Hepatitis C - Frequently Asked Questions 
Centers for Disease Control, Prevention Diagnosis and Testing & NATAP

What is hepatitis C?

Hepatitis C is a liver disease caused by the hepatitis C virus (HCV), which is found in the blood of persons who have this disease. HCV is spread by contact with the blood of an infected person.

What is Co-Infection?

When a person has HIV and Hepatitis C it's called co-infection. It's estimated that 60-90% of everyone who got HIV through IV drug use also has HCV. If you have HIV you should be tested for HCV. A co-infected person should also be tested for hepatitis A and B. If negative for hepatitis A one should consider getting the hepatitis A vaccine, because getting hepatitis A can be very harmful if you have HIV. 

What blood tests are available to check for hepatitis C?

There are several blood tests that can be done to determine if you have been infected with HCV. Your doctor may order just one or a combination of these tests. The following are the types of tests your doctor may order and the purpose for each:

Anti-HCV (antibody to HCV):

Anti-HCV does not tell whether the infection is new (acute), chronic (long-term) or is no longer present.

Qualitative tests to detect presence or absence of virus (HCV RNA. The Food and Drug Administration (FDA) just approved the Roche qualitative PCR test):

Quantitative tests to detect amount (titer) of virus (HCV RNA). Roche is submitting its quantitative PCR test to the FDA for approval:

A single positive PCR test indicates infection with HCV. A single negative test does not prove that a person is not infected. Virus may be present in the blood and just not found by PCR. Also, a person infected in the past who has recovered may have a negative test. When hepatitis C is suspected, such when a person got HIV by IVDU, and PCR is negative, PCR should be repeated.

Can you have a "false positive" anti-HCV test result?

Yes. A false positive test means the test looks as if it is positive, but it is really negative. This happens more often in persons who have a low risk for the disease for which they are being tested. For example, false positive anti-HCV tests happen more often in persons such as blood donors who are at low risk for hepatitis C. Therefore, it is important to confirm a positive anti-HCV test with a supplemental test as most false positive anti-HCV tests are reported as negative on supplemental testing.

Can you have a "false negative" anti-HCV test result?

Yes. Persons with early infection may not as yet have developed antibody levels high enough that the test can measure. In addition, some persons may lack the (immune) response necessary for the test to work well. In these persons, research-based tests such as PCR may be considered. Persons with HIV may test false-positive. So you should re-test if you have HIV and get a false-positive.

How long after exposure to HCV does it take to test positive for anti-HCV?

Anti-HCV can be found in 7 out of 10 persons when symptoms begin and in about 9 out of 10 persons within 3 months after symptoms begin. However, it is important to note that many persons who have hepatitis C have no symptoms.

It is possible to find HCV within 1 to 2 weeks after being infected with the virus.

Who should get tested for hepatitis C?

What is the next step If you have a confirmed positive anti-HCV test?

Measure the level of ALT ( alanine aminotransferase, a liver enzyme) in the blood. An elevated ALT indicates inflammation of the liver and you should be checked further for chronic (long-term) liver disease and possible treatment. The evaluation should be done by a healthcare professional familiar with chronic hepatitis C.

Can you have a normal liver enzyme (e.g., ALT) level and still have chronic hepatitis C?

Yes. It is common for persons with chronic hepatitis C to have a liver enzyme level that goes up and down, with periodic returns to normal or near normal. Some persons have a liver enzyme level that is normal for over a year but they still have chronic liver disease. If the liver enzyme level is normal, persons should have their enzyme level re-checked several times over a 6 to 12 month period. If the liver enzyme level remains normal, your doctor may check it less frequently, such as once a year.

CO-INFECTION: a co-infected person may have normal ALT but still have moderate to severe liver damage (fibrosis). It may be necessary to do a biopsy to properly assess liver condition. Biopsy ought to be considered as soon as HCV diagnosis is known in order to assess liver damage, because HCV may progress more quickly when a person also has HIV. Rapid HCV progression, within 2 years, has been seen in coinfection. One small study suggests HCV may progress the same as if a person had HCV without HIV if they are receiving HIV therapy with HAART (CD4s above 200). But, liver damage, progression, and silent progression to cirrhosis may occur prior to being treated for HIV even with CD4s above200. In another study, 21% of HCV/HIV coinfected persons had minimal liver damage.

