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

Test	Site/Specimen	Consideration
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
Situation	Recommended	Alternative
Acute hepatitis	Consider urgent referral for possible treatment	Observation as some patients will clear hepatitis C.
Chronic infection	Direct-acting antiviral drugs offer curative treatment in over 95% of patients. See for current treatment recommendations http://www.hepcguidelines.org.au/	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
Notify the state/territory health department if required.

Special treatment situations

Situation

Recommended

Pregnant women

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: Thursday, 29 March 2018