Causes

  • Hepatitis C virus transmitted by blood-to-blood contact
  • Most transmission of HCV is parenteral. Intravenous drug use (IDU) accounts for about 90% of incident cases.
  • Sexual transmission of   hepatitis C virus (HCV) is  generally considered uncommon. However, high rates of sexual transmission have been reported amongst men who have sex with men (MSM) living with HIV.
  • HCV infection resolves in about 25% of those with acute HCV infection (up to 40% if jaundiced). The remaining 75% develop chronic HCV defined as positive Hepatitis C RNA at 6 months

Clinical presentation

  • Most acute and chronic HCV infection is asymptomatic.
  • Acute hepatitis is uncommon. Symptoms include upper right quadrant pain, lethargy, nausea, fever and jaundice.
  • Chronic hepatitis: infection lasting over 6 months.

Diagnosis

Test Site/ specimen Comments
HCV Antibodies Blood

The presence of HCV antibodies does not distinguish between current and past infection. Testing for HCV RNA is required to determine if a person has current infection. infection is active.  

There is a window period of up to six months before anti-HCV antibodies are detectable in serum, but most are positive at three months post exposure.

False positive HCV antibody results can occur andbut can be difficult to interpret.  If an antibody result is just above the cut-off point for positivity, a different second ELISA test is performed. If one test is positive and the other is negative, the result is reported as “equivocal” and clinical judgement is needed for interpretation. If both ELISA results are at this low level for cut off for positivity, it will be reported as “low reactivity which may be non-specific”.

In equivocal cases where the HCV ab is equivocal or low reactivity, , a repeat HCV antibody test can be performed with a HCV RNAshould be performed. This can be done 2 weeks after the initial test, because with seroconversion, the titre of antibody rises rapidly. HCV PCR, LFTs, Hepatitis A and B serology, if not already done should be performed at the same time.
If the HCV ab level reading remains low, the differential diagnosis with a negative PCR is either a false positive result or past HCV infection with decreasing antibodies. 
HCV PCR will usually be positive by one month from initial exposure. It is estimated that the blood donor population has about 1/1000 false positives.  
HCV RNA Blood A negative HCV RNA with positive HCV antibody test usually indicates viral clearance (either spontaneous clearance or post-treatment).  In those with an ongoing risk of re-infection an annual HCV RNA is recommended.
HCV viral load Blood

 

Consider screening for HCV in:

  • People who inject drugs (current/ever), particularly those with a history of sharing needles or injecting equipment
  • People with abnormal LFTs that are otherwise unexplained
  • People living with HIV* or HBV infection
  • Men who have sex with men* People who have been in prison
  • People who received unsterile tattooing or piercing or unsterile medical/dental procedures, including vaccinations overseas
  • Migrants from areas with a high prevalence of hepatitis C.
  • People who received a blood transfusion or organ transplant in Australia before 1990.
  • People born to a mother with HCV infection Occupational exposure: needlestick carries 2-10% risk from a known infected source
  • Any clients requesting an HCV test

 * Annual screening is recommended in PLHIV and MSM on PrEP

Management

Index patient
Referral for treatment should be considered in all cases of chronic Hepatitis C.

Referral for HCV treatment

Please refer to ASHM guidelines: Decision Making in Hepatitis C 

Patients who are HCV positive and HIV negative should be referred to their GP who are s100 prescribers for hepatitis C, hepatitis or liver clinic for their hepatitis C follow-up. For people living with HIV, please discuss with a sexual health physician or specialist at the hepatitis or liver clinic.

Baseline testing prior to HCV treatment would usually include:Prior to the first visit, the following tests should be performed and results copied to the treatment clinic:

  • Serology for HIV, hepatitis A and B
  • HCV RNA pcr and genotype is not already done
  • FBE
  • U&E
  • LFT
  • INR
  • An assessment of fibrosis should be performed either using serum biomarkers such as an APRI score or elastography (Fibroscan)
  • Where cirrhosis is clinically suspected or confirmed on these tests, the physician should consult with a hepatologist.

Contact tracing & partner management

  • Notification of contacts where hepatitis C is acquired through needles and injecting equipment is a high priority. 

Contact tracing of sexual partners is  a lower priority due to low risk of sexual transmission.

Disclaimer

We recognise that gender identity is fluid. In our treatment guidelines, the words and language we use to describe genitals and gender are based on the sex assigned at birth.

The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines. 

The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.