How Is HCV Spread from One Person to Another?

How could a person have gotten hepatitis C?

HCV is spread primarily by direct contact with human blood. For example, you may have gotten infected with HCV if:

        you ever injected street drugs, as the needles and/or other drug "works" used to prepare or inject the drug(s) may have had someone else's blood that contained HCV on them

        you received blood, blood products, or solid organs from a donor whose blood contained HCV

        you were ever on long-term kidney dialysis as you may have unknowingly shared supplies/equipment that had someone else's blood on them

        you were ever a healthcare worker and had frequent contact with blood on the job, especially accidental needlesticks

        your mother had hepatitis C at the time she gave birth to you. During the birth her blood may have gotten into your body

        you ever had sex with a person infected with HCV

        you lived with someone who was infected with HCV and shared items such as razors or toothbrushes that might have had his/her blood on them

Is there any evidence that HCV has been spread during medical or dental procedures done in the United States?

Medical and dental procedures done in most settings in the United States do not pose a risk for the spread of HCV. There have, however, been some reports that HCV has been spread between patients in hemodialysis units where supplies or equipment may have been shared between patients.

Can HCV be spread by sexual activity?

Yes, but this does not occur very often. See section on counseling for more information on hepatitis C and sexual activity.

Can HCV be spread by oral sex?

There is no evidence that HCV has been spread by oral sex. See section on counseling for more information on hepatitis C and sexual activity.

Can HCV be spread within a household?

Yes, but this does not occur very often. If HCV is spread within a household, it is most likely due to direct exposure to the blood of an infected household member.

Since more advanced tests have been developed for use in blood banks, what is the chance now that a person can get HCV infection from transfused blood or blood products?  

 1 chance out of 100,000, per each transfused unit.

Pregnancy and Breast Feeding

Should pregnant women be routinely tested for anti-HCV?

Pregnant women have no greater risk of being infected with HCV then non-pregnant women. If pregnant women have risk factors (HIV) for hepatitis C, they should be tested for anti-HCV.

What is the risk that HCV infected women will spread HCV to their newborn infants?

About 5 out of every 100 infants born to HCV infected women become infected. This occurs at the time of birth, and there is no treatment that can prevent this from happening. Most infants infected with HCV at the time of birth have no symptoms and do well during childhood. More studies are needed to find out if these children will have problems from the infection as they grow older. There are no licensed treatments or guidelines for the treatment of infants or children infected with HCV. Children with elevated ALT (liver enzyme) levels should be referred for evaluation to a specialist familiar with the management of children with HCV-related disease.

Co-Infection:

The risk  may be greater if a person has HIV. One study conducted in Italy found that 17 out of every 100 infants born to HCV infected women with HIV became infected

Should a woman with hepatitis C be advised against breast-feeding?

There is no evidence that breast-feeding spreads HCV. HCV-positive mothers should consider abstaining from breast-feeding if their nipples are cracked or bleeding. But one study found HCV in breastmilk. However, it's uncertain if its infectious.

When should babies born to mothers with hepatitis C be tested to see if they were infected at birth?

Children should not be tested for anti-HCV before 12 months of age as anti-HCV from the mother may last until this age. If testing is desired prior to 12 months of age, PCR could be performed at or after an infant's first well-child visit at age 1-2 months.

Counseling

How can persons infected with HCV prevent spreading HCV to others?

        Do not donate blood, body organs, other tissue, or semen.

        Do not share personal items that might have your blood on them, such as toothbrushes, dental appliances, nail-grooming equipment or razors.

        Cover your cuts and skin sores to keep from spreading HCV.

How can a person protect themselves from getting hepatitis C and other diseases spread by contact with human blood?

        Don't ever shoot drugs. If you shoot drugs, stop and get into a treatment program. If you can't stop, never reuse or share syringes, water, or drug works, and get vaccinated against hepatitis A and hepatitis B.

        Do not share toothbrushes, razors, or other personal care articles. They might have blood on them.

        If you are a healthcare worker, always follow routine barrier precautions and safely handle needles and other sharps. Get vaccinated against hepatitis B

        Consider the health risks if you are thinking about getting a tattoo or body piercing: You can get infected if:

        the tools that are used have someone else's blood on them.

        the artist or piercer doesn't follow good health practices, such as washing hands and using disposable gloves.

