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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.

Hep C is a very slow acting virus, and you may not feel unwell for Many years. The first six to twelve months of infection is called the ‘acute phase’. During this time the body’s immune system starts fighting the virus. A small number of people may feel unwell and experience flu-like symptoms. But you may not experience any illness at all. In one out of four people (25%), the immune system clears the virus but for most people, unless they are cured, they will have a life-long (also called ‘chronic’) hep C infection.

Hep C is a liver illness caused by the hepatitis C virus. Most people don’t clear the virus (75%) and, unless cured, have the illness for life. Hep C can cause liver problems. Over a long period of time some people may develop cirrhosis (scarring of liver) or liver cancer. Although people usually talk about hep C as if it were a single virus, there are six different main genotypes. All hep C genotypes affect the liver in the same way. Most people in Australia have hep C genotypes 1 and 3.

Viral hepatitis is inflammation of the liver caused by a virus. There are five different hepatitis viruses, hepatitis A, B, C, D and E.

Transmission: Hepatitis C is mainly spread through blood-to-blood contact. In rare cases it can be transmitted through certain sexual practices and during childbirth

Prevention: There is no vaccination for hepatitis C. It is therefore necessary to reduce risk of exposure, by avoiding sharing needles and other items such as toothbrushes, razors or nail scissors with a person living with hepatitis C. It is also wise to avoid getting tattoos or body piercings from unlicensed facilities.

Treatment: A highly effective treatment has been available for Hepatitis C since 2016. These medications are called Direct Acting Antivirals and are 98% effective.

Your GP is able to prescribe this medication for you.

Your chemist will have to order this medication, so it may not be available immediately. In most cases the medication will arrive the next day

The medication costs approximately $35 a month. If you have a concession card, the cost is $6.50 a month.

Reference: Originally published by Hepatitis Australia via worldhepatitisday.org and hepatitisaustralia.com

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)

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 transmitted 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.

Testing positive for antibodies DOES NOT mean that the Hepatitis C virus is active in your body. It is important to have what is called a PCR RNA test to find out if you have chronic, or active, Hepatitis C.

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)

It is estimated that 71 million people worldwide are chronically infected with hepatitis C. (WHO Hepatitis C Fact Sheet)

In Australia, it is estimated that 199,412 people are living with chronic hepatitis C. (Kirby Institute, Annual Surveillance Report (ASR) 2017 – p16)

It was estimated that 11,949 new cases of hepatitis C infection were diagnosed in the year 2016.

Since the introduction of Direct Acting Antivirals, it is estimated that 30,434 have been people were cured from hepatitis C infection. This number continues to grow.(Kirby Institute, Annual Surveillance Report (ASR) 2017 – p16)

References

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 2017. The Kirby Institute, The University of New South Wales, Sydney, NSW. Available from: https://kirby.unsw.edu.au/sites/default/files/kirby/report/SERP_Annual-Surveillance-Report-2017_compressed.pdf

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 Hepatitis 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.
Injecting Equipment

Currently, 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 which are not considered high risk.

Reducing the Risk

There are a number of ways the risk of hepatitis C, and other infections passed on by blood to blood contact (such as HIV and hepatitis B) can be reduced.

These include:

  • Wiping down the preparation area 1 part bleach to 10 parts water;
  • clean hands (wash your hands thoroughly);
  • a clean injecting space;
  • a new fit (needle and 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 products 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. Consumers have the right to ask the practitioner about their use of standard infection control procedures and their understanding of why these procedures are important.

Receiving a tattoo or piercing in a juvenile detention centre, prison, by a backyard operator, and overseas tattoos and body piercing increase the risk of hepatitis C infection. Often the equipment is not sterile and may have been used on more than one client. It is strongly recommended not to 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 the mother has detectable levels of the virus in her blood, that is if she has a PCR test that shows the presence of the virus in her blood. (Dore GJ, Kaldor JM, McCaughan W. – 1997)

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 breastfeeding. 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 baby’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 Australian Guidelines for the Prevention and Control of Infection in Healthcare (2010) guidelines are published by the National Health and Medical Research Council (NHMRC) and 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. These vaccinations are available through your GP.

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 transmitted 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 transmitted, 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
  • public transport

There is no risk 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 include:

  • Seeking treatment and getting cured – this will reduce the number of people with the virus
  • 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.
References

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.

The National Health and Medical Research Council (2010). Australian Guidelines for the Prevention and Control of Infection in Healthcare.

Treatment of Hepatitis C

Introduction

A new generation of direct-acting antiviral medications taken orally 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 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 include:

  • Epclusa® (sofosbuvir + velpatasvir)
  • Harvoni® (sofosbuvir + ledipasvir)
  • Zepatier® (grazoprevir + elbasvir)
  • Maviret® (Glecaprevir + pibrentasvir)

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 8 to 12 weeks of taking tablets 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 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 factors which include genotype, prior treatment experience and whether or not you have developed fibrosis or cirrhosis (liver scarring).

What about people who currently inject drugs?

There are no restrictions applied to people who inject drugs – in fact they are a priority population for hepatitis C treatment. Whether or not a person currently injects drugs is not, and 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. There may be some criteria depending on a prisoner’s length of stay as to whether they will be able to access the treatments whilst incarcerated.

Are there interferon-free options available for all genotypes?

Yes there are interferon-free options available for all genotypes.

