Hepatitis CAbout Hepatitis C
Viral hepatitis is inflammation of the liver caused by a virus. There are five different hepatitis viruses, hepatitis A, B, C, D
Transmission: Hepatitis C is mainly spread through blood-to-blood contact. In rare
Prevention: There is no vaccination for hepatitis C. It is
Treatment: Treatment for chronic hepatitis C aims to eradicate the virus. There is an increasing use of
About Hepatitis C
The hepatitis C virus is a member of the flavivirus family of ribonucleic acid (RNA) viruses. The virus reproduces by making many copies of itself in liver cells.
The hepatitis C virus does not kill liver cells directly, but the immune response initiated by the presence of the virus in the liver can cause liver inflammation and cell death. (Farrell, G.C. 2002)
There are six main genotypes (strains) of hepatitis C. Each genotype contains numerous subtypes, labelled a, b, or c. Genotypes 1a and 1b (54% prevalence) and 3a (37% prevalence) are the most common genotypes in Australia. (McCaw, R., et al. 1997)
Hepatitis C was discovered by scientists in 1988 and found to be responsible for most of the cases of non-A, non-B hepatitis. Early studies confirmed that hepatitis C was spread through blood-to-blood contact. An accurate test to diagnose hepatitis C became available in Australia in 1990. The test detected antibodies produced in reaction to the hepatitis C virus.
It is estimated that 130-150 million people worldwide are chronically infected with hepatitis C. (WHO Hepatitis C Fact Sheet)
In Australia, it is estimated that 230,470 are living with chronic hepatitis C. (Kirby Institute, Annual Surveillance Report (ASR) 2015 – p12)
The estimated number of new cases diagnosed of hepatitis C infection has declined from 16,000 in 2001 to 10,261 in 2011. The majority of these had hepatitis C for some time.
In 2011, 80% of newly acquired hepatitis C infections (within that last two year) were identified as having resulted from unsafe injecting drug use. The number of new infections where the exposure category was undetermined increased to 106 from 75 in 2010. The remaining people with hepatitis C were infected in other ways, including:
- unsterile tattooing or body piercing procedures
- unsterile medical procedures or vaccinations (particularly in countries with high rates of hepatitis C)
- needle-stick injuries and accidental exposure to infected blood or blood products
- exposure to blood in the home
- some other form of blood-to-blood contact.
Some people with hepatitis C cannot identify how they were infected.
Farrell, G. C. (2002). Hepatitis C, other liver disorders, and liver health: A practical guide. Sydney, Australia: MacLennan and Petty Pty Limited.
McCaw, R., Moaven, L. D., Locarnini, S. A. & Bowden, D. S. (1997). Hepatitis C virus genotypes in Australia. Journal of Viral Hepatitis.
The World Health Organisation (WHO) (2014). Hepatitis C Fact Sheet. Available from: http://www.who.int/mediacentre/factsheets/fs164/en/index.html. Accessed 15 July 2014.
The Kirby Institute (2012). HIV, viral hepatitis and sexually transmissible infections in Australia Annual Surveillance Report 2012. The Kirby Institute, The University of New South Wales, Sydney, NSW. Available from: http://www.kirby.unsw.edu.au/surveillance/2012-annual-surveillance-report-hiv-viral-hepatitis-stis. Accessed 17 October 2012.
National Centre in HIV Epidemiology and Clinical Research (NCHECR) (2010). Estimates and projections of the hepatitis C virus epidemic in Australia.
Poynard, T., Ratziu, V., Charlotte, F., Goodman, Z., McHutchison, J. G. & Albrecht, J. (2001). Rates and risk factors of liver fibrosis progression in patients with chronic hepatitis C. Journal of Hepatology.
Transmission of Hep C
The hepatitis C virus is found in blood. Blood containing the virus must enter the bloodstream of another person for transmission to take place. This is called blood-to-blood contact. Even invisible (microscopic) amounts of blood can transmit hepatitis C. This section outlines some of the more common ways of transmitting hepatitis C through blood-to-blood contact.
Understanding how hepatitis C is transmitted is equally important for people who are already hepatitis C positive so they can reduce the chance of:
- being infected with another genotype of hepatitis C;
- being reinfected with the same genotype of hepatitis C; and
- transmitting hepatitis C to another person.
Currently in Australia, the greatest risk for the transmission of hepatitis C is through blood-to-blood contact involving the sharing, or re-using of injecting equipment such as needles and syringes. Other injecting equipment, surfaces used for mixing up, disposal containers, hands and puncture sites can become contaminated during the injecting process and also pose a risk of transmission. Some people who have only injected drugs once or twice in their life have become infected with hepatitis C. Some people choose other ways of consuming drugs, such as snorting or swallowing.
