PA’s hepatitis editor Andrew Reynolds answers frequently asked questions about hepatitis C—what you should know

1. What is hepatitis C?

“Hepatitis” means “inflammation of the liver.” There are lots of things that can cause hepatitis, or liver inflammation, including certain medications, excessive amounts of alcohol, and other diseases as well as viruses. Hepatitis can be both short-lived (called “acute”) or ongoing (called “chronic”). 

Hepatitis C virus (HCV) is transmitted from blood-to-blood contact that leads to either acute or chronic infection, and can lead to long-term liver damage. If chronically infected, HCV infects the cells of the liver, where it reproduces. Over time, this can lead to scarring and as more and more scarring occurs, it can lead to cirrhosis (where the scars build up and cause malfunction) and serious liver problems. Fortunately, HCV can be cured, preventing further liver damage and reducing the risk of developing liver cancer and other problems.

There are other hepatitis viruses. Hepatitis A and B are vaccine preventable, and hepatitis D and E are very rare in the U.S. There is no vaccine for HCV.

2. How is hepatitis C transmitted?

Hepatitis C is mainly transmitted from blood: When HCV-infected blood gets into you. The main way it is transmitted today is through the sharing of injection equipment: syringes, cookers, cotton, and water. If HCV infected blood gets in or on any of these injection items (“works”), they can transmit HCV to the next person who uses them. 

Hepatitis C is not commonly transmitted through sex, especially in HIV-negative heterosexuals. In people living with HIV, especially men who have sex with men (MSM), the risk is higher and sexual transmission of HCV does happen in this group. HCV has been found in the semen and rectal fluids of HIV-positive MSM; sexual practices that can lead to bleeding, including but not limited to fisting and rough sex toy play, can transmit the virus during sex.

3. What are the symptoms of hepatitis C infection?

The most common symptom is actually no symptom! Hepatitis C is called “The Silent Epidemic” for a reason: most people who get infected with it, never know they have it. The only way to know for sure is to test for it. 

That said, there are different symptoms for different stages. In the acute stage (early infection), there can be flu-like symptoms, dark urine, and clay-colored stools (poop). In the chronic stage (living with HCV until cured), there can be skin problems, cryoglobulinemia (blood disorder), and peripheral neuropathy (discomfort or pain in the hands and feet). In end-stage with cirrhosis (after living with HCV for 20-30+ years for most), there can be fluid retention (especially in the abdomen and legs), cognitive dysfunction or mental confusion, and severe itching. All stages experience fatigue, loss of appetite, and jaundice (yellowing of the skin or eyes). This list is not exhaustive.

Talk with your provider if you experience any symptoms. It’s better to be safe than sorry! Many can be managed or treated, and once a person is cured, many of them can go away or become much less problematic.

4. How do I test for hepatitis C?

Hepatitis C testing is a two-step process: first, you take an HCV antibody test; and second, you confirm the result with a viral load (HCV RNA) test. 

The HCV antibody test will come up either negative or positive. However, there’s a window period before antibodies appear, similar to HIV. It may take up to 6 months to develop HCV antibodies after your most recent exposure. About 1 in 4 persons will clear hepatitis C on their own within six months of infection, but they’ll still always show “positive” on an antibody test. Therefore, you’ll need to get a viral load test too. If you clear HCV, these antibodies cannot protect you from another hepatitis C infection. So, it’s important to protect yourself from re-infection.

A viral load test confirms a positive antibody test. If it comes back positive, then you are chronically infected, meaning that you will have it for the rest of your life until you get cured. 

A negative HCV antibody test result with a positive viral load test means (1) you were very recently infected and your body hasn’t yet produced enough antibodies to come back antibody-positive, or (2) you have a weakened immune system (low CD4 cells) and your body may not be able to produce enough antibodies in response to HCV. In either situation, discuss this with your medical provider.

5. Who should get tested for hepatitis C?

This one is now easy to answer: Everyone! HCV testing is now recommended for everyone over the age of 18 without the need to ask about potential risk factors. Some people, such as those who inject drugs, will need to test routinely. 

Risk factors

Anyone with risk factors for HCV should be tested on an ongoing basis if the risks continue. The frequency of testing should be at least once per year, but you may want to do it more frequently if you are injecting drugs or are living with HIV and sexually active.

The following risk behaviors or potential exposures call for routine HCV testing:

  • injection drug use, even if just once in your life
  • intranasal drug use (sniffing from a straw)
  • any incarceration
  • getting a tattoo in an unregulated setting
  • long-term hemodialysis
  • child born to a mother with HCV
  • blood exposures on the job, including needle sticks or blood splashes to the eyes

Past medical procedures

Today’s blood supply and blood products are very safe, as are organs for transplant. That said, HCV is a relatively recent discovery; we did not screen for it prior to July 1992. You should test for HCV if you received:

  • a blood transfusion before July 1992
  • an organ transplant before July 1992
  • clotting factors before 1987 (clotting factors now have all viruses removed, including HCV by coincidence, hence the difference from blood transfusions or organ transplants)

Other conditions and circumstances

  • HIV infection
  • people starting PrEP (pre-exposure prophylaxis)
  • people on PrEP (recommended monitoring)
  • organ donors
  • people with unexplained chronic liver disease

6. Can hepatitis C be cured?

Yes, and it is really pretty easy to cure these days! The old days of HCV treatment where you had to take pills every day and do an injection once a week for a year and maybe get lucky and get cured are long behind us. Today, HCV direct-acting antivirals, or DAAs, are all oral (pills only), and taken once per day for as little as 8-12 weeks (rarely 24 weeks). They are usually very well tolerated with few side effects, all of which are usually very mild. Once cured, your risk of ongoing HCV-related liver disease will stop and you’ll likely reap a host of additional health benefits.

Benefits of HCV cure

  • Negative HCV viral load for life
  • Disappearance of HCV from the liver
  • Normalization of AST, ALT, and GGT (liver function enzymes)
  • Platelet increase in patients with thrombocytopenia
  • Reduced risk of developing cirrhosis
  • Reversion of fibrosis and, in some cases, cirrhosis
  • Disappearance of esophageal varices (dilated blood vessels in the esophagus), which can burst
  • Reduced risk of progression to liver cancer
  • Reduced risk of decompensated liver disease
  • Reduced risk of progression to liver failure and liver transplant
  • Eliminates risk of transmission to drug using or sexual partners
  • Eliminates risk of mother-to-child transmission
  • Improved quality of life
  • Reduction of psychological distress (anxiety, depression, etc.)
  • Elimination of HCV-related stigma
  • Lessens healthcare utilization and costs
  • Return to the workforce and/or improved productivity

SOURCE: Rui Marinho, 2014

HCV testing now free

According to the Hepatitis Plan (see Briefly), “In 2020, the U.S. Preventive Services Task Force (USPSTF) issued a Grade B recommendation that all adults aged 18–79 years be screened for hepatitis C, which will result in hepatitis C screening without cost-sharing [such as co-pays] for most people with Medicare, Medicaid, or private health insurance. These updated screening recommendations should result in greater numbers of adults being diagnosed with hepatitis C. However, these screening recommendations will only reach people engaged in the health care system.”