Table of Contents
What Is Hepatitis C?
is a disease of the liver caused by the hepatitis C virus (HCV). Over time, HCV can cause serious liver damage including cirrhosis (scarring), liver cancer, and life-threatening liver failure.
HIV and HCV Co-Infection
Because both HIV and HCV can be spread by contact with infected blood, many people are infected with both viruses. This is called co-infection. It is estimated that 12 million people worldwide are co-infected with HIV and HCV. In the US, about one in four people living with HIV (HIV+) are co-infected with HCV. Co-infection is even more common among HIV+ injection drug users, of whom about eight out of ten also have HCV.
HCV can progress more rapidly and lead to serious liver damage more often in HIV+ people. According to the US Centers for Disease Control and Prevention (CDC), having HIV more than triples the risk of liver disease, liver failure, and liver-related death due to HCV. Co-infection with HCV may also make HIV treatment more challenging. Therefore, it is important for HIV+ people to know whether they have HCV. The CDC recommends that all HIV+ people be routinely screened for both hepatitis B and hepatitis C. Many experts recommend that HIV+ people at continued risk for HCV be screened every year.
Treatment of HIV/HCV co-infection is complicated (for more information, see treatment section below). It is important to have a health care provider who is familiar with HIV and HCV to get the best treatment for both diseases. The good news is that HCV can be treated successfully, even in HIV+ people.
Who Should Get Treatment?
Not everyone who has HCV needs treatment. Among those who develop chronic HCV, many will not develop serious liver damage. Research shows, however, that HIV+ people are more likely to develop HCV-related liver damage and develop it faster than HIV-negative people. In addition, research shows that treating HCV earlier has a better outcome for those at risk for HCV disease progression and liver damage.
Health care providers look at a variety of tests and health-related factors when deciding whether or not to recommend HCV treatment. Treatment decisions are not based on symptoms alone, since the early stages of liver damage do not always cause symptoms or abnormal lab test results. Instead, health care providers consider any symptoms, your overall health, the results of liver enzyme tests, and the results of tests that determine the extent of any liver damage.
Tests for HCV include:
- HCV antibody and nucleic acid tests
If you have HIV, you should be tested for HCV. The standard HCV test is one that looks for antibodies to HCV in your blood. If your antibody test is positive for HCV, your body has been infected with HCV at some point in time. However, this antibody test can not tell whether you were infected in the past and got rid of the virus, or if you are currently infected.
If your antibody test is positive, you may also get a test for HCV RNA (the actual genetic material of the hepatitis C virus) called a nucleic acid test (NAT). If your NAT is positive, you are most likely infected currently infected with HCV. If your NAT is negative (no HCV RNA in your blood), then you were infected in the past and are not now currently infected.
If your antibody test is positive, your provider may get an HCV viral load. The HCV viral load cannot tell if or when someone with HCV will develop liver damage. However, the HCV viral load can help predict how well someone will respond to HCV treatment. Generally, the lower the HCV viral load, the better the chances that treatment will work well.
- Liver enzyme (or liver function) tests
Liver enzyme tests are blood tests that look at levels of liver enzymes. Because levels of liver enzymes can tell us how well the liver is working, liver enzyme tests are often referred to as liver function tests. Liver enzyme tests measure several things that the liver produces, including ALT, AST, bilirubin, albumin, and some indicators of your blood's ability to clot. Elevated liver enzymes may indicate liver damage. However, some people with HCV have normal liver enzymes, even in very advanced disease.
- Genotype tests
Worldwide, there are six different types of HCV called genotypes. These genotypes differ in their regional distribution and can predict how well treatment will work. Genotype 1 is the most common globally (six out of every ten infections) and is also the most common in the US. Genotypes 2 and 3 are less common in the US. Genotype 3 is very common in Southeast Asia, while genotype 4 is found mostly in the Middle East and central Africa. Genotype 5 is located almost entirely in South Africa, and genotype 6 is found in Asia.
Because different genotypes of HCV respond differently to different treatments, it is important to have a genotype test before you begin treatment. This will help you and your health care provider make decisions about which treatments to use and how long to use them.
- Liver biopsy
A liver biopsy (inserting a needle through the skin and into the liver to obtain a small sample that is examined under a microscope) is the most reliable way to determine how much damage has been done to your liver. It can also help you and your health care provider figure out when to start HCV treatment. However, a liver biopsy is not necessary in order to start treatment.
- FibroSURETM (or FibroTest)
FibroSURETM is a blood test that looks at six markers of liver activity to measure liver damage. It is often used as a non-invasive alternative to liver biopsy. This test is good at identifying either no liver damage or advanced liver damage. However, if the damage is somewhere between none and advanced, it does not give very helpful information. A liver biopsy gives more detailed information about all levels of liver damage.
FibroScan is a relatively new non-invasive test that is currently approved for use in 70 countries. In April of 2013, the US Food and Drug Administration (FDA) approved its use in the US. It is similar to an ultrasound, and is done in the office or clinic by your provider. The scan uses a dull probe that is pressed against the skin over the liver. FibroScan is used to measure liver damage and determine the stage of liver fibrosis. Because the sound waves it uses to measure liver damage must pass through body fat, it is not a good test for those who are obese, since its results are likely to be unreliable.
In general, health care providers are more likely to suggest treatment if you:
- want and are motivated to be treated
- have a liver biopsy or FibroSURE test that shows liver damage (inflammation, and particularly fibrosis)
- have early cirrhosis (scarring of the liver) but are not ill
- have HIV in addition to HCV
- are otherwise in good health or have other medical problems that are well controlled
- have acute hepatitis C (infected within the last six months)
There are also several factors to consider that have been shown to be associated with faster disease progression in HCV-infected people. Some of these factors include:
- Being older than 50
- Being male (most women with HCV do not develop liver damage as quickly as men)
- Using alcohol
- Co-infection with HBV or HIV