatitis C. The database may include each person’s name, date of birth, gender, infection(s) and contact information. The type of information that gets reported to Public Health and stored in a database depends on the law and practice in that region. There are rules in place to protect the privacy of personal information stored by Public Health. For the rules in your region, contact your local Public Health office.

b) At home:

The hepatitis C virus is not transmitted by casual contact, such as sharing dishes, shaking hands and hugging. But blood and items that come in contact with blood may be infectious to other people. So it is important to be careful around blood and to avoid exposing other people to infected blood. As long as a person follows proper precautions there is really no risk of passing on HCV to the people he or she lives with, so there is no legal duty to disclose his or her hepatitis C infection to them. (See below for information about “Sharing drugs and drug equipment” and “Having sex.”)

c) At work:

Because HCV is not transmitted through casual day-to-day contact, employees do not have to disclose to employers or unions that they have hepatitis C. Employers cannot ask about a hepatitis C infection during the application or interview process.

Hepatitis C infection is considered a “disability” under antidiscrimination law in Canada. It is illegal for an employer or union to harass or discriminate against a person because of a “disability,” even if the only thing that limits the person’s ability to do the job is prejudice or stereotypes about the disability.

Employers and unions cannot fire or treat a person negatively because he or she is infected with HCV or needs some time off because of symptoms of hepatitis C or side effects of hepatitis C treatment. If a person is sick because of the virus or medications used to treat HCV, the employer or union may need to make “accommodations” so that the employee can continue to do the essential duties of the job. For example, this may mean working out a different work schedule or shifting some job duties to other employees. The employee will have to ask the employer (and union) to accommodate his or her disability but does not have to tell them that he or she has hepatitis C.

For more information about hepatitis C and work, see the pamphlet “Hepatitis C in the Workplace.”

d) Accessing healthcare:

People can choose whether or not to tell healthcare providers about their HCV infection. People with hepatitis C do not have a legal duty to tell them. However, people are encouraged to think about the benefits of disclosing to healthcare staff.

For example, it may be important for the healthcare provider to know about the hepatitis C infection in order to provide high-quality healthcare that will take into account the existing liver disease. If hepatitis C is not disclosed to a healthcare provider and the treatment provided causes harm because of the hepatitis C, it will be more difficult to hold the healthcare provider responsible for making a mistake.

It is not legal to refuse to provide services to people because of a “disability” and this can include healthcare services. For example, doctors should not discriminate against a person, refuse them as a patient or end the healthcare provider-patient relationship because of a “disability.” However, a healthcare provider may not have the skills or knowledge to treat a patient effectively, so they may refer that patient to another care provider and must clearly communicate the reasons to the patient.

If you believe that a medical professional has discriminated against you, there are at least three places you can find information on your options and rights. You can seek legal advice from a lawyer, contact the human rights commission or tribunal in your province or territory, or contact the provincial or territorial college (the governing and licensing agency) of the professional in question. You can find more information at the Canadian Human Rights Commission.

e) Insurance:

An insurance policy is a contract. When you apply for various types of insurance coverage (including health insurance) you may be asked to provide personal health information so that the insurance company can determine whether you are eligible for insurance and how much it will cost to get insurance. If you do not answer questions truthfully—for example, if a person does not report the he or she has the hepatitis C virus—and the insurance company finds out, the insurance policy will be void and the insurance company may claim that fraud was committed. Not all insurance policies require that you provide medical information in order to become insured. Policies that insure large groups of people, like insurance benefits that come with a job, often do not require this type of information.

f) Having sex:

Under Canadian criminal law, a person with a sexually transmitted infection has a legal duty to tell his or her partner about that infection before they have sex if the sex will involve a significant risk of serious bodily harm. It is unclear whether people infected with the hepatitis C virus have a legal duty to disclose to their sex partners before sex. However, until the courts figure this out, disclosure beforehand may be the safest way to avoid prosecution. As far as we know, there has only been one criminal prosecution in Canada involving hepatitis C. The accused person was acquitted because the judge decided that the evidence did not prove there was a significant risk of hepatitis C virus transmission during oral sex or sexual intercourse. However, until the courts figure this out, disclosure beforehand may be the safest way to avoid prosecution.