HCV can be spread by sex, but this does not occur very often.  HOWEVER, if a person is co-infected with HIV and HCV, the risk for transmitting HCV may increase. If you are having sex, but not with one steady partner:

        You and your partners can get other diseases spread by having sex (e.g., AIDS, hepatitis B, gonorrhea or chlamydia).

        You should use latex condoms correctly and every time.

        You should get vaccinated against hepatitis B.

Should patients with hepatitis C change their sexual practices if they have only one long-term steady sex partner?

There is a very low chance of spreading HCV to that partner through sexual activity. But, if a person has HIV and HCV, they risk of spreading HCV through sex increases. If you want to lower the small chance of spreading HCV to your sex partner, you may decide to use barrier precautions such as latex condoms. Ask your doctor about having your sex partner tested.

Certain sexual practices may increase the risk of sexually spreading HCV. Any type of sex where blood may be exchanged increases the risk.  Men who have sex with men may have an increased risk for spreading HCV if they use risky sexual practices such as fisting.

What can persons with HCV infection do to protect their liver?

        Stop using alcohol.

        See your doctor regularly.

        Don't start any new medicines or use over-the-counter, herbal, and other medicines without a physician's knowledge.

        Get vaccinated against hepatitis A if liver damage is present.

What other information should patients with hepatitis C be aware of?

        HCV is not spread by sneezing, hugging, coughing, food or water, sharing eating utensils or drinking glasses, or casual contact.

        Persons should not be excluded from work, school, play, child-care or other settings on the basis of their HCV infection status.

        Involvement with a support group may help patients cope with hepatitis C.

What about if a person also has HIV?

        Discuss treatment options and strategies with a doctor knowledgeable about both HIV and HCV

        When to begin HCV therapy is a key question. It may be beneficial to start therapy when CD4s are high. It may be preferable to treat HCV before treating HIV,, in part because HIV therapy may be tougher on the liver if a person has HCV. Also, HCV therapy may be more successful if started earlier. But the decision on when to begin therapy varies by individual circumstances, and should be discussed thoroughly with a knowledgeable doctor

        If ALT is normal, moderate to severe liver damage may still be present and biopsy may be needed to properly assess

Should persons with chronic hepatitis C be vaccinated against hepatitis B?

Consult with your doctor. For some people getting the HBV vaccine is recommended. If persons are in risk groups for whom hepatitis B vaccine is recommended, they should be vaccinated.

Long-Term Consequences of HCV Infection

What are the chances of persons with HCV infection developing long term infection, chronic liver disease, cirrhosis liver cancer, or dying as a result of hepatitis C?

Of every 100 persons infected with HCV about:

        85 persons may develop long-term infection

        70 persons may develop chronic liver disease

        15 persons may develop cirrhosis over a period of 20 to 30 years

        5 persons may die from the consequences of long term infection (liver cancer   or cirrhosis)

CO-INFECTION- If a person has HIV and HCV, this may accelerate the progression of HCV. One small study suggests HCV may progress the same as if a person had HCV without HIV if they are receiving successful HIV therapy with HAART.

Do medical conditions outside the liver occur in persons with chronic hepatitis C?

A small percentage of persons with chronic hepatitis C develop medical conditions outside the liver (this is called extrahepatic). These conditions are thought to occur due to the body's natural immune system fighting against itself. Such conditions include: glomerulonephritis, essential mixed cryoglobulinemia, and porphyria cutanea tarda.

Management and Treatment of Chronic Hepatitis C

When might a specialist (gastroenterologist or hepatologist) be consulted in the management of HCV-infected persons?

A referral to or consultation with a specialist for further evaluation and possible treatment should be considered if a person is antibody-HCV positive and has elevated liver enzyme levels, or if a person also has HIV. Any physician who manages a person with hepatitis C should be knowledgeable and current on all aspects of the care of a person with hepatitis C.

What is the treatment for chronic hepatitis C?

Antiviral drugs such as interferon used alone or in combination with ribavirin, are approved for the treatment of persons with chronic hepatitis C. Interferon works in 15 to 20 persons out of 100 treated (undetectable viral load). Interferon combined with ribavirin works (on the viral strain that is mostly found in the U.S.) in about 40 persons out of 100. Ribavirin, when used alone, does not work. The most effective and most often used treatment is ribavirin plus interferon.

