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Hepatitis C

Hepatitis C can cause the same types of symptoms and long-term liver damage as hepatitis B, though the two viruses are not related. Recent estimates find that about 215,000 people in the UK are chronically infected with hepatitis C. Overall, about one-third of people with HIV also have hepatitis C. The majority of people living with hepatitis C do not know they have it.

Transmission and prevention

Hepatitis C virus (HCV) can be transmitted in some of the same ways as HIV and hepatitis B. It is usually transmitted by direct blood-to-blood contact. In the past, many people got hepatitis C from being given blood products in a medical procedure – for example blood transfusion during trauma or surgery, and treatment for haemophilia – before screening and sterilisation were introduced in the UK in 1991.

The most common route of transmission in the UK is using non-sterile needles and other equipment for injecting drugs. HCV can survive in syringes for several weeks. Sharing equipment for drug sniffing or snorting (such as straws or banknotes) has also been shown to be a risk. Needles, syringes and other equipment used to inject drugs, and equipment used to sniff drugs, should never be shared.

Sexual transmission of hepatitis C is less common, but it does occur. Over the past several years there has been a large increase in the number of HIV-positive gay and bisexual men who have acquired hepatitis C through sexual transmission in the UK and elsewhere. However, sexual transmission of hepatitis C between heterosexual people and between HIV-negative gay men appears to be rare.

Though study results have been inconsistent, there appears to be an association between sexual transmission of HCV and several factors including anal sex, rough sex, fisting, group sex, having other sexually transmitted infections and using non-injected recreational drugs during sex.

Condoms can reduce the risk of sexual transmission of hepatitis C as well as HIV, hepatitis B and other sexually transmitted infections. Using gloves for fisting may also help prevent hepatitis C transmission. In group sex situations, don’t share sex toys (or cover them with a new condom for each use) or pots of lubricant. Change condoms and gloves between partners. Clean any hard surfaces, such as benches or slings, between uses.

Some HIV-positive gay men try to only have unprotected sex with other men who are also HIV positive (often called ‘serosorting’). However, this does not protect against hepatitis C, hepatitis B, or other sexually transmitted infections. HIV pre-exposure prophylaxis (PrEP) also offers no protection against hepatitis C.

Mother-to-child transmission of hepatitis C is uncommon, but the risk is increased if the mother is also HIV positive. Having a high HCV viral load increases the likelihood that a mother will pass on hepatitis C to her baby.

It is also possible to acquire hepatitis C through personal care items such as razors, toothbrushes and manicure tools that may come into contact with blood. These items should not be shared. New, sterile needles should be used for piercings, tattooing and acupuncture.

There is no risk of transmission through normal social contact, such as sharing crockery or cutlery, or touching someone with hepatitis C. Blood spills from someone with hepatitis C should be cleaned up using undiluted household bleach. Scratches, cuts and wounds should be carefully cleaned and covered with a waterproof dressing or plaster.

There is currently no vaccine to protect against hepatitis C.

Unlike hepatitis A and B, having hepatitis C once does not mean you are immune from getting it again, so even if you have completed successful treatment, you can be re-infected if you are exposed to hepatitis C again. It is also possible to be re-infected with a different strain of hepatitis C.

Diagnosis and monitoring

Treatment for hepatitis C has the best chance of success if it is started soon after a person is infected. If you’re at risk, it makes good sense to be regularly tested for hepatitis C.

A blood test can show if you have been exposed to hepatitis C and have produced antibodies against it. Another type of test measures hepatitis C viral load (also called HCV RNA). This test shows whether the virus is actively reproducing in your body. A minority of people will naturally clear hepatitis C without treatment. They will still have HCV antibodies but will also have an undetectable viral load.

In the UK, standards for HIV treatment and care are set and monitored by the British HIV Association (BHIVA), the professional association for HIV doctors and other healthcare professionals. These standards are reviewed regularly. The most recent guidelines on HIV treatment for adults who also have hepatitis were produced in 2013 and updated in 2014 (see  

Current guidelines say that all people with HIV should be screened for hepatitis C at the time of HIV diagnosis and then at least once a year.

If your HCV antibody test is positive, it should be followed by a viral load test and a test to determine HCV genotype. Viral load and genotype are two factors that affect treatment outcome. For more information, see the section on Factors that affect treatment success.

If you are at risk of hepatitis C infection, and you have unexplained abnormal liver function tests, it is recommended you have an HCV RNA test to see if you have recent, or acute, infection with hepatitis C.

If you are diagnosed with hepatitis C, it is recommended you have regular tests to see how your liver has been affected. These liver function tests measure levels of certain chemicals which give an indication of how well your liver is working. These include two enzymes, known as ALT and AST, which can indicate liver inflammation. However, some people with hepatitis C can still have normal liver function tests despite significant liver damage.