Under public health law in some provinces and territories, people have a legal obligation to not pass on infections like HCV—in other words, to protect sex partners from becoming infected through sex. That is why Public Health (or physicians and nurses working in cooperation with Public Health) often counsel people living with hepatitis C to disclose their HCV infection to sex partners and to practice safer sex, including using condoms for intercourse.

For more information on the sexual transmission of hepatitis C, see Safer Sex.

g) Sharing drugs and drug equipment:

The criminal law in Canada is not clear about whether a person has a duty to disclose his or her hepatitis C virus infection when sharing drugs and drug equipment. As far as we know, there has not been a case where a person with hepatitis C virus has been criminally charged for exposing someone to the virus by sharing drugs or drug equipment.

There is a high risk of transmitting HCV when an infected person shares equipment used to inject drugs (e.g., needles, filters, cookers). There is also a risk—a lower risk—of transmitting HCV when a person with hepatitis C shares drug smoking and drug snorting equipment. (See the Staying Safe section for more information on risk.) Because of these risks of transmission, it is possible that people have a legal obligation to tell people about their hepatitis C before they share drug equipment or to use harm reduction measures to reduce the risk of HCV transmission to drug sharing partners. But because there has never been a case about this, the criminal law is not clear about it.

Because of these risks of transmission, it is possible that people have a legal obligation to tell people about their hepatitis C before they share drug equipment or to use harm reduction measures to reduce the risk of HCV transmission to drug sharing partners. But because there has never been a case about this, the criminal law is not clear about it.

Under public health law in some provinces and territories, people have a legal obligation to not pass on infections such as HCV—in other words, to protect drug-sharing partners from becoming infected. That is why Public Health (or physicians and nurses working in cooperation with Public Health) often counsel people living with hepatitis C to avoid sharing drug use equipment. And many public health departments and community agencies provide access to harm reduction supplies, such as sterile needles and clean mouthpieces for crack pipes.

h) Exposure by accident or during a crime:

Five Canadian provinces have laws that can be used to force a person to get tested for hepatitis C after his or her blood or other bodily substance comes into contact with another person. The provinces are Alberta, Manitoba, Nova Scotia, Ontario and Saskatchewan. These laws say that a person can only be forced to take a blood test if a judge or medical officer of health orders the person to be tested. Before a judge or medical officer can make an order, he or she must be satisfied that there was a real risk of HCV transmission. Only certain people can apply for an order forcing someone to get tested—police, EMS workers, firefighters, other people who provide assistance during an accident or emergency, and victims of crime. These laws also apply to other infections transmitted by blood and other bodily substances, including hepatitis B and HIV.

Disclaimer / For more information and advice:

This FAQ is designed to provide you with basic information about HCV disclosure and the law. The difference between legal information and legal advice is important. Legal information can help you understand the law and legal options, but it is basic and general. Legal advice is specifically about your situation and can help you to decide what to do. If you want legal advice you should talk to a lawyer. The information in this FAQ was written in January 2011. But the law can change at any time, so contact a lawyer if you have a question.

Hepatitis is a viral infection that affects the liver.

How do you get it?

Hepatitis A

You can get hepatitis A through contaminated food or water and by not washing hands after the toilet or before touching food.

Hepatitis A can be spread through unprotected sex (no condom) which involves oral to anal contact (rimming).

Hepatitis B

Hepatitis B is spread:

  • by having unprotected (without a condom) vaginal, anal or oral sex with someone who is infected
  • from mother to baby
  • sharing items that may pierce the skin or have blood on them (needles, syringes, unsterilised instruments, razors, toothbrushes)
  • blood transfusion (in countries that do not pre-test blood for transfusion).