What is the goal of therapy?

The primary goal of HCV therapy is undetectable viral load. The secondary goal is to improve the condition of the liver (fibrosis).

Pegylated Interferon

This is a new form of interferon that is injected only once a week, but it has not yet been approved by the Food and Drug Administration (FDA). The current approved dose of interferon is an injection 3 times per week on 3 separate days. Pegylated interferon is made by a new chemical process that permits the interferon to remain in the blood for one week. Pegylation delays the body from eliminating interferon. With pegylation, interferon stays in the blood continuously compared to 3 times per week injections, and it appears to be more potent. The side effects appear to be about the same as regular interferon, or maybe a little better. The FDA is reviewing two pegylated interferons and should be approving them around December-January 2000/2001.

What are the side effects of interferon therapy?

Most persons have flu-like symptoms (fever, chills, headache, muscle and joint aches, fast heart rate) early in treatment, but these lessen with continued treatment. Later side effects may include tiredness, hair loss, low blood count, trouble with thinking, moodiness, and depression. Severe side effects are rare (seen in less than 2 out of 100 persons). These include thyroid disease, depression with suicidal thoughts, seizures, acute heart or kidney failure, eye and lung problems, hearing loss, and blood infection. Although rare, deaths have occurred due to liver failure or blood infection, mostly in persons with cirrhosis. An important side effect of interferon is worsening of liver disease with treatment, which can be severe and even fatal. Interferon dosage must be reduced in up to 40 out of 100 persons because of severity of side effects, and treatment must be stopped in up to 15 out of 100 persons. Pregnant women should not be treated with interferon.

What are the side effects of combination (ribavirin + interferon) treatment?

In addition to the side effects due to interferon described above, ribavirin can cause serious anemia (low red blood cell count) and can be a serious problem for persons with conditions that cause anemia, such as kidney failure. In these persons, combination therapy should be avoided or attempts should be made to correct the anemia. Anemia from ribavirin can be treated while remaining on HCV therapy. Anemia may go away after treatment is stopped. Anemia caused by ribavirin can be life-threatening for persons with certain types of heart or blood vessel disease. Ribavirin causes birth defects and pregnancy should be avoided during treatment. Patients and their healthcare providers should carefully review the product manufacturer information prior to treatment.

Can anything be done to reduce symptoms or side effects due to antiviral treatment?

You should report what you are feeling to your doctor. Some side effects may be reduced by giving interferon at night or lowering the dosage of the drug. In addition, flu-like symptoms can be reduced by taking acetaminophen before treatment.

Can children receive interferon therapy for chronic hepatitis C?

Antiviral drugs are not licensed for persons under 18 years of age. Children with hepatitis C should be referred to a children's specialist in liver diseases. You may want to ask your doctor about clinical trials that may be on-going for children.

Are new drugs in development?

Research and development for HCV treatments are receiving much attention because of the need. Antivirals and immune based therapies are being researched and so there should be additional treatments becoming available within several years.

Genotype

What does the term genotype mean?

Genotype refers to the genetic make-up of an organism or a virus. There are at least six distinct HCV genotypes identified. Genotype 1 is the most common genotype seen in the U.S.

Is it necessary to do genotyping when managing a person with chronic hepatitis C?

Yes. Although persons with genotype 1 respond less often to treatment, genotype should not be a deciding factor on whether or not to treat. With newer therapies, however, treatment regimens might differ on the basis of genotypes. But, genotype 1 may need longer treatment, so it helps to know your genotype to design treatment.

What about HCV viral load?

A person with a high viral load (>2 million) may not respond as well to therapy. Such a person also may need longer therapy.

Why do most persons remain infected?

Persons infected with HCV mount an antibody response to parts of the virus, but changes in the virus during infection result in changes that are not recognized by preexisting antibodies. This appears to be how the virus establishes and maintains long-lasting infection.

Can persons become infected with different genotypes?

Yes. Because of the ineffective immune response described above, prior infection does not protect against reinfection with the same or different genotypes of the virus. For the same reason, there is no effective pre- or postexposure prophylaxis (i.e, immune globulin) available.