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Hepatitis C
   Last updated: 06.01.05
 
Hepatitis C virus (or HCV) was first identified in 1989 and can affect the liver and lymphatic system. It is not related to hepatitis B, even though it often causes similar symptoms.
It's thought that as many as 500,000 people in the UK are infected with hepatitis C.

Transmission
Hepatitis C is transmitted through blood. The sharing of drug injecting equipment is the most common route if transmission in the UK.
Many people also contracted hepatitis C from blood products before screening and sterilisation was introduced.
Sexual transmission of hepatitis C is a controversial subject. It used to be thought that this was very rare. However there have been recent reports of increasing numbers of gay men testing positive for hepatitis C. Many of these are HIV-positive and reported unprotected sex as their only risk activity. Fisting and any other kind of sex that involves contact with blood is likely to pose an increased risk of hepatitis C infection.
Sharing household items that may have tiny amounts of blood on them, such as razors, toothbrushes and nail scissors should be avoided.
Mother-to-baby transmission of hepatitis C is thought to be uncommon, but the risk is increased if the mother is also infected with HIV. A high hepatitis C viral load also increases the chance that a mother will pass on hepatitis C to her baby. As with HIV, a caesarean delivery reduces the chance of mother-to-child transmission of hepatitis C.
Some studies have found a risk from breast-feeding, but the evidence is inconclusive. However, in the UK and other countries where safe alternatives are available, mothers with HIV should never breast-feed.

Symptoms
Less than 5% of people experience symptoms when they are first infected with hepatitis C. When they do occur, symptoms can include jaundice, diarrhoea, and feeling sick.
In the longer term, about half of people with hepatitis C will experience some symptoms. The most common ones are feeling generally unwell, extreme tiredness, weight loss, intolerance of alcohol and fatty food, and depression.

Disease progression
A small proportion of people infected with hepatitis C clear the infection naturally. Around 85% will go on to develop chronic hepatitis C.
Patterns of disease vary from person to person. Some people never experience any symptoms, but about a third will develop serious liver disease after 15 to 25 years of infection.
The severity of disease can be affected by the strain of hepatitis C you have been infected with, and the way your body is able to respond to the infection. It's thought that it may take between 30 and 40 years for hepatitis C to cause cirrhosis, serious scarring to the liver. But men, people who drink alcohol, older people, and people who also have HIV seem to have faster hepatitis C disease progression.

Cirrhosis
Cirrhosis causes permanent scaring of the liver that can no longer works properly. This can be very serious, causing jaundice, internal bleeding, and swelling of the abdomen. Damage caused by cirrhosis is permanent.

Liver cancer
Chronic hepatitis B and hepatitis C significantly increase the chances of liver cancer developing.
If you have hepatitis C, liver cancer is most likely to happen when you have cirrhosis, particularly if you are a heavy drinker. Smoking may also speed up the rate of cirrhosis and increase the risk of developing liver cancer.
Liver cancer is difficult to treat and surgery is often the only option, involving the removal of part of the liver. Small tumours can be removed, but the chance of a new tumour developing within five years is high. Chemotherapy has no proven benefit against liver cancer.

Diagnosing and monitoring hepatitis C
A blood test can tell if you have been exposed to hepatitis C and have antibodies to it. The British HIV Association recommend that you are tested for hepatitis C at least once, and have more frequent tests if you are at risk of hepatitis C.
A test is also available to measure hepatitis C viral load (PCR). This can show if you are one of the small number of people who clear hepatitis C from the body naturally. Unlike HIV viral load testing, a hepatitis C viral load is not an indicator of when to start treatment. However, it can be used to show how long you should continue to take treatment against hepatitis C. If you have a very high hepatitis C viral load (above 2 million copies) you may require a longer course of treatment.
Tests on levels of enzymes produced by your liver, called 'liver function tests', can give an indication of whether or not hepatitis C has damaged your liver. However, some people with hepatitis C can have normal liver function tests even though they have suffered significant liver damage.
If the degree of liver damage you have suffered is unclear, then you may need to have a liver biopsy. This involves using a hollow needle to remove a small sample of the liver which is checked under the microscope for signs of liver damage.
Liver biopsies can also be used to help decide what kind of hepatitis C treatment you need and how long it should last for.
However, liver biopsies can be uncomfortable and can cause bleeding. If you have haemophilia you may need to receive extra Factor VIII or Factor IX before and after the biopsy, and a very small number of people with haemophilia may not be able to have a biopsy at all because of very low clotting factor levels. Because of these issues, some doctors are exploring the possibility of using a number of different blood tests that viewed together can give an accurate impression of liver function and damage, rather than using biopsies.

