Hepatitis C

Causes

Hepatitis C virus transmitted by blood to blood contact
Most transmission of HCV is parenteral. Intravenous drug use (IDU) accounts for about 90% of incident cases.
Sexual transmission of hepatitis C virus (HCV) is controversial but is generally considered low risk. High rates of sexual transmission have been reported amongst men who have sex with men (MSM) living with HIV.
HCV infection resolves in about 25% of those with acute HCV infection (up to 40% if jaundiced). The remaining 75% develop chronic HCV defined as positive Hepatitis C RNA at 6 months

Clinical presentation

Most acute and chronic HCV infection is asymptomatic.
Acute hepatitis is uncommon. Symptoms include upper right quadrant pain, lethargy, nausea, fever and jaundice.
Chronic hepatitis: infection lasting over 6 months.

Diagnosis

Test	Site/ specimen	Comments
HCV Antibodies	Blood	The presence of HCV antibodies does not distinguish between current and past infection. Testing for HCV RNA is required to determine if infection is active. There is a window period of up to six months before anti-HCV antibodies are detectable in serum, but most are positive at three months post exposure. False positive HCV antibody results can occur but can be difficult to interpret. If an antibody result is just above the cut-off point for positivity, a different second ELISA test is performed. If one test is positive and the other is negative, the result is reported as “equivocal” and clinical judgement is needed for interpretation. If both ELISA results are at this low level for cut off for positivity, it will be reported as “low reactivity which may be non-specific”. In equivocal cases, a repeat HCV antibody test should be performed. This can be done 2 weeks after the initial test, because with seroconversion, the titre of antibody rises rapidly. HCV PCR, LFTs, Hepatitis A and B serology, if not already done should be performed at the same time. If the reading remains low, the differential diagnosis with a negative PCR is either a false positive result or past HCV infection with decreasing antibody. HCV PCR will be positive by one month from initial exposure. It is estimated that the blood donor population has about 1/1000 false positives.
HCV RNA	Blood	A negative HCV RNA with positive HCV antibody test usually indicates viral clearance. Repeat testing at six months is needed to confirm clearance.
HCV viral load	Blood

Test

Site/ specimen

Comments

HCV Antibodies

Blood

The presence of HCV antibodies does not distinguish between current and past infection. Testing for HCV RNA is required to determine if infection is active.

There is a window period of up to six months before anti-HCV antibodies are detectable in serum, but most are positive at three months post exposure.

False positive HCV antibody results can occur but can be difficult to interpret. If an antibody result is just above the cut-off point for positivity, a different second ELISA test is performed. If one test is positive and the other is negative, the result is reported as “equivocal” and clinical judgement is needed for interpretation. If both ELISA results are at this low level for cut off for positivity, it will be reported as “low reactivity which may be non-specific”.

In equivocal cases, a repeat HCV antibody test should be performed. This can be done 2 weeks after the initial test, because with seroconversion, the titre of antibody rises rapidly. HCV PCR, LFTs, Hepatitis A and B serology, if not already done should be performed at the same time.
If the reading remains low, the differential diagnosis with a negative PCR is either a false positive result or past HCV infection with decreasing antibody. HCV PCR will be positive by one month from initial exposure. It is estimated that the blood donor population has about 1/1000 false positives.

HCV RNA

Blood

A negative HCV RNA with positive HCV antibody test usually indicates viral clearance. Repeat testing at six months is needed to confirm clearance.

HCV viral load

Blood

Consider screening for HCV in:

Individuals with abnormal LFTs that are otherwise unexplained
Individuals who inject drugs, especially with a history of equipment sharing
People living with HIV. Annual screening is recommended
Individuals who have been in prison
Unsterile tattooing or piercing or risk of unsterile medical procedures, including vaccinations overseas
Occupational exposure: needlestick carries 2-10% risk from a known infected source
Clients requesting an HCV test
Aboriginal and Torres Strait islander clients.

Management

Index patient
Referral for treatment should be considered in all cases of Hepatitis C if the patient is agreeable.

Referral for HCV treatment

Patients who are HCV positive and HIV negative should be referred to their GP who are s100 prescribers for hepatitis C, hepatitis or liver clinic for their hepatitis C follow-up. For people living with HIV, please discuss with a sexual health physician or specialist at the hepatitis or liver clinic.

Baseline LFTs, Hepatitis A and B serology can be performed prior to referral
Genotype and monitoring of LFTs should be done by the GP or hepatitis or liver clinic

HCV and HIV co-infected patients should be referred to a HIV/hepatitis co-infection clinic.

Prior to the first visit, the following tests should be performed and results copied to the treatment clinic:

FBE
U&E
LFT
INR
Hepatitis A and B serology if not already done and vaccination as needed
Repeat HCV PCR if not done in the past 12 months
HCV genotype
Alpha fetoprotein
Liver ultrasound
HCV viral load should not be ordered. HCV viral load should be ordered by the treating doctor as it is usually done just prior to treatment.

Contact tracing & partner management

Contacts via parenteral exposure (shared needles, injecting equipment) should be tested
Contact tracing is not generally not performed for sexual partners
See the Australasian Contact Tracing Guidelines for more information

Disclaimer

We recognise that gender identity is fluid. In our treatment guidelines, the words and language we use to describe genitals and gender are based on the sex assigned at birth.

The content of these treatment guidelines is for information purposes only. The treatment guidelines are generic in character and should be applied to individuals only as deemed appropriate by the treating practitioner on a case by case basis. Alfred Health, through MSHC, does not accept liability to any person for the information or advice (or the use of such information or advice) which is provided through these treatment guidelines.

The information contained within these treatment guidelines is provided on the basis that all persons accessing the treatment guidelines undertake responsibility for assessing the relevance and accuracy of the content and its suitability for a particular patient. Responsible use of these guidelines requires that the prescriber is familiar with contraindications and precautions relevant to the various pharmaceutical agents recommended herein.