If you do inject drugs, there are ways you can reduce your risk of hepatitis C and other infections passed on by blood to blood contact such as HIV and hepatitis B. If you inject drugs, always wash your hands, wipe down the preparation area 1 part bleach to 10 parts water and always inject with:
- clean hands (wash your hands thoroughly);
- a clean injecting space;
- a new fit (syringe);
- new sterile water;
- new swabs (at least one to swab your spoon and one to swab your injecting site – remember to swab in one direction only, rubbing back and forth with a swab spreads dirt and germs);
- your own tourniquet – never share;
- new filter;
- a clean spoon; and
- an approved disposal bin (always dispose of your fits in a puncture proof container).
For more information on safer injecting practices please contact your local peer-based user group for copies of the Guide to Safer Injecting developed by the Australian Injecting and Illicit Drug Users League.
Blood Transfusions and Blood Products
The Australian Red Cross Blood Bank now tests all donated blood and blood product for hepatitis C virus and antibodies. Screening for hepatitis C began in February 1990. Before this time, some people were infected with hepatitis C when they received blood or blood products contaminated with the virus.
Tattoos and Body Piercing
A small number of people have been infected with hepatitis C through unsterile tattooing, or body piercing procedures. Anyone considering a piercing or a tattoo should make sure that their tattoo artist or body-piercer applies infection-control procedures, which means using single-use disposable needles, dye tubs, surgical gloves, and so on. You have the right to ask the practitioner about their use of standard infection control procedures and their understanding of why these procedures are important.
If you get a tattoo or piercing in a juvenile detention centre, prison or by a backyard operator, your chance of becoming infected with the hepatitis C virus is very high. The equipment is not sterile and has probably been used on other people before your turn. Don’t get a tattoo or piercing in these settings.
Pregnancy and Breastfeeding
Research shows that the risk of transmission to a baby during pregnancy or childbirth is low. The risk is about 6% if you have detectable levels of the virus in your blood, that is, if you have a PCR test that shows the presence of the virus in your blood.
(Dore GJ, Kaldor JM, McCaughan W. – 1997)
Women with very low levels of the virus (where PCR test showed negative for the presence of hepatitis C in the blood) are highly unlikely to transmit hepatitis C to their baby. However, women co-infected with both HIV and hepatitis C have a higher risk of transmitting hepatitis C to their baby.
There are no confirmed reports of hepatitis C transmission from mother-to-baby through breast milk and the current scientific opinion remains that there is no significant evidence of HCV transmission through breast-feeding. Scientists have found traces of the virus in some breast milk and colostrum (the breast fluid produced by the mother in the first few days of breastfeeding) but not enough to transmit hepatitis C. Damage to the nipples such as cracked and bleeding nipples could pose a possible risk to the baby if blood-to-blood contact occurs through small tears or scratches in or around the babyâ€™s mouth. Therefore, it is recommended that women with hepatitis C who have cracked or bleeding nipples should express and discard their breast milk while their nipples are cracked.
Transmission in Health Care Setting
Some people in Australia contracted hepatitis C through unsterile medical injections (such as vaccinations)and other medical procedures in their country of origin. The risk of transmission of hepatitis C through unsterile medical procedures has been virtually eliminated in Australia since the introduction of standard infection-control procedures (Standard Precautions).
Standard Precautions are guidelines for infection control, and assume that all blood and body fluids are contaminated.
Some Standard Precautions Include:
- using gloves when cleaning up blood spills;
- carefully wiping up any blood spills with a paper towel, and washing the area with soapy water and then, if there is a possibility of bare skin contact, disinfecting the area with household bleach;
- completely covering any cuts or wounds with a waterproof dressing or a band-aid; and
- placing bloodstained tissues, sanitary towels or other bloodstained dressings in a leak-proof plastic bag before disposal.
The Infection Control Guidelines for the Prevention of Transmission of Infectious Diseases in the Health care setting, 2004 edition, have now been superseded by the Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010). These guidelines, published by the National Health and Medical Research Council (NHMRC) are available through their website.
The risk of acquiring hepatitis C from a needle stick (or sharps) injury in a healthcare setting where the needle (or sharp) was used in a procedure on someone with hepatitis C is 3% . Health care and custodial workers are advised to practice standard infection-control procedures at all times and should consider getting vaccinated against hepatitis A and B.