Hepatitis C

You can get hepatitis C through contact with infected blood, sharing needles, syringes and any other equipment and, possibly, through sexual contact. You can also get it with a blood transfusion in countries that do not pre-test blood for transfusion.

What are the symptoms of these infections?

Although there are often no symptoms, they can include:

  • yellowing of the skin and the whites of the eyes
  • dark urine
  • mild flu-like symptoms
  • abdominal pain
  • nausea.

How is it treated?

To recover, you should eat a well-balanced, low fat diet, and make sure you rest and get some exercise. It is best to avoid alcohol and drugs, as well as sexual contact, until you are better. If you are using any other medicines, check with your doctor that they don’t affect your liver.

There are vaccines available for hepatitis A and hepatitis B. These stop you getting the infection if the first place.

There are now some antiviral treatments for hepatitis C, so talk to your doctor about these.

Will it affect my partner/s?

If you have hepatitis A: Your partner/s should be immunised for prevention. You should avoid anal sex until you are better.

If you have hepatitis B: Free immunisation is available for household and sexual contacts of people known to carry hepatitis B. If your partner is not immunised, you should always use a condom. Protection is offered to babies on the immunisation schedule and to children under 16 years.

If you have hepatitis C: Anyone you’ve had sex with, or shared a needle with can have a blood test to check for hepatitis C antibodies.

PMC

What is hepatitis C?

It is a liver infection caused by the hepatitis C virus.

What are the symptoms?

When people are first infected with hepatitis C, some have symptoms such as nausea (feeling like they might throw up) and jaundice (yellow skin and eyes), but most have no symptoms. Sometimes the body can clear the virus on its own, but usually the virus stays in the liver.

People who have the virus in their liver for more than 6 months are known as hepatitis C carriers. Most carriers live for many years without major health problems, but some develop severe liver damage (cirrhosis) and cancer of the liver. These complications usually happen many years after the person first gets infected with hepatitis C.

How do children get hepatitis C?

Most children get it from their mothers at birth.

Before 1991, children sometimes got hepatitis C from blood transfusions. This almost never happens now.

Hepatitis C can also be spread from using intravenous drugs (drugs injected with a needle) or from tattoos done with needles and paints that have not been properly sterilized (cleaned). Very rarely, hepatitis C can come from having sex with a person who has the infection.

I am pregnant. Should I be tested for hepatitis C?

There is a blood test for hepatitis C. Doctors usually only test women who are at risk – especially women who have used intravenous drugs. You should ask to be tested if you have ever used intravenous drugs–even just once.

Women with hepatitis C may need antiviral drugs (medicines for treating viral infections) after the baby is born. Your baby will also need to be tested to see if he has hepatitis C.

There is no need to do a caesarian section just because you have hepatitis C.

How can I protect my baby from getting hepatitis C?

If you have hepatitis C, there is approximately 1 in 20 chance that you will pass it to your baby. The risk is higher if you also have HIV and are not being treated. To date, there is no way to prevent the spread of hepatitis C to the baby.

Can I breastfeed if I have hepatitis C?

Although we do not think hepatitis C is spread by breast milk, we cannot be 100% certain. If you are infected, you should discuss breastfeeding with your doctor. Most doctors think women with hepatitis C should breastfeed, unless they also have HIV.

What happens if my child has hepatitis C?

Approximately 1 in 4 children with hepatitis C clear the virus on their own. The others become carriers. Even though the virus stays in the liver of children who are carriers, most stay healthy.

Children who are hepatitis C carriers need to see their doctors regularly and have blood tests. Most do not need any medicine, but some will be treated with antiviral drugs to prevent severe liver damage (cirrhosis) or cancer of the liver.

For more information

  • Vertical transmission of the hepatitis C virus: Current knowledge and issues, a position statement developed by the Infectious Diseases and Immunization Committee <http://www.cps.ca/english/publications/InfectiousDiseases.htm>.

DOCTOR’S VIEWS ARCHIVE


Topic: Hepatitis C, June 2000

Dr. Lee:
Who are at increased risk of getting hepatitis C? Can hepatitis C be transmitted sexually?