How does HIV affect hepatitis C?
In the past few years several studies have confirmed the link between HIV and hepatitis C coinfection and faster progression of liver disease. It seems that people coinfected with HIV and hepatitis C are more likely to develop liver disease than people infected only with hepatitis C. This seems to be the case even if you have a high CD4 count. More severe liver damage is seen in people who have advanced HIV.


The effect of hepatitis C on HIV
In countries like the UK, where HAART is widely available and people are living longer, healthier lives with HIV, liver disease is now a major cause of hospital admission and death among HIV-infected people.
This is because of hepatitis B and C liver-related problems. Hepatitis C does not appear to significantly alter your chances of becoming ill due to HIV, developing AIDS, dying of an AIDS-defining illness, or responding poorly to anti-HIV treatments.

HAART if you have HIV and hepatitis C
HAART can be used safely and effectively if you are coinfected with HIV and hepatitis C. However, you may be at greater risk of side-effects affecting the liver which some anti-HIV drugs can cause.
You and your doctor should bear this in mind when selecting which anti-HIV drugs you are going to take, and careful monitoring of your liver after you start taking HAART is strongly recommended.
Your decision when to start HAART
should be based on your CD4 cell count and HIV viral load, as it is in people who have HIV alone.
You may be at greater risk of developing some of the metabolic disorders that can be a side-effect of HAART, such as insulin resistance and diabetes.
Some people with hepatitis C have a lower CD4 count rise on HAART than those without hepatitis C.

Treatments for hepatitis C
Treatments are available for hepatitis C.
The British HIV Association recommends that before you start treatment for hepatitis C you are assessed by doctors who are expert in the treatment of hepatitis C and HIV.
Before treatment is started it is important to have a test to show which strain, or genotype, of hepatitis C you have been infected with, as hepatitis C genotype can predict your response to treatment.
There are at least six type of hepatitis C genotype. Type 1 is the most common in the UK and Europe. Unfortunately, type 1 responds least well to the currently available treatments for hepatitis C.
Unlike HAART, treatment for hepatitis C is not indefinite. It consists of a 24 or 48 week course of treatment, and the length of treatment you receive is dependent upon the genotype you are infected with and your response to treatment. A test after 12 weeks can predict if you are not going to respond to treatment.
There are currently three antiviral drugs available for the treatment of hepatitis C. These are alpha interferon, pegylated interferon (or peg-interferon), and ribavirin.
Alpha interferon can be used by itself or in combination with ribavirin. Pegylated interferon can also be used either by itself or in combination with ribavirin. Ribavirin should never be used as a treatment for hepatitis C by itself.
Treatment with pegylated interferon and ribavirin is becoming the standard treatment as it seems to produce better results, and is the standard of care recommended by the British HIV Association

Aims of hepatitis C treatment
If you have a CD4 cell count above 200, the aim of treatment should be to eradicate hepatitis C completely. Although 50-80% of non HIV-positive individuals respond to treatment with pegylated interferon and ribavirin, the response rate in people coinfected with HIV and hepatitis C is much lower.
If this is not possible, then treatment should have the aim of normalising liver function, reducing the inflammation in your liver caused by hepatitis C, and the prevention of further damage to the liver.
If you have very advanced HIV disease the aim of hepatitis C treatment is likely to be different and focus on improving your tolerance of anti-HIV drugs, improving liver function, reducing your risk of death from liver problems, and improving your quality of life.

Side effects of hepatitis C treatment
The side-effects of hepatitis C treatment can be very severe, though they tend to lessen as treatment goes on.
Side-effects include high temperatures, joint pain, weight loss, feeling sick, and depression. Depression is particularly common in people taking alpha or peg-interferon and you may be offered antidepressants if you are taking this drug.
Other major side-effects of alpha interferon include blood abnormalities such as a low white blood cell (neutropenia), and/or a low platelet count (thrombocytopenia).
If you are taking ribavirin you should not take it with the anti-HIV drugs ddI, d4T
or tenofovir because of the risk of the very serious side-effects, such as pancreatitis and lactic acidosis.

Which infection to treat first – HIV or hepatitis C?
The British HIV Association recommends that the infection that is the greatest threat to your health should be treated first.
If you have a good CD4 cell count and are not becoming ill because of HIV, then you should be offered the choice of receiving treatment for hepatitis C before you start anti-HIV treatments.
However, if your CD4 cell count is low (below 200), falling rapidly, or are becoming ill because of HIV, then you should start HAART first.

Hepatitis C drugs in the pipe-line
Many doctors are optimistic that much better drugs will be available for hepatitis C in the future. These include hepatitis C protease inhibitors, and a new form of interferon called interferon-tau. However, it could be many years before these drugs are available.
If you are going to take treatment for hepatitis C, then you might want to consider joining a clinical trial, if there's one available. This means that you will be monitored more frequently and may receive newer treatments.