Hepatitis C

HCV |

Overview

  • Sexual transmission is rare but can occur in men who have sex with men (MSM), particularly those with HIV.
  • Hepatitis C can cause acute hepatitis (uncommon), chronic hepatitis C (longer than 6 months, 75%) or spontaneously clear (25%).
  • Disease progression is usually slow but may cause cirrhosis, liver failure and hepatocellular carcinoma.
  • Disease progression can be affected by age at infection, duration of infection, heavy alcohol intake, coinfection with HIV or HBV, male gender, stage of fibrosis and higher ALT levels.
  • Almost all patients can be successfully treated with DAA (directly acting antiviral) therapy.

Cause

Infection with the single-stranded RNA hepatitis C virus.

Clinical presentation

Symptoms
Asymptomatic infection: common
Acute hepatitis: uncommon. Symptoms such as lethargy, nausea, fever, anorexia for a few days then jaundice, pale stools and dark urine
Chronic hepatitis: infection lasting over 6 months, can be life-long, may cause extra-hepatic manifestations such as skin or joint symptoms
Complications
Cirrhosis: ankle swelling, ascites, gastrointestinal bleeding, encephalopathy, jaundice
Hepatocellular carcinoma: abdominal mass

Diagnosis

Decision making tool for hepatitis C

TestSite/SpecimenConsideration
Hep C Ab Blood

Infection with hepatitis C (past or current)
HCV RNA (NAAT)/HCV PCR Blood

Positive indicates current/active HCV infection. Negative indicates past/cleared HCV (should be repeated).
LFT Blood

Raised  ALT, AST indicate hepatitis
HCV quantitative NAAT Blood May be performed in primary care or by specialist
HCV genotype Blood May be performed in primary care or by specialist,  genotype determines treatment regimen and duration of therapy
HCV – Hepatitis C virus
Hep C Ab – Hepatitis C antibody
RNA – Ribonucleic acid
NAAT – Nucleic Acid Amplification Test
PCR – Polymerase chain reaction
LFT – Liver function test
ALT – Alanine aminotransferase
AST – Aspartate aminotransferase
  • About 75% will progress to chronic hepatitis.
  • Past cleared hepatitis C infection does not provide immunity to reinfection.
  • Medicare Benefits Schedule (MBS) allows 1 HCV RNA qualitative test annually for patients who are Hep C Ab positive or where the results are indeterminate, the patient is immunosuppressed or before seroconversion if necessary for clinical management. A maximum of 4 HCV RNA quantitative RNA tests are allowed on the MBS for patients undertaking treatment.

Management

Management Options
SituationRecommendedAlternative

Acute hepatitis

Consider urgent referral for possible treatment

Observation as some patients will clear hepatitis C.

Chronic infection

Direct-acting antiviral drugs +/- Interferon depending on the genotype

http://www.ashm.org.au/HCV/management-hepc

Observation if other comorbidities require management/stabilising.

Complications

Referral to specialist if complications suspected e.g. cirrhosis.

n/a 

HCV – Hepatitis C virus

Treatment advice

  • Offer treatment to all patients
  • Work-up and treatment initiation in collaboration with authorised HCV treatment providers.

Other immediate management

  • No significant risk of sexual transmission except for HIV positive men
  • Vaccinate for hepatitis A and B, if susceptible
  • Consider comprehensive other STI testing, depending on the patient’s sexual history
  • Provide patient with fact sheet or medicines factsheet
  • Notify the state/territory health department if required.

Special treatment situations

SituationRecommended
Pregnant women 
pregnancy
All babies should have close follow-up, including testing for Hep C Ab and HCV RNA at 18 months of age.

HCV – Hepatitis C virus
RNA – Ribonucleic acid

Contact tracing

  • Low risk for sexual exposure (except for HIV positive men) so contact tracing not generally performed for sexual partners.
  • Contacts via parenteral exposure (shared needles, injecting equipment) should be tested if possible.
  • Children of mothers who are hepatitis C positive should be tested.

See Australasian Contract Tracing Manual - Hepatitis C for more information.

Follow up

Patients with chronic hepatitis C should be assessed for other causes of hepatitis (e.g. alcohol, fatty liver), and should be counselled to reduce these factors if relevant (e.g. reduced alcohol intake).

Test of Cure (TOC)

Following successful treatment or natural clearance of hepatitis C, HCV RNA will be negative although hepatitis C antibody will remain positive.

Retesting

Clearance of hepatitis C does not provide immunity from reinfection. Retesting is required if there is a continued risk of re-exposure.

Auditable outcomes

  • 100% of hepatitis C antibody positive patients should have hepatitis C RNA performed.
  • 100% of hepatitis C antibody positive/RNA positive patients should be offered HCV treatment.
Last Updated: Friday, 20 May 2016