Dr. Edward Block:
Blood transfusion used to be a major risk factor. Fortunately, as a result of the increased stringency requirements, blood transfusions are no longer a major risk factor in this country. So, our viewers should know that if they should ever require a blood transfusion, they should feel fairly secure because the risk for hepatitis C exposure from blood transfusion is very small.

At this time, the principal risk for acquiring hepatitis C appears to be the use of injection drugs, primarily IV drug abuse. IV drug users comprise upwards of 40% of those who are diagnosed with new cases of hepatitis C. Other high-risk activities include other drug use (including intra-nasal cocaine use). People with multiple sex partners are also considered to be at high risk (although the actual risk of sexual transfer of this disease is thought to be relatively low).

Dr. Lee:
As opposed to, let’s say, sexual transmission of Hepatitis B.

Dr. Edward Block:
Yes, as opposed to hepatitis B, the risk of sexual transmission of hepatitis C is small.

There is probably some small risk of sexual transmission here and certainly it would be prudent to tell our viewers that if they are known to be hepatitis C positive and are single that they should take appropriate precautions, such as the use of condoms.

The more difficult issue is how to counsel husbands and wives. My advice is that if you have been living successfully with some one for many years and that someone is diagnosed as having hepatitis C, yet you are still infection free, then sexual activity should continue unchanged.

People receiving tattoos are also felt to be at risk, particularly if needles have been reused.

There are some household risks to people who live with patients who have hepatitis C through use of utensils that could possibly spread blood. People in prisons have an increased risk.

The published answers represent the opinions and perspectives of the doctors and pharmacists of MedicineNet.com and are for educational purposes only. They should not be used to replace or substitute for timely consultation with your doctor. Accuracy of information cannot be guaranteed.

Please remember, information can be subject to interpretation and can become obsolete.

