Hepatitis C

Introduction

HCV is the most common blood-borne pathogen and is most often acquired through injection drug use. Screening for HCV infection is recommended in groups who are at high risk for infection (Table 25–7). The CDC recommends one-time screening of all patients born between 1945 and 1965.

• Transmission may occur by sexual contact; hemodialysis; or household, occupational, or perinatal exposure.
• In up to 85% of patients, acute HCV infection leads to chronic infection defined by persistently detectable HCV RNA for 6 months or more.

Clinical Presentation

• Patients with acute HCV are often asymptomatic and undiagnosed. One third of adults will experience some mild and nonspecific symptoms, including persistent fatigue. Additional symptoms include right upper quadrant pain, nausea, or poor appetite.
• An estimated 20% of patients with chronic HCV infection will develop cirrhosis, and half of those patients will progress to decompensated cirrhosis or hepatocellular carcinoma.
• The diagnosis of HCV infection is confirmed with a reactive enzyme immunoassay for anti-HCV. Serum transaminase values are elevated within 4 to 12 weeks after exposure.

Recommendations for Hepatitis C Virus (HCV) Screening

Anyone born between 1945 and 1965, Current or past use of injection-drug use, Coinfection with HIV, Received blood transfusions or organ transplantations before 1992, Received clotting factors before 1987, Patients who have ever been on hemodialysis, Patients with unexplained elevated ALT levels or evidence of liver disease, Healthcare and public safety workers after a needle-stick or mucosal exposure to HCV positive blood, Children born to HCV-positive mothers, Sexual partners of HCV-positive patients.

TREATMENT

• Goals of Treatment: The goal is to eradicate HCV infection, which prevents the development of chronic HCV infection and sequelae.
• Treatment is indicated in patients previously untreated who have chronic HCV, circulating HCV RNA, increased ALT levels, evidence on biopsy of moderate to severe hepatic grade and stage, and compensated liver disease.
• Adherence to therapy is a crucial component in response, especially among genotype 1–infected patients. Patients who take at least 80% of their medications for at least 80% of the treatment time are more likely to successfully respond to therapy.
• The current standard of care for chronic HCV genotype 1 patients is a combination therapy of a once-weekly injection of peg-IFN, a daily oral dose of ribavirin, and either boceprevir or telaprevir. The PIs must be used in combination with peg-IFN and ribavirin to limit the development of resistance. For all other genotypes, the standard of care remains peg-IFN and ribavirin.
• All patients with chronic HCV infection should be vaccinated for HAV and HBV. Patients should be advised to maintain good overall health, stop smoking, and avoid alcohol and illicit drugs.

Recommended Hepatitis C Virus Treatment Algorithm

Genotype Therapeutic Regimen Duration1 Peg-IFN + ribavirin + boceprevir or telaprevir Variable 24–48 weeks2, 3, 4 Peg-IFN + ribavirin 24 weeks

PREVENTION

No HCV vaccine is currently available.