Other Activities Where Blood May Be Involved
Transmission of hepatitis C through safer sex is unlikely, and hepatitis C is not classified as a sexually transmissible infection (STI). However, where there is a risk of blood-to-blood contact during foreplay or sex, or where there is a risk of the transmission of sexually transmissible infections, it is recommended you practice safer sex.
Personal grooming items used for everyday hygiene may present a possible transmission risk if blood is present. To minimise the risk of transmission, it is suggested that people do not share razor blades, clippers, toothbrushes (due to the possibility of bleeding gums) and sharp personal grooming aids.
Stepping on a used needle in a public place, such as a street, a park or a beach, is regarded as an unlikely source of transmission.
Finally, remember hepatitis C is spread through blood-to-blood contact. Thus for transmission to take place, blood containing the virus must enter the bloodstream of another person. In the ordinary course of life, hepatitis C is not easily caught, however, it is worth thinking about any instances in which blood-to-blood contact may take place and subsequently take appropriate precautions.
Hepatitis C cannot be caught from sharing hugs, kisses, food, cups, gym equipment, office space or public transport. There is no risk of contracting hepatitis C from a mosquito or other blood-sucking insects.
Preventing the Spread of Hepatitis C
People with hepatitis C can take simple precautions to minimise the risk of transmitting the virus to others. These involve:
- reducing any opportunity where other people may come in contact with infected blood;
- not sharing injecting equipment;
- not sharing personal toiletry items like toothbrushes, razors, nail clippers or any items able to puncture the skin and draw blood;
- having a first aid kit at hand;
- keeping cuts, abrasions or wounds clean and covered with waterproof dressings;
- cleaning up any blood spills with paper towels and soapy water or undiluted bleach; and
- securing all bloodstained items, such as wound dressings, tampons and sanitary pads in a plastic bag before putting them in a rubbish bin.
Dore GJ, Kaldor JM, McCaughan W. (1997)
‘Systematic review of role of polymerase chain reaction in defining infectiousness among people infected with hepatitis C virus’. British Medical Journal.
Treatment for Hep C
A new generation of direct-acting antiviral medications are now available to Australians living with chronic hepatitis C. They are more effective, easier to take and have fewer side-effects than the older medications. The Australian Government has listed these new medicines on the Pharmaceutical Benefits Scheme (PBS), ensuring they are accessible and affordable to people with hepatitis C. This is a leap forward in the management and treatment of hepatitis C and positions Australia as a world leader in publicly-funded access to these new, highly effective medicines.
What are the new medicines?
The new, direct-acting antiviral (DAA) medicines available on the PBS from 1 May 2016 include:
- Daklinza® (daclatasvir)
- Harvoni® (sofosbuvir + ledipasvir)
- Ibavyr® (ribavirin)
- Sovaldi® (sofosbuvir)
- Viekira Pak® (paritaprevir + ritonavir + ombitasvir + dasabuvir)
- Viekira Pak RBV® (paritaprevir + ritonavir + ombitasvir + dasabuvir + ribavirin)
- Zepatier® (grazoprevir + elbasvir)
Following a clinical assessment, these medicines are used independently or in combination with other medicines depending on the person’s particular situation. For most people, this will mean treatment without the need to use interferon.
Are the new medicines better than the previous ones?
Yes, the new DAA medicines are:
- more effective, resulting in a cure for 90-95% of people
- taken as tablets only, and have very few side-effects
- taken for as little as 8-12 weeks in most cases, and;
- provide interferon-free treatment options for all common genotypes in Australia
Are the new medicines available for all people with Hepatitis C?
Yes, treatment using the new DAA medicines is available through the PBS for all people living with hepatitis C over the age of 18 and who have a Medicare Card. However, the particular combination of medicines used will depend on a range of individual factors including genotype, prior treatment experience and whether or not you have developed cirrhosis (liver scarring).
What about people who currently inject drugs?
There are no restrictions applied to people who inject drugs as they are a priority population for hepatitis C treatment. Whether or not a person currently injects drugs should not be used as criteria for restricting access to the new medicines.
Can people in prison access the new medicines?
Yes, people in prison are a priority population for hepatitis C treatment. The Australian Government has ensured the new medicines will be funded for people in prison.
Are there interferon-free options available for all genotypes?