Back to Doctors’ Dialogue Index

CONTINUE SCROLLING FOR RELATED SLIDESHOW

Norah A. Terrault Gastroenterology Division, Department of Medicine, University of California, San Francisco, CA. Hepatology November 2002
“…..While there is sufficient evidence to support the conclusion that sexual transmission of HCV occurs, quantifying the magnitude of an individual’s risk of HCV acquisition by sexual contact is more difficult….”
ABSTRACT. The accumulated evidence indicates that hepatitis C virus (HCV) can be transmitted by sexual contact but much less efficiently than other sexually transmitted viruses, including hepatitis B virus and human immunodeficiency virus (HIV). However, because sex is such a common behavior and the reservoir of HCV-infected individuals is sizable, sexual transmission of HCV likely contributes to the total burden of infection in the United States.
Risk of HCV transmission by sexual contact differs by the type of sexual relationship. Persons in long-term monogamous partnerships are at lower risk of HCV acquisition (0% to 0.6% per year) than persons with multiple partners or those at risk for sexually transmitted diseases (0.4% to 1.8% per year). This difference may reflect differences in sexual risk behaviors or differences in rates of exposure to nonsexual sources of HCV, such as injection drug use or shared razors and toothbrushes. In seroprevalence studies in monogamous, heterosexual partners of HCV-infected, HIV-negative persons, the frequency of antibody-positive and genotype-concordant couples is 2.8% to 11% in Southeast Asia, 0% to 6.3% in Northern Europe, and 2.7% in the United States.
Among individuals at risk for sexually transmitted diseases (STDs), the median seroprevalence of antibody to HCV (anti-HCV) is 4% (range, 1.6% to 25.5%). HIV coinfection appears to increase the rate of HCV transmission by sexual contact.
Current recommendations about sexual practices are different for persons with chronic HCV infection who are in steady monogamous partnerships versus those with multiple partners or who are in short-term sexual relationships.
What factors increase the risk of HCV transmission by sexual contact?
HIV coinfection is associated with higher rates of anti-HCV in persons engaged in higher-risk sexual practices. Additionally, in studies of STD clinic attendees and men having sex with men, other STDs (herpes simplex virus, Trichomonas, gonorrhea) and sexual practices that may traumatize the mucosa (e.g., anal receptive sex) are more frequent in anti-HCV positive than anti-HCV negative individuals, suggesting these factors increase the sexual transmission of HCV. Whether the risk of HCV transmission differs for males versus females is unclear. In one study of heterosexual couples in STD clinics, anti-HCV–positive female clinic attendees were 3.7 times more likely to have an anti-HCV-positive male partner than the anti-HCV-positive male clinic attendees. The titer of HCV RNA and HCV genotype do not appear to influence the risk of HCV transmission, but high-quality studies to assess these virological factors are lacking. The stage or clinical status of liver disease of the HCV-infected individual is also not predictive of transmission risk. However, studies to date have focused only on individuals with chronic disease; whether individuals with acute hepatitis represent a subgroup at particular risk for HCV transmission is unknown.
Current recommendations are as follows:
1. HCV-positive individuals in longer-term monogamous relationships need not change their sexual practices. If couples wish to reduce the already low risk of HCV transmission by sexual contact, barrier precautions may be used. Partners of HCV-positive persons should be considered for anti-HCV testing.
2. For HCV-infected individuals with multiple or short-term sexual partners, barrier methods or abstinence are recommended.
The following are additional “common-sense” recommendations:
3. Use of barrier precautions if other STDs are present, if having sex during menses, or if engaging in sexual practices that might traumatize the genital mucosa.
4. Couples should not share personal items that may be contaminated by blood such as razors, toothbrushes, and nail-grooming equipment.
Future research needs
Additional prevalence and incidence studies may help to refine the current estimates of risk but will not be predicted to substantially change the overall findings of a low risk of HCV transmission by sexual contact. To be informative, such studies must include detailed virological analyses of antibody- and genotype-concordant sexual partners and perform complete ascertainment of nonsexual sources of HCV. Because the rate of transmission is low, a large sample size (greater than 1,000 individuals and/or partners) would be required to have sufficient power to determine the specific factors associated with HCV transmission. Given the cost, time, and logistics of executing large prevalence and incidence studies, and the questionable ability of such studies to advance our knowledge about key features of sexual transmission of HCV, alternative research strategies are necessary.