It is recommended you have a liver function test when you are first diagnosed with HIV, at each of your routine HIV clinic appointments and if you become ill. These tests are also used to see if antiretroviral drugs are harming the liver.

Find out more about tests to monitor liver health in NAM’s booklet, CD4, viral load & other tests.

Other tests are also done to see how much the liver is damaged and whether you need treatment. One such test, elastography or FibroScan, uses sound waves to determine the degree of liver fibrosis or cirrhosis. Another is a liver biopsy, which uses a hollow needle to remove a small sample of liver tissue to examine under a microscope. Doctors are also exploring a number of different combination blood tests that can indicate the health of your liver. 

People with chronic hepatitis C who have cirrhosis should also be screened every six months for liver cancer (hepatocellular cancer), which is usually done with ultrasound scans.

Symptoms and disease progression

Most people with hepatitis C do not experience symptoms when they are first infected with hepatitis C, which is known as acute infection. Among people with HIV, routine liver function monitoring sometimes reveals elevated liver enzymes that signal inflammation due to hepatitis C. Even if you do not have any symptoms, you can still pass the virus on to others.

When they do occur, signs and symptoms of acute hepatitis C infection may include the following:

  • Fatigue (unusual tiredness).
  • Fever (high temperature).
  • Nausea and vomiting.
  • Pain in the upper abdomen or belly.
  • Feeling generally unwell (malaise).
  • Yellowing of the skin and whites of the eyes (jaundice).

Only about 20% of people infected with HCV appear to clear the virus naturally without treatment, while about 80% develop chronic hepatitis C that lasts more than six months. People with chronic infection will continue to be infectious and can pass on the virus to others.

In the longer term, about half of people with chronic hepatitis C will experience some symptoms. The most common include fatigue, loss of appetite, muscle and joint pain, and feeling generally unwell. Some people may experience 'brain fog' (mild cognitive problems) or depression. Symptoms may worsen or become more numerous over time.

After years or decades, chronic hepatitis C can cause serious liver damage including fibrosis, cirrhosis or liver cancer. Patterns of disease vary from person to person. Some people never experience any of these complications. Up to 20% will develop cirrhosis over 20 to 30 years, and in the most severe cases it can lead to liver failure, resulting in the need for a liver transplant or ultimately death. Men, people who drink alcohol, older people and people living with HIV tend to have faster hepatitis C disease progression.

Chronic hepatitis C can contribute to other conditions that affect the body beyond the liver (known as extra-hepatic conditions). Studies have found that people with hepatitis C are at higher risk for cardiovascular (heart) disease, strokes and diabetes. People with both HIV and hepatitis C are at even higher risk. Research increasingly shows that infection with both viruses contributes to inflammation and excessive immune system activity which can lead to problems throughout the body.

Hepatitis C and HIV

About 10% of people with HIV in the UK also have hepatitis C, but co-infection is much more common in certain groups, such as people who inject drugs. In some European countries, a much higher proportion of people with HIV also have hepatitis C, especially in countries where injecting drug use is a major route of HIV transmission.

In countries such as the UK, effective HIV treatment is widely available and people with HIV are living longer, healthier lives. However, liver disease is now a major cause of illness, hospital admissions and death among HIV-positive people because of liver damage due to hepatitis B or C.

Having hepatitis C does not appear to alter your chances of becoming ill due to HIV, or dying of an AIDS-related illness.

On the other hand, having HIV does appear to contribute to worse hepatitis C liver disease. People with HIV are less likely to naturally clear HCV infection, go on to develop fibrosis faster, and do not respond as well to treatment with pegylated interferon, currently the standard treatment for hepatitis C. This is especially true for people with low CD4 cell counts.

However, more recent research done after effective and well-tolerated antiretroviral drugs became widely available shows that people with well-controlled HIV can do nearly as well as HIV-negative people. There is evidence that HIV treatment can slow hepatitis C disease progression, and people with HIV and hepatitis C co-infection have high cure rates in studies of the newest hepatitis C drugs.

HIV & hepatitis

Published April 2015

Last reviewed April 2015

Next review April 2018

Contact NAM to find out more about the scientific research and information used to produce this booklet.

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This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.
Community Consensus Statement on Access to HIV Treatment and its Use for Prevention

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We can end HIV soon if people have equal access to HIV drugs as treatment and as PrEP, and have free choice over whether to take them.

Launched today, the Community Consensus Statement is a basic set of principles aimed at making sure that happens.

The Community Consensus Statement is a joint initiative of AVAC, EATG, MSMGF, GNP+, HIV i-Base, the International HIV/AIDS Alliance, ITPC and NAM/aidsmap

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.