Currently, interferon-free treatment options are only available for genotypes 1, 2, 3 and 4 – these are the most common genotypes in Australia. For now, treatment for people with genotypes 5 and 6 will still require taking a combination of one of the new medicines in conjunction with pegylated interferon and ribavirin, but for a shorter duration than before. Other new DAA medicines in development are likely to be considered by the Government for listing on the PBS. Also, as new data becomes available the use of current medicines may be broadened to include other genotypes. Hepatitis Australia will provide further information about interferon-free options for genotypes 5 and 6 as it becomes available.
What information will the doctor need to know about your health before treatment can be prescribed?
There are a number of tests the doctor will do and information you will be asked to provide before treatment can be prescribed. These include:
- undergoing blood tests to confirm you have active hepatitis C infection
- undergoing tests to determine the genotype (strain) you have
- undergoing an assessment to see if you have developed cirrhosis (liver scarring)
- discussing any previous treatments for hepatitis C you may have taken,
- identifying any other illnesses or health complaints you have, and;
- discussing any other prescription medications, over-the-counter medications or substances you are taking. This is important to avoid any possible drug interactions.
It is very important that medicines are taken as instructed, so the doctor or nurse may also talk with you about your readiness to start treatment and discuss things that may impact on your ability to take the medicine regularly, as prescribed.
What does treatment with the new medicines involve?
The treatment regimens for the new DAA medicines range between 8 and 24 weeks for a complete course of treatment, depending on your genotype, treatment history, whether you have cirrhosis and the combination of medicines used.
(Refer to the table at the end).
Some treatments require only 1 to 2 tablets once or twice a day. For some treatment regimens, more medicines may be required to be used together. Depending on treatment history and genotype, some people may still need to include an injection (of peg-interferon) as well as taking tablets. Your doctor will explain the options available to you in more detail.
Will you need to have more tests during treatment?
Yes, the doctor will need to do blood tests to monitor how your body is responding to the medicines. This means checking if the medicine is working effectively against the hepatitis C virus and that it is not negatively affecting your overall health.
Can General Practitioners (GPs) prescribe treatment for hepatitis C?
Yes, GPs in Australia can prescribe the new medicines. Before prescribing any medicines, your GP will be required to collect information and conduct tests (see above) to establish which combination of medicines will be the most effective for you. Based on that information, the GP will then consult with a specialist before prescribing the medicine for you. This means it is likely you will need a couple of appointments before receiving a prescription. In some cases, where there are other significant health factors to consider, the GP may refer you to a specialist before treatment is commenced.
Can you still see your specialist to access the new medicines?
Yes, gastroenterologists, hepatologists or infectious diseases physicians experienced in the treatment of chronic hepatitis C will continue to prescribe the new medicines. These specialists will also provide advice to GPs prescribing the new medicines, so you may consider seeing your GP if this is more convenient for you.
Where can you get your prescription filled?
This will depend on the type of prescription you receive and the doctor will provide more details. There are two types of prescriptions known as either s100 or s85.
Most people will receive the s85 prescription, which can usually be filled by your local pharmacy. However, it is important to note that some pharmacies may not have the medicines in stock and you may need to wait up to 72hrs to collect them. This is due to the very high cost the pharmacies have to outlay to keep the medicines in stock. If a pharmacy cannot fill your prescription, ask them for a referral to a pharmacy that can, or contact HepatitisWA for assistance. This situation should improve over time as more people start accessing treatment.
Some people accessing specialists may receive the s100 type of prescription. These prescriptions can only be filled through hospital-based pharmacies and not local, community-based pharmacies. As well as some initial delays, some prescriptions may only allow you to collect 4 weeks supply of medicine at a time. So it is important to plan ahead so you don’t run out of medicine.
How much do the medicines cost you?
You will be charged the usual co-payment price you pay for the dispensing fee of each prescription. This is currently $38.80 for general patients and $6.30 for concessional patients. This fee is reviewed each year.
Remember, as these medicines are “PBS Authority required” the doctor can only prescribe one medicine on each prescription. This means you may be required to pay the dispensing fee for each medicine.
What if treatment is not effective for you?
For most people it is highly likely the new DAA medicine will be effective. If the new treatment does not work for you, your doctor will refer you to a specialist for further assessment prior to commencing any further treatment.
Where can you get further information?
You can talk to your GP, specialist, clinic nurse or call HepatitisWA on (08) 9227 9800.
Treatment options available on the PBS
The treatment options below are based on the Australian recommendations for the management of hepatitis C virus infection: a consensus statement 2017. You can view this at hepcguidelines.org.au
Some variations to these regimens may be required depending on a person’s individual clinical history or health status and Interferon containing regimens are only shown where there are no other PBS option is currently approved. For more detailed information you can discuss options with your doctor.