The key research questions relate to identifying the specific factors that promote or prevent sexual transmission of HCV. Issues of critical importance include whether the level of HCV RNA predicts risk of transmission, if other STDs such as herpes simplex virus 2 or Trichomonas increase the risk of HCV acquisition, whether specific sexual practices (e.g., anal versus vaginal sex) affect the risk of HCV, whether transmission is more likely to occur during acute rather than chronic hepatitis C, and whether females are at higher risk of HCV acquisition through sex than males. The insights gained by addressing these specific questions will allow more detailed future recommendations for HCV-infected persons and their sexual partners and ultimately lead to interventions that may reduce the risk of transmission of HCV through sexual contact.
BACKGROUND
Percutaneous exposures, such as blood transfusion and injection drug use, are well-established risk factors for hepatitis C virus (HCV) infection. The risk of HCV transmission by sexual contact, however, is less well defined. The accumulated epidemiologic evidence indicates that HCV can be transmitted by sexual contact but much less efficiently than other sexually-transmitted viruses, including hepatitis B virus and human immunodeficiency virus (HIV).
There are several case reports of acute hepatitis C occurring in persons whose only risk factor appeared to be a HCV-infected sexual partner. The strength of these reports lay in their ability to document seroconversion in an individual at risk in temporal relationship to sexual activity with an HCV-infected partner. The mode of transmission was ascertained by carefully questioning the infected individual to exclude nonsexual sources of HCV. A high degree of sequence homology between the viral strains in the sexual partners provided virological confirmation that a transmission event had occurred.
While there is sufficient evidence to support the conclusion that sexual transmission of HCV occurs, quantifying the magnitude of an individual’s risk of HCV acquisition by sexual contact is more difficult. Epidemiologic studies have had several methodological shortcomings that tend to overestimate the proportion of HCV infections attributed to sexual contact. Early studies used first-generation antibody to HCV (anti-HCV) assays which have a higher false positive rate than second- and third-generation assays. Studies varied in the completeness of risk ascertainment in partners, and many failed to carefully exclude HCV acquisition from nonsexual sources:
When evaluating a partner for possible acquisition of HCV through sexual contact, it is essential to exclude other sources of HCV. The female partner may have her own risk factor for HCV infection, such as a prior history of injection drug use or blood transfusion (A). Alternatively, she may have been infected by her partner, but the mode of transmission may have been nonsexual, such as sharing of needles, razors, or other contaminated personal items.
Nondisclosure of injection drug use is particularly important because assessing the independent contribution of sexual activity in HCV transmission is difficult in the presence of injection drug use. Finally, only a limited number of studies performed virological analyses to confirm that anti-HCV concordant sexual partners were infected with the same virus.
Sexual transmission has been evaluated in different populations of HCV-infected individuals. Two main risk groups are discernable: (1) those who are more sexually promiscuous and likely to have multiple sexual partners, including female sex workers, men having sex with men, those in HIV surveillance studies, and attendees of sexually-transmitted diseases (STDs) clinics; and (2) those in steady monogamous sexual relationships. Rates of anti-HCV positivity vary by risk group, with higher rates of HCV reported in persons at risk for STDs and lower rates in heterosexual partners in long-term relationships. This difference in rate of HCV infection may reflect differences in sexual risk behaviors (frequency or type of sexual activities). Alternatively, differences between risk groups may reflect differing rates of exposure to nonsexual sources of HCV, such as injection drug use, as well as other potential risk factors such as intranasal cocaine use and tattooing, or sharing of razors and toothbrushes. The findings regarding sexual transmission defined by one risk group may not be generalizable to others.
Detection of HCV RNA in Bodily Fluids
Sexual transmission of virus occurs when infected body secretions or infected blood are exchanged across mucosal surfaces. The presence of virus in body secretions is necessary but may not be sufficient for transmission to occur. Other factors that may influence transmission include the titer of virus in body secretions, the integrity of the mucosal surfaces, and the presence of other genital infections (viral or bacterial).
Studies to detect HCV RNA in semen (seminal fluid and cells), vaginal secretions, cervical smears, and saliva have yielded mixed results. Failure to detect HCV RNA in body secretions may be caused by technical factors, including specimen collection and storage, and the ability to exclude cellular components and to overcome the presence of polymerase chain reaction inhibitors. Even in studies using optimal methods to isolate HCV RNA, the minority of samples were positive for HCV RNA and all positive samples were of low titer (equal to 102 copies/mL). A low titer of virus in genital secretions may be one reason that HCV is transmitted less efficiently than hepatitis B virus or HIV. Additionally, there may be an absence of suitable target cells in the genital tract to allow infection to occur or infection may require the presence of abnormal mucosa. Finally, while the presence of HCV RNA in semen and vaginal or cervical secretions supports the contention that HCV is sexually transmissible, a cell culture system or animal model is needed to prove that the HCV RNA detected in genital secretions represents infectious virus.