What information will the doctor need to know about your health before treatment can be prescribed?

There are a number of tests the doctor may order, and s/he may also request specific information before treatment can be prescribed. These include:

  • undergoing blood tests to confirm you have active hepatitis C infection, viral load and genotype (strain)
  • undergoing an ultrasound to see if you have developed cirrhosis (liver scarring)
  • discussing any previous treatments for hepatitis C under taken,
  • identifying any other illnesses or health complaints a client may have such as Hepatitis B, HIV, Epilepsy or Diabetes and;
  • discussing any other prescription medications, over-the-counter medications or substances a client may be taking. This is important to avoid any possible drug interactions with the DAA treatment.

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. The length of treatment depends on the genotype, treatment history, whether cirrhosis has occurred and the combination of medicines used.

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, a very small percentage of 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 the body is responding to the medicines.

Can General Practitioners (GPs) prescribe treatment for hepatitis C?

Yes, GPs in Australia can prescribe the new medicines. Before prescribing any medicines, the GP will be required to collect information and conduct tests (see above) to establish which combination of medicines will be the most effective.   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 the client to a specialist before treatment.

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?

The prescription can usually be filled by a local pharmacy.

It is important to note that some pharmacies may not have the medicines in stock and people 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 the prescription, request a referral to a pharmacy that can, or contact HepatitisWA for assistance.

Most pharmacies will only dispense 1 month of the drug at a time. Therefore, it is important for you to plan ahead so they don’t run out of medicine. Leaving your repeat scripts with your pharmacist can be helpful.

How much do the medicines cost?

Prescriptions attract the usual co-payment price 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.

What if treatment is not effective?

For most people, it is highly likely the new DAA medicine will be effective. If the new treatment does not work, the doctor will discuss options and may choose to refer 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.

Don’t put your health at risk by waiting too long.

It’s easy to understand why people may have waited for the new interferon-free treatments to become available. However, now treatment is much simpler, by waiting, a person could be putting their health at risk. If 40 years of age or over is living with hepatitis C, they are likely to experience an accelerated rate of liver damage which increases the risk of developing cirrhosis, liver cancer or liver failure. This is called the “Liver Danger Zone”. A person should also bear in mind that symptoms of liver disease may not be felt until the liver is significantly scarred. It is not advisable for people to put their health at risk by waiting too long for treatment. It is recommended to make an appointment with a doctor or HepatitisWAs Deen Clinic to have a liver health assessment and to discuss treatment options.

What does a liver health assessment involve?

The doctor will conduct a clinical examination and blood tests. They may also send the client for an ultrasound which is a non-invasive test 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)

Video of a liver health assessment – view now If a person has chronic hepatitis C and particularly if they are in the “Liver Danger Zone”, ask the 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 can save lives.

Tests for Hepatitis C

This section provides a brief introduction to the most common tests available to test for and monitor hepatitis C.

Testing for Hepatitis C

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.

A person must give their consent to be tested for hepatitis C.

Antibody Test

The antibody test looks for those specific antibodies, not for the virus itself, to work out if a person has been exposed to the hepatitis C virus. It may take up to three months for antibodies to appear in the 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 the person 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 naturally within 6 months. If people are able to clear the virus, the antibodies remain in the blood for life. This means a positive antibody test doesn’t necessarily mean someone has the virus.

One situation when the antibody test is not reliable is in a new-born 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

The Polymerase Chain Reaction (PCR) test is used to see whether a person has the virus in their blood.

Unlike an antibody test, the PCR test can detect whether the virus (not just the antibodies to the virus) is present in blood. The 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.

  1. HCV PCR Viral Load Test

The PCR viral load test looks for the virus and estimates the amount of HCV circulating in someone’s blood, formally called quantitative test.

  1. HCV PCR Genotype Test

The genetic makeup 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 was important to predict a person’s chances of responding to therapy and the medicines to be used. However, with the new generation treatments used a person’s Genotype is becoming less and less relevant in determining what medication to use.

Note: cure is defined as having no presence of the virus immediately after therapy, and for 12 weeks afterward. This is called a Sustained Virological Response or SVR.

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. It should be noted that having a normal range of ALT or LFT is not an indicator of whether or not a person has hepatitis C.

Liver Biopsy

A liver biopsy is no longer required before a person is provided with treatment. Diagnosis of cirrhosis is mainly down through ultrasound or fibroscans.

Hepatitis C and HIV 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 HIV.

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 the Liver when living 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. It is recommended that people living with a co-infection get treated for their hepatitis C.

Vaccination against hepatitis A and hepatitis B is essential for people with hepatitis C and HIV.

Preventing the transmission of Hepatitis C and HIV

Hepatitis C and HIV are both transmitted 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. If you are wanting further prevention from HIV you may want to look at taking PREP (Pre-Exposure Prophylaxis). PREP is a treatment that can protect you from getting HIV when taken daily. If you have any questions or concerns about HIV/AIDS transmission we recommend visiting Western Australian Aids Council website.

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.

References

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

Coinfection of hepatitis B and hepatitis C can be managed through DAA therapy and HBV antiviral therapy. However, treatment will differ depending on the needs of the patient. Therefore, discussing treatment options with a GP and gastroenterologist is recommended.

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 transmitted 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.

References

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, are at risk of developing cirrhosis of the liver and can transmit the virus to others. 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.

References

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.