Don’t put your health at risk by waiting too long.
It’s easy to understand why you might have waited for the new interferon-free treatments to become available. However, now treatment is much simpler and by waiting, you could be putting your health at risk. If you’re 40 years of age or over, you’re likely to experience an accelerated rate of liver damage which increases your risk of developing cirrhosis, liver cancer or liver failure. This is called the “Liver Danger Zone”.You should also bear in mind that symptoms of liver disease may not be felt until the liver is significantly scarred.Please don’t put your health at risk by waiting too long for treatment. Make an appointment with your doctor to have a liver health assessment and treatment discussion with your doctor at least once a year. What does a liver health assessment involve?
Your doctor will give you a clinical examination and blood tests. They may also use a Fibroscan – a quick, non-invasive test (similar to an ultrasound) that measures the level of liver scarring to determine the severity of liver disease. For further information on the liver health assessments see our: Liver Assessment Factsheet – download now (PDF 184kb)
Video of a liver health assessment – view now If you have chronic hepatitis C and particularly if you are in the “Liver Danger Zone”, ask your doctor about having a regular liver health check-up today. A liver check-up is nothing to worry about, it is simple, easy and it could save your life.
Tests for Hep C
This section provides a brief introduction to the most common tests available to test for and monitor hepatitis C. If you have decided to be tested, make an appointment with your doctor to receive the test results in person. Your doctor can explain the results, answer your questions, and recommend follow-up if necessary.
Preparing for Testing
The initial screening test for hepatitis C is a blood test which checks for antibodies. The human body produces antibodies in response to the virus.
The antibody test looks for these specific antibodies, not for the virus itself, to work out if you have been exposed to the hepatitis C virus (HCV). It may take up to three months for antibodies to appear in your blood following infection (although it is usually positive by 6 weeks). This is known as the “window period”. During this time antibody testing may not provide an accurate result.
A negative antibody test result usually means that a person has not been infected with the virus. However, the blood sample may have been taken in the window period before antibodies can be detected.
A person must give their consent to be tested for hepatitis C. If needed, doctors can refer you to specialists and to support services that can provide you with more support when the test results are known.
The initial screening test for hepatitis C is a blood test which checks for antibodies. The human body produces antibodies in response to the virus.
The antibody test looks for these specific antibodies, not for the virus itself, to work out if you have been exposed to the hepatitis C virus. It may take up to three months for antibodies to appear in your blood following infection (although it is usually positive by 6 weeks). This is known as the “window period”. During this time antibody testing may not provide an accurate result.
A negative antibody test result usually means that a person has not been infected with the virus. However, the blood sample may have been taken in the window period before antibodies can be detected.
A positive antibody test result means antibodies were found, which is proof that the virus must have infected you at some point in time. About 25% of people who develop hepatitis C antibodies in response to infection get rid of (or clear) the virus within 6 months. If people are able to clear the virus, the antibodies remain in the blood for some time, possibly the rest of their life. This means a positive antibody test doesn’t necessarily mean someone has the virus.
A different test, the Polymerase Chain Reaction (PCR) test is used to see whether you have the virus in your blood.
One situation when the antibody test is not reliable is in a newborn baby. Babies born to mothers infected with hepatitis C can have a positive antibody test without actually being infected. This positive maternal antibody usually only lasts 12 – 18 months, therefore, it is recommended that testing of children should not be done until after this time.
Polymerase Chain Reaction (PCR) Test
Unlike an antibody test, the PCR test can detect whether the virus (not just the antibodies to the virus) is present in your blood. The hepatitis C virus (HCV) is usually found in low levels in the blood and the PCR test uses a laboratory technique to amplify up the genetic material of the virus (hence, Chain Reaction). There are three types of PCR tests:
1. HCV PCR Viral Detection Test
The basic PCR viral detection tests are used to determine if a person has the virus, called qualitative test. This is especially useful in the case of people who have an inconclusive (unclear) HCV antibody test, or when their liver function tests are consistently normal, or where their liver function tests are abnormal but there are other possible causes of liver disease. It is recommended for anyone who is antibody positive that they have the PCR test done to see if they still have the virus.
Unlike the antibody test a PCR test can also confirm if the virus is present during the window period after infection. Using the PCR test, the virus can be detected in the blood as early as two weeks after infection. This test can also be used to confirm the HCV status when a person has immunodeficiency (e.g. due to HIV infection) or has been immunosuppressed by drugs (such as in organ transplantation) as this can also be associated with a false negative HCV antibody test result.
