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Guide to Hepatitis C for People Living With HIV

Testing, Coinfection, Treatment and Support

August 2007

What Happens to People Who Have Hepatitis C

The Natural History of HCV

Although hepatitis C also affects other parts of the body, your liver is the organ most affected.

Your liver is an essential organ with hundreds of functions. On a daily basis, it:

  • filters chemicals and waste from the blood;
  • stores vitamins, minerals, and iron;
  • converts nutrients from food into energy;
  • helps to balance levels of sugar and hormones;
  • produces cholesterol;
  • makes bile (necessary for digestion); and
  • creates the hormone that helps to produce platelets (to stop bleeding).

Hepatitis C does not directly damage your liver. Instead, after infection, the immune system reacts to hepatitis C by trying to rid the liver of infected cells. This immune response can cause liver inflammation, which in turn leads to scarring. As the immune system tries to isolate infected cells, the scarring worsens. The result is that the liver hardens and becomes less elastic. Therefore, scarring makes it increasingly difficult for blood and other necessary fluids to flow freely through the liver.

Even though a badly damaged liver can keep working, the ongoing effects of HCV and inflammation can slowly interfere with liver function. A person with chronic HCV experiences health complications when his or her liver is no longer able to carry out important tasks.

Acute HCV

The first six months of HCV infection are referred to as the acute infection period. Eighty percent of people do not have symptoms during acute infection, so HCV is rarely diagnosed at this time. When symptoms do occur during acute infection, they include fever, fatigue, abdominal pain, nausea, vomiting, dark urine, and jaundice.

During acute HCV infection, a person's liver enzyme levels can be 10 to 20 times normal. People receiving HIV treatment get their liver enzyme levels checked regularly. Sometimes, in the course of this routine monitoring, doctors find abnormally high liver enzyme levels that signal HCV. This can help them to diagnose acute HCV in HIV-positive patients.

In the first few months after HCV infection, some people will eliminate the virus from their bodies without treatment. This is called spontaneous clearance. The people most likely to clear HCV during acute infection are those who are symptomatic, female, and under age 40.

HIV-positive people are only half as likely to spontaneously clear hepatitis C.

People of African descent are less likely to clear hepatitis C than those of European descent. The reasons for this difference are unclear.

If you've cleared the virus during acute infection, you may test positive for antibodies to HCV. However, the virus is not detectable in your blood, and you are no longer infected.

If HCV does not clear spontaneously within the first few months, some people choose to start treatment during acute infection because there are higher success rates at this stage. It is important to discuss the risks and benefits of treating acute hepatitis C with your doctor.

Chronic HCV

An HCV infection that still exists after the acute infection period has ended is referred to as chronic HCV.

In HIV-negative people, HCV progresses very slowly, usually over decades, with a wide range of outcomes. The liver might not be the only part of the body affected. The i-Base guide available online at provides more information about non-liver-related consequences of HCV.

Some people never seem to experience significant consequences of HCV infection. Others may develop mild to moderate fibrosis (liver scarring) and experience symptoms such as fatigue, depression, and confusion (often called brain fog). There seems to be no clear relationship between the symptoms a person has and the degree of liver damage.

Some people may develop fat in their liver cells, a condition known as steatosis. Steatosis is linked with more serious liver disease.

About 20% to 30% of people with chronic, untreated HCV will progress to cirrhosis (serious liver scarring). A cirrhotic liver can still function; this condition is called compensated cirrhosis.

End-Stage Liver Disease

Compensated cirrhosis may progress to end-stage liver disease, which occurs when a person's liver can no longer function. This is known as decompensated cirrhosis. A person with decompensated cirrhosis needs a liver transplant in order to survive. The majority of liver transplants in the United States and Europe are attributed to complications of HCV.

Each year, between 1% and 5% of people with cirrhosis develop hepatocellular carcinoma (HCC; liver cancer).

HIV and Hepatitis C Coinfection

Hepatitis C behaves differently in HIV-positive people. HIV accelerates hepatitis C disease progression. (Still, many people have lived with both HIV and hepatitis C for years, often without knowing that they are coinfected.) The risk of serious liver damage is greatest among HIV-positive people with fewer than 200 CD4 cells.

HCV can be treated, regardless of a person's HIV status. Antiretroviral therapy has dramatically reduced the number of deaths from HIV. Now, end-stage liver disease from hepatitis C coinfection has become a leading cause of death among HIV-positive people in parts of the United States and Western Europe. This is partly because HCV may not be diagnosed until after severe liver damage has already occurred.

The Effect of Hepatitis C on HIV

Hepatitis C does not worsen HIV but may complicate HIV treatment, since many HIV drugs are metabolized by the liver. Coinfected people are at greater risk for ART-associated hepatotoxicity than those with HIV alone. Still, the benefit of HIV treatment outweighs the risk of liver toxicity. (For more information, see "Drug Interactions Between HCV Treatment and HIV Drugs.")

How Can You Protect Your Liver?

There are many things that you can do to support liver health:

  • Having another viral infection in your liver can worsen HCV, so get vaccinated against hepatitis A and hepatitis B.
  • Drink less or stop drinking alcohol altogether -- the less you drink, the better for your liver. Sometimes drinking less, or not at all, is more important than treating HCV.
  • Maintain normal weight -- being overweight increases your risk for fat deposits in the liver, which makes HCV harder to treat.
  • Drink a lot of water to help your liver filter out waste and toxins.
  • Eat less fatty, salty, and sugary food when possible.
  • Try to eat more fresh fruit and vegetables, complex carbohydrates, low-fat, high-fiber foods, and an adequate amount of protein.
  • Ask questions and get support. Talk with other people who are living with hepatitis C or HIV and HCV.

Factors That Accelerate HCV Progression

  • HIV coinfection
  • Alcohol intake, especially more than 50 grams/day, or the equivalent of four to five glasses of wine (see "Alcohol and HCV," for more information)
  • Aging
  • Duration of infection
  • Older at time of infection (over 40 years of age)
  • Hepatitis B coinfection
  • Male sex

Fig. 1: Risk of HCV Progression in HIV-Positive People

Fig. 1: Risk of HCV Progression in HIV-Positive People
Click to enlarge

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This article was provided by Treatment Action Group. It is a part of the publication Guide to Hepatitis C for People Living With HIV.