Hepatitis C (HCV)

What is hepatitis C?

Hepatitis C is an infectious disease caused by the hepatitis C virus (HCV), affecting primarily the liver. The illness may be short-lived (acute), or, where the virus is not cleared from the body, may become chronic hepatitis C, continuing for years.

One of the important characteristics of hepatitis C is that the infection can progress for many years without giving any symptoms. A person may therefore be carrying HCV while feeling entirely healthy.

Untreated chronic infection can over time lead to damage in the liver, to fibrosis (scarring), to cirrhosis and, in some patients, to liver cancer.

Against that, hepatitis C has a very important advantage today: with modern drugs the virus can be cleared completely in more than 95% of patients.

How is hepatitis C transmitted?

HCV is transmitted principally through contact between infected blood and another person’s blood.

The chief routes of transmission are:

• Sharing needles and syringes, or using ones that are not sterile,
• Medical or surgical equipment that has not been sufficiently sterilised,
• Tattooing and piercing carried out in non-sterile settings,
• Sharing personal items such as razors, shaving blades or toothbrushes that have been in contact with blood containing HCV,
• Blood contact in healthcare workers, such as an accidental needlestick with an infected needle,
• Transfusions of blood and blood products given in the period before blood products were reliably screened for HCV,
• Transmission from a mother carrying HCV to her baby during birth,
• Less often, sexual transmission, particularly where there is contact with blood.

Because blood and blood products are now screened for HCV, the risk of transmission from properly regulated blood transfusions is far lower than in the past.

How is hepatitis C not transmitted?

Hepatitis C is not transmitted by:

• Shaking hands,
• Embracing,
• Being in the same room,
• Coughing or sneezing,
• Eating from the same plate,
• Food or water,
• Everyday social contact.

For this reason people with hepatitis C do not need to be isolated from their families or from society in daily life.

How common is hepatitis C worldwide?

Hepatitis C is an important health problem throughout the world. According to current World Health Organization (WHO) data, about 47 million people worldwide were living with active hepatitis C virus (HCV) infection in 2024. That figure corresponds to about 0.6% of the world’s population.

Around 900,000 people are estimated to be newly infected with HCV each year. Hepatitis C matters not only for how widespread it is but because it can progress unnoticed for many years.

Untreated, HCV infection can in some patients lead over the years to fibrosis of the liver, to cirrhosis and to liver cancer. Around 240,000 people worldwide are estimated to have died in 2024 from HCV-related cirrhosis and liver cancer.

Even so, hepatitis C is today an infection that can be completely treated in more than 95% of patients with antiviral tablets. Recognising the disease early and starting appropriate treatment therefore matters a great deal.

Does hepatitis C cause symptoms?

A substantial proportion of people with hepatitis C infection have no symptoms at all for a long time.

Where there are symptoms, the complaints that may appear are:

• Weakness and tiredness,
• Loss of appetite,
• Nausea,
• Abdominal pain or discomfort in the right upper abdomen,
• Muscle and joint pains,
• Darkening of the urine,
• Paling of the colour of the stool,
• Yellowing of the eyes and skin (jaundice).

None of these symptoms is specific to hepatitis C. The definite diagnosis is therefore made with blood tests.

How is hepatitis C diagnosed?

A two-stage approach is generally used in diagnosing hepatitis C.

1. The anti-HCV test

The first test done is mostly the anti-HCV test.

A positive anti-HCV shows that the person met the hepatitis C virus at some point in their life. But a positive anti-HCV does not on its own mean that the person currently has hepatitis C.

This is because anti-HCV can stay positive for a long time — mostly for life — even where the virus has cleared on its own or has been eliminated by treatment given earlier.

For this reason a second test must be done when anti-HCV is found positive.

2. HCV RNA (PCR)

The HCV RNA test shows whether the virus is still present in the blood.

Anti-HCV positive + HCV RNA positive: there is active HCV infection.

Anti-HCV positive + HCV RNA negative: the person may have met the virus in the past, but in most cases there is no current active infection.

The HCV RNA test can also be used to establish the amount of virus in the blood (the viral load).