2. HCV PCR Viral Load Test
The PCR viral load test looks for the virus and estimates the amount of hepatitis C virus (HCV) circulating in someone’s blood, formally called quantitative test. This test can help in determining the likelihood of response to treatment, particularly in regard to people with genotype 1. There are also alternative technologies other than PCR which can be used to determine the level of virus in the blood.
3. HCV PCR Genotype Test
The genetic make up of the hepatitis C virus (HCV) is highly variable and this has allowed scientists to divide the virus up into six genetic groups known as genotypes. The PCR genotype test looks for the virus, and determines the particular strain (genotype) of HCV a person has. The genotype testing can help predict a person’s chances of responding to therapy and the medicines to be used. New generation treatments used provide a 90-95% chance of cure for people with genotype 1. Other genotypes can be more difficult to treat and can still require combinations therapy including pegylated interferon and ribavirin. As new treatments continue to become available it is likely all genotypes will be simpler to treat..
Note: cure is defined as having no presence of the virus immediately after therapy, and for six months afterwards.
Liver Function Test
A Liver Function Test (LFT) is a blood test that gives an indication of whether the liver is functioning properly. A liver function test measures the amount of particular chemicals (enzymes) in the blood. This provides a gauge of possible damage to liver cells. The damaged liver cells release the enzymes into the bloodstream where they can be detected. This damage can be caused by many things including the hepatitis C virus.
For people with hepatitis C, the enzyme Alanine Aminotransferase (ALT) is one of the most relevant enzymes measured by an LFT. ALT is an enzyme in the liver that can leak out into the blood when liver cells are inflamed. When ALT levels are elevated, it can indicate liver damage. Viruses, alcohol and some drugs can damage liver cells. Damage to your liver can occur even with normal ALT test results. This test is a basic guide and should only be viewed as part of the overall picture of your health.
If your ALT levels are consistently abnormal (elevated), it is important to discuss referral to a liver specialist with your GP. If your LFT results show a certain pattern, or don’t seem to correspond with your symptoms, your doctor may suggest you have different tests.
A liver biopsy is no longer required before a person is provided with treatment. A liver biopsy is one method used to diagnose cirrhosis, which is a condition where liver cells are damaged and replaced by scar tissue because of chronic inflammation. The scar tissue affects the flow of blood and other fluids through the liver. Without good blood flow, together with a reduction in total liver cells, the liver cannot function properly and it becomes lumpy and hard. Scar tissue can form in the liver due to inflammation that occurs with hepatitis C. A liver biopsy determines how much scar tissue has formed in your liver and whether or not you are developing cirrhosis.
Today, doctors will most likely conduct a non-invasive test using transient elastography, commonly known as a Fibroscan, or other method to establish the degree of liver scarring, if any. This can be required prior to being prescribed treatment. In some circumstances the doctor may still recommend that you have a liver biopsy and you should discuss the pros and cons of having this test with them.
A liver biopsy is generally performed in day clinics at hospitals and involves removing a tiny sample of your liver by inserting a thin needle into your upper abdominal region.
You can also download the infographic here.
Hepatitis C and HIV Co-infection
Epidemiology of HIV and Viral Hepatitis Co-infection
In Australia, it is estimated that about 13% of people with HIV also have hepatitis C. [Dore, G. & Sasadeusz, J. (Eds); 2006] It is possible that a person with HIV will not know they have either hepatitis B or hepatitis C unless they are specifically tested for the hepatitis viruses.
Both hepatitis B and hepatitis C are more common in people with Human Immunodeficiency Virus (HIV) than in the general population because of shared risk factors for viral transmission. HIV shares major routes of transmission with both hepatitis C and hepatitis B.
People who inject drugs are at particularly high risk for hepatitis C and HIV co-infection. Sexual transmission is responsible for the majority of the cases of HIV-hepatitis B co-infections.
Disease Course of HIV and Hepatitis Co-infection
Current evidence suggests that HIV worsens hepatitis C-related liver disease and can fasten the progression to cirrhosis, decompensated liver disease and lead to earlier development of hepatocellular carcinoma (a form of liver cancer) because HIV decreases immunity. It is unclear what impact hepatitis C infection has on HIV progression. [Dore, G. & Sasadeusz, J. (Eds); 2006]
Testing for Hepatitis C and HIV
A simple blood test will check whether you have hepatitis C and/or HIV. In some people who are co-infected with hepatitis C and HIV, the results of the first blood tests may be unclear or show a negative result. This could be caused by the HIV decreasing the antibody “markers” for hepatitis C. It may be necessary to have ongoing blood tests that specifically look for the virus (PCR test) in order to make an accurate diagnosis.