How prevalent is the risk factor of sexual activity in acute hepatitis C?
The Centers for Disease Control and Prevention collects detailed risk factor data on cases of acute hepatitis C identified through the Acute Hepatitis Sentinel County Surveillance program. Between 1995 and 2000, 18% of individuals with acute community-acquired HCV infection reported sexual contact with an anti-HCV–positive person in the preceding 6-month period (two thirds of cases) or multiple sexual partners (one third of cases) as their only risk factor for HCV acquisition. Currently, sexual activity ranks as the second most common risk factor for HCV reported by individuals with acute hepatitis. This suggests that sexual transmission may contribute significantly to the total burden of HCV infection in the U.S. population.
What is the prevalence of HCV in persons at risk for STDs?
In U.S. seroprevalence studies conducted among those at risk for STDs, 1.6% to 25.5% of individuals were anti-HCV positive (Table 1).
Table 1. Seroprevalence of anti-HCV among individuals at risk for STDs
First you’ll see listed below the risk group, followed by the % HCV-infected (range & average, followed by the factors associated with being antibody HCV+.
Female sex workers
1%-19% (6%); Number of partners, other STDs, non-use of condoms, sex with trauma
MSM
2.9%-13% (4%); With IDU included: risk for IDU > sexual factors; if IDU excluded: anti-HIV positivity, number of partners
STD clinic attendees
1.6%-26% (4%); With IDU included: risk for IDU > sexual factors
1.6%-7% (if no IDU history); If IDU excluded: number of recent and lifetime sexual partners, high-risk sexual contacts, anti-HIV positivity
Abbreviations: STDs, sexually transmitted disease(s); MSM, men who have sex with men; IDU, injection drug use; HIV, human immunodeficiency virus.
Median rates of anti-HCV positivity were 6% among female sex workers, 4% among men having sex with men, and 4% among attendees of STD clinics and individuals participating in HIV surveillance studies (Table 1). The HCV seroprevalence rates were lower than other viral infections such as hepatitis B virus and HIV.7 In those studies including persons with a history of injection drug use, anti-HCV positivity was more strongly associated with drug use than with factors related to sexual practices. In those studies limited to individuals without a history of injection drug use, factors predictive of anti-HCV positivity included the number of recent and lifetime partners, high risk sexual practices (variably defined), other STDs, and anti-HIV positivity. These factors are consistent with a sexual route of transmission.
In persons engaged in higher-risk sexual behaviors, those with HIV infection were more likely to be anti-HCV positive (odds ratio, 2.5 to 4.4) than those who were HIV negative, even after controlling for other sexual factors that might enhance risk of transmission such as number of partners, non-use of condoms, and other STDs. The precise mechanism by which HIV increases the risk of sexual transmission of HCV is unknown.
What is the prevalence of HCV infection in monogamous heterosexual partners?
Seroprevalence studies in monogamous, heterosexual partners of HCV-infected, HIV-negative persons have reported prevalence rates ranging from 0% to 24% in studies from Southeast Asia and Southern Europe but lower rates in studies from the United States and Northern Europe. North America: 2-4.8%; South America: 11.8%; Africa: 5.6%-20.7%; Europe 0-5%; Asia: 8.8%-27%.
The factors most consistently associated with HCV positivity among heterosexual partners were the presence of percutaneous risk factors for HCV (injection drug use, blood transfusion, sharing glass syringes). Early studies found the rate of HCV positivity in partners increased with the longer duration of marriage, suggesting risk of sexual transmission correlated with frequency of contact. However, subsequent studies adjusting for age did not find a consistent relationship between the duration of the sexual relationship and HCV positivity in partners.
The majority of published studies did not evaluate antibody-concordant couples with additional virological testing to confirm that partners were infected with the same virus. In the more informative studies, genotyping was used to evaluate antibody-concordant couples. In all cases, use of genotyping led to a reduction in the estimated rate of transmission by sexual contact.