In a possible recent transmission, anti-HCV may not yet have become positive. In such a situation the doctor may, if they think it necessary, request an HCV RNA test directly.

What investigations are done once the diagnosis is made?

When HCV RNA is found positive, showing the presence of the virus is not enough on its own. How far the liver has been affected also has to be assessed.

Depending on the patient, the following investigations may be done:

• ALT and AST,
• Bilirubin,
• Albumin,
• INR,
• A full blood count and platelet count,
• Kidney function tests (creatinine, eGFR),
• The HCV RNA level,
• The HCV genotype where needed,
• Hepatitis B tests,
• An HIV test,
• Ultrasound of the liver,
• Blood tests that assess liver fibrosis,
• Elastography (FibroScan and the like).

Today, in many patients, the degree of fibrosis in the liver can be assessed with methods such as blood tests and elastography, without the need for a liver biopsy.

Establishing whether there is advanced fibrosis or cirrhosis matters particularly, because it also affects the patient’s follow-up programme after treatment.

Can hepatitis C be treated?

Yes. Hepatitis C is today one of the viral diseases that can be eliminated completely by treatment.

The interferon-containing treatments used in the past took a long time and could cause significant side effects. Treatment has changed greatly since.

Most patients now take tablets called direct-acting antivirals (DAA).

These treatments:

• Are generally in tablet form,
• Mostly last 8 to 12 weeks,
• Are far better tolerated than the old interferon treatments,
• Can eliminate the virus permanently in more than 95% of patients.

Which drug and what length of treatment is suitable is decided by assessing the patient’s previous treatments, the degree of their liver disease, whether there is cirrhosis, their kidney function, the other medicines they take and certain particular circumstances.

For this reason treatment of hepatitis C should be planned for the individual.

How is it known that hepatitis C has been cured?

HCV RNA is checked again after treatment finishes.

If HCV RNA is not detected at least 12 weeks after treatment is completed, this shows that the treatment succeeded and that the infection has been cleared permanently. This is called a sustained virological response (SVR).

In practice this means that hepatitis C has been cured, that is, treated.

But there is an important point:

Having had hepatitis C once and been treated does not protect a person from becoming infected again.

If the virus is met again, hepatitis C can develop again.

Is follow-up needed after treatment?

This depends on the state of the liver before treatment.

In patients who have not developed significant fibrosis or cirrhosis in the liver, follow-up after successful treatment is generally simpler.

But in patients who have developed cirrhosis, the risk of liver cancer does not disappear entirely even when the virus has been cleared completely. These patients therefore need to continue with regular checks of the liver.

How can hepatitis C be prevented?

There is still no effective vaccine against hepatitis C in routine use. The principal way of protecting oneself is therefore to prevent contact with infected blood.

To protect yourself:

• Syringes and needles must never be shared,
• Personal items on which blood may be present, such as razors and toothbrushes, should not be shared,
• Tattooing and piercing should be done in sterile and reliable places,
• Sterile equipment should be used in medical and dental procedures,
• Appropriate precautions should be taken where there will be contact with another person’s blood,
• Open wounds soiled with blood should be covered,
• A healthcare provider should be seen after a risky blood contact or a needlestick.

What should patients with hepatitis C attend to?

It matters that a person found to have HCV infection protects their liver from further damage.

The following are advised in particular:

• Avoiding alcohol,
• Not using herbal products or supplements without consulting a doctor,
• Reaching a healthy weight in people who are overweight,
• Telling the doctor all the medicines being taken,
• Assessing immunity against hepatitis A and hepatitis B and vaccinating where needed.

Who should be tested for hepatitis C?

Because hepatitis C may give no symptoms for years, testing only people with complaints is not enough.

Assessment should be considered particularly for people who have had blood or blood products in the past, those with a history of intravenous drug use, people who have had a tattoo or piercing in non-sterile conditions, healthcare workers with occupational exposure to HCV-positive blood, patients on haemodialysis, and people with unexplained raised liver enzymes.

Current international recommendations also advise that adults be screened at least once in their lifetime for hepatitis C, and that HCV screening be carried out during pregnancy.