If the results show co-infection with hepatitis C and HIV, it is important to find a doctor with experience in co-infection and HIV. An HIV/AIDS organisation or Hepatitis organisation will be able to suggest appropriate doctors. Regular blood tests and viral load tests are needed to track how fast the disease is progressing. Developing a good partnership with your doctor will help you feel comfortable about the management of your illness.
Treatment of HIV/Hepatitis Co-infection
People with HIV can be treated for hepatitis C but it may be more complicated than treating either infection by itself, particularly if a person is on HIV treatment. The treatment for hepatitis C changed from March 2016 and is now simpler for most people with minimal side-effects. Due to the potential for adverse drug interactions between HIV medicines and hepatitis C medicines it is important that a person with HIV/hepatitis C co-infection receives specialised care from their doctor and other referred specialists.
Having chronic hepatitis C can also affect HIV treatment choices due to the potentially toxic effects some HIV drugs have on the liver. The treatment options for people with HIV/hepatitis C co-infection changes depending on the degree of liver damage, as the liver cannot tolerate some of the antiviral drugs used in the treatment of HIV.
Taking Care of Your Liver with HIV/Hepatitis C Co-infection
It is important for people who are co-infected with HIV and hepatitis C to have their liver function carefully and regularly tested. In addition, avoiding any damage or stress to the liver is vital. Refer to the Hepatitis C: Guide to Healthy Living.
Vaccination against hepatitis A and hepatitis B is essential for people with hepatitis C and HIV.
Preventing the spread of Hepatitis C and HIV
Hepatitis C and HIV are both spread through blood-to-blood contact, therefore, transmission of both viruses can be prevented by being blood aware. HIV is also sexually transmitted and can be prevented through the use of condoms and safer sex.
Decisions around safer sex when someone has HIV/hepatitis C co-infection are likely to be very individual but should be based on reliable information. Using condoms may be the preferred option. However, some HIV positive people with HIV positive partners often choose not to use condoms. If an individual is having sex with someone who is HIV positive, but not hepatitis C positive, they may want to discuss some of the potential risks for the sexual transmission of hepatitis C with a doctor, and whether they need to use a condom or barrier protection.
Recent studies have reported a higher than expected prevalence of hepatitis C infections occurring in men with HIV, particularly in men who have sex with men. (Filippina. et.al, Ghosn. et.al & Serpaggi. et.al) If a man is co-infected with HIV and hepatitis C he may wish to avoid high risk sexual activities with multiple casual partners and where there is the potential for blood-to-blood contact including unprotected oral and anal sex.
Dore, G. & Sasadeusz, J. (Eds) (2006). Co-infection: HIV & Viral hepatitis a guide for clinical management. ASHM.
Filippini, P., Coppola, N., Scolastico, C. et al. (2001). ‘Does HIV infection favour the sexual transmission of hepatitis C?’. Sexually Transmitted Diseases. Vol 28:725-729.
Ghosn, J., Pierre-Francois, S., Thibault, V. et al. ‘Acute hepatitis C in HIV-infected men who have sex with men’. HIV Medicine 2004; 5:303-306.
Serpaggi, J., Chaix, M-L., Batisse, D. (2006) ‘Sexually transmitted acute infection with a clustered genotype 4 hepatitis C virus in HIV-1 infected men and inefficiency of early antiviral therapy’. AIDS. 20:233-240.
Hepatitis C and Hepatitis B Co-infection
Infection with more than one virus is often referred to as co-infection. This section will discuss co-infection with hepatitis C and hepatitis B.
Hepatitis B and Hepatitis C Co-infection
There is relatively little research on hepatitis B and hepatitis C co-infection, therefore, no accurate figures on the number of people who have both hepatitis viruses is available for Australia. However, it appears that hepatitis B and hepatitis C co-infection is not uncommon, especially in areas where hepatitis B is common, for example, Asia. Hepatitis B and hepatitis C are both transmitted through blood-to-blood contact, therefore, it is possible to contract both viruses at the same time or a person with one of the viruses may be infected with the other virus at a later time.Being infected with both hepatitis B and hepatitis C can lead to severe liver disease including cirrhosis and/or liver failure and increases the risk of developing hepatocellular carcinoma (HCC), a form of liver cancer. (Crockett, 2005)
Testing for Hepatitis B and Hepatitis C
Hepatitis B and hepatitis C co-infection can be difficult to diagnose because when the viruses exist together in the body they can interact with each other, which means that one virus usually becomes dominant over the other. Several studies have demonstrated that the hepatitis C virus can suppress the reproduction of the hepatitis B virus, which can affect the detection of the hepatitis B virus in the blood. Similarly, it has been reported that hepatitis B can also reduce the reproduction of the hepatitis C virus. However, the overall dominant effect appears to be hepatitis C over the hepatitis B virus. (Crockett, 2005) It is important to remember that suppression of one hepatitis virus does not mean that it has gone from the body. Instead its effects have simply been slowed or stopped, until the dominant virus is treated, after which the suppressed virus could flare up again.