Genotyping, however, is suboptimal for determining whether partners are infected with the same virus because HCV genotypes that are prevalent in the population may be present in both partners but represent HCV infection from different sources. The importance of nucleotide sequencing was highlighted in a detailed study of 24 anti-HCV concordant heterosexual couples from France. The investigators found 12 of the 24 couples (50%) had concordant genotypes, 7 had discordant genotypes, and 5 were untypable. Seven of the 12 genotype-concordant couples were further analyzed by sequence analysis of the hypervariable region of E2 (envelope region of the HCV genome) and only 3 couples had highly homologous viral strains that were consistent with a transmission event. Interestingly, in each of the 3 concordant couples, an alternative, nonsexual mode of HCV transmission was present. Thus, overestimation of the rate of sexual transmission of HCV occurs if antibody testing alone is used to assess sexual pairs. Based on only those seroprevalence studies using genotyping or sequence analysis to evaluate antibody concordant couples, the estimated prevalence of HCV among heterosexual couples in monogamous relationships is 2.8% to 11% in Southeast Asia, 0% to 6.3% in Northern Europe, and 2.7% in the United States.
The U.S.-specific published data are sparse, with 1 small study (N = 42) conducted in heterosexual partners of patients attending a liver clinic and 2 studies conducted in hemophiliacs (variable proportion HIV coinfected). Seroprevalence rates varied from 2.0% to 4.8%. Preliminary data from the HCV Partners Study, a cross-sectional study of heterosexual monogamous couples, provides the best available estimate of risk among U.S. couples. In this study, which excludes couples in which injection drug use is present in both partners, the prevalence of anti-HCV among 401 partners was 4.2%, with genotype concordance present in 2.7% of couples (Terrault N, unpublished data).
What is the incidence of HCV infection in “at risk” individuals?
A prospective cohort study of discordant couples followed closely for newly acquired infection is the ideal method to characterize the risk of transmitting HCV through sexual contact. However, even this method may not be perfect because the exclusion of couples in which the partner is already infected may leave a more selected and less representative population of sexual partnerships for follow-up.
In retrospective cohorts of female partners of hemophiliacs, the incidence of HCV infection, defined by presence of anti-HCV, was 1 to 1.87 per 1,000 person-years; among male partners of women infected by contaminated anti-D immunoglobulin, it was 0.28 per 1,000 person-years; and among liver clinic patients and their sexual partners it was 1 to 3.86 per 1,000 person-years.
In a prospective cohort study of 499 Italian heterosexual monogamous couples followed for a mean of 12.4 months, the incidence of new infection in sexual partners was 12 per 1,000 person-years. Sequence analysis of the anti-HCV positive couples showed a high degree of sequence homology in only 50% of couples, suggesting a true incidence of 6 per 1,000 person-years.29 In another prospective cohort of 112 Taiwanese couples followed for an average of 46 months, the incidence was 2.3 per 1,000 person-years. The variability in risk of HCV infection reported in studies of long-term partners may reflect differences in the frequency or types of sexual activity in the different populations, but more likely represents differences in the rates of nonsexual HCV transmission.
The incidence of new HCV infections among individuals who are at risk for sexually transmitted diseases is higher than in monogamous heterosexual couples. In prospective studies conducted in sex workers and attendees of STD clinics who were not injection drug users, the incidence of HCV was 0.4 to 1.8 per 100 person-years with follow-up periods of 1 to 3.7 years. In retrospective cohorts of hemophiliacs with high rates of HIV and HCV coinfection (more than 50%), the incidence of HCV infection was 0 to 0.19 per 100 person-years in sexual partners (primarily females) with a median follow-up of 12 to 15 years. In these coinfected cohorts, HIV was transmitted more frequently than HCV, and partners were more likely to be infected with HIV and HCV than HCV alone.
Summary
The available data indicate HCV can be sexually transmitted, but the efficiency of transmission by the sexual route is low. Nonetheless, because sex is a common behavior and the reservoir of HCV-infected individuals is substantial (approximately 2.7 million), sexual contact likely contributes to the total burden of HCV infection in the United States. The contribution of sexual transmission is supported by findings from the Acute Hepatitis Surveillance Study, in which 18% of newly infected individuals reported sexual contact with an HCV-infected person or multiple sexual partners as their only risk factor for HCV acquisition.
For the individual with chronic HCV infection, the estimated risk of sexual transmission of virus is 0% to 0.6% per year for those in monogamous relationships, and 1% per year for those with multiple sexual partners. Because risk varies by type of sexual relationship, the recommendations for preventing transmission of HCV differ for those in monogamous relationships versus those with multiple or short-term sexual partners. The latter group is not only at risk for HCV acquisition, but also for other types of sexually transmitted diseases, including HIV.

About the author

Leave a Reply

Your email address will not be published. Required fields are marked *