Treatment of Hepatitis B and Hepatitis C Co-infection
Treatment of hepatitis B and hepatitis C co-infection is not well established, therefore, the same treatment criteria is applied to patients who are co-infected as are applied to patients who have either hepatitis B or hepatitis C only. (Liu, 2003) Deciding which treatment is best for patients with hepatitis B and hepatitis C co-infection should be based on assessing which is the dominant hepatitis virus. Interferon has been widely studied in the case of hepatitis B and hepatitis C co-infection, because it is effective against both viruses individually. One study showed that using interferon and ribavirin in 24 patients with hepatitis B and hepatitis C co-infection, resulted in a sustained virological response (SVR) of 43%, compared to 60% SVR for patients with hepatitis C only. Therefore, in co-infected patients with hepatitis C dominant disease, treatment with interferon and ribavirin has proven efficacy. In patients with hepatitis B dominant disease, interferon with or without Lamivudine is a reasonable option. To date, there have not been published studies regarding treatment of co-infected patients with adefovir and entecavir. (Crockett, 2005) Caution must be exercised in treating patients with co-infection because flares (high virus activity) of the untreated virus may occur as its reproduction is no longer being slowed or stopped by the dominant virus.
Taking care of your liver with Hepatitis B and Hepatitis C Co-infection
People co-infected with hepatitis B and hepatitis C should have their liver function checked regularly by a liver doctor or hepatitis specialist. In addition, avoiding any damage or stress to the liver is vital (refer to the Hepatitis C: Guide to Healthy Living).
Preventing the spread of Hepatitis B and Hepatitis C
Hepatitis B and hepatitis C can be spread in similar ways. Therefore, it is very important to be blood aware and take precautions to prevent contact with other people’s blood (refer to Preventing the spread of hepatitis C) even if you already have a hepatitis virus. Most importantly people who have hepatitis C or those who are at risk of being exposed to other people’s blood need to consider being vaccinated against hepatitis A, but most importantly hepatitis B.
Crockett, S.D. and Keeffe, E.B. (2005). ‘Natural history and treatment of hepatitis B virus and hepatitis C virus co-infection’. Annals of Clinical Microbiology and Antimicrobials.Liu, C.J., Chen, P.J., Lai, M.Y. et al. (2003). Ribavirin and interferon is effective for hepatitis C virus clearance in hepatitis B and C dually infected patients. Hepatology. 37: 568-567.
Disease Course of Hepatitis C
Research has shown that if 100 people are infected with hepatitis C, about 25 of those will clear the virus completely within two to six months of infection, but will continue to have hepatitis C antibodies in their blood.
About 75 of the 100 people who do not clear the virus will develop ongoing (or chronic) infection and are at risk of developing cirrhosis of the liver. Of the 75 people who develop chronic hepatitis, about 20 people will not experience any noticeable illness or symptoms. However, they can still transmit the virus to others.
After an average of 15 years, between 40 and 60 of the 75 people with chronic hepatitis C will experience some symptoms and develop some liver damage.
After 20 years, between five and ten people with liver damage will develop cirrhosis. Between two and five of these people will experience liver failure or develop a form of liver cancer known as hepatocellular carcinoma.
Duration of infection is the most likely determinant of the risk of cirrhosis and liver cancer. Other factors which affect the progression of liver disease include:
- age when first infected (people infected over the age of 40 years, experience faster disease progression)
- male gender
- alcohol use
- co-infection with hepatitis B virus and/or HIV
- obesity (Poynard, T., et.al; 2001)
There is no evidence to confirm whether genotype influences disease progression.
Poynard, T., Ratziu, V., Charlotte, F., Goodman, Z., McHutchison, J. G. & Albrecht, J. (2001). Rates and risk factors of liver fibrosis progression in patients with chronic hepatitis C. Journal of Hepatology, 34(5), 730-739.