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What is Hepatitis C (HCV)?
HCV is an infection caused by a virus that results in inflammation (swelling) of the liver. This infection can lead to varying degrees of liver damage including cirrhosis, liver failure and liver cancer. HCV is a very common condition - almost 4 million Americans and 200 million people worldwide are infected with the virus, and it is the most common reason for liver transplantation.

How is HCV contracted?
At this time, there is no vaccine available to protect individuals from contracting HCV. Hepatitis C is most often contracted from exposure to blood infected with the HCV virus, however HCV can be transmitted through bodily fluids as well. You are put at highest risk for contracting HCV when you share items that may be exposed to the bodily fluids of a person infected with HCV. And, remember HCV is an under diagnosed condition, so the HCV virus-carrier may not even know that they are putting you at risk.

Who is at risk?
Approximately 38% of all HCV cases are associated with unsafe practices related to drug use You could be at great risk for HCV if you have ever shared IV drug needles or straws/spoons that may have touched the mucous membrane in your nose. Toothbrushes may also pass along the virus if shared by an infected individual.

Health care workers who are accidentally exposed via a needle stick can also be at risk. Other routes of transmission include un-safe sex practices, non-sterile tattooing or body piercing practices, blood transfusions with contaminated blood, organ transplants from donors infected with HCV, and rarely, mother to child transmission in the uterus. It is important to note that transmission of HCV via blood transfusions and organ transplantation has been virtually eliminated since 1992 , when advanced screening for the HCV virus with sensitive tests was implemented, greatly reducing the risk of transmission to patients.

Individuals who are exposed to infected bodily fluids, particularly blood are at risk for contracting HCV. The most common risk behavior is past or present IV drug use including sharing contaminated needles or other drug paraphernalia such as cocaine straws.

What are the symptoms of HCV?
Very frequently individuals who are infected with HCV are not even aware that they are infected. In fact, it has been estimated that as many as 60-70 percent of patients experience no symptoms at all. Individuals may live with this condition for a long time without developing symptoms or, in turn, symptoms may arise quickly. So, even if you haven't done drugs since the 70's, you should still be tested. This is a very concerning aspect of HCV since individuals who are symptom-free will likely not seek medical attention or treatment. This allows the infection to progress and may also put contacts of the infected individual at risk of disease transmission. And, although you are not experiencing symptoms, the disease is devastating your liver.

Hepatitis C symptoms are difficult to pinpoint because they typically resemble those of the flu, and include fatigue, weakness, fever, nausea, diarrhea, achy joints, loss of appetite, and abdominal pain. In some cases, more specific signs of hepatitis may be present: light colored stools, dark urine, itchy skin, and yellowing of the skin and whites of the eyes. If you think you have been exposed to HCV, talk to your doctor about getting tested to determine if you are infected. Early detection is important for treatment and preventing transmission to others.

How is HCV detected?*
Early detection is important for individuals at risk for HCV. With early detection, damage to the liver may be slowed or minimized by prompt treatment with the proper medications. Furthermore, patients are also more likely to respond better to treatment the earlier the virus is detected. Early detection also allows patients to take steps to prevent spreading the virus to others.

1. Enzyme Immunoassay (EIA) - The EIA is the oldest and most important method of detection of hepatitis C viral antibodies. Detecting antibodies means that the body has been exposed to HCV at some point, and the individual is therefore infected with the virus. This test is very sensitive, however one disadvantage is that it does not evaluate whether the patient is having acute hepatitis, chronic hepatitis or a resolved infection (see What is the natural course of HCV?"). If the EIA is positive, an HCV RNA test is typically performed to determine if the patient is having active disease.

2. HCV RNA - Blood can be screened for HCV RNA, which appears within one to two weeks after viral infection. This test will detect the number and presence of circulating HCV in the bloodstream, and differentiates between active and latent disease. If the patient does have active disease according to this test, then the doctor may recommend a liver biopsy (see "What is a liver biopsy?") and/or genotype (see "What is genotype?") determination prior to proceeding with treatment.

3. Alanine aminotransferase (ALT) - Another method of detection is to monitor an enzyme in the liver known as ALT. If the level of ALT is significantly elevated above normal, this indicates that HCV may be present. Elevated ALT can be a sign for a doctor to order an EIA.

4. Home tests - The FDA has approved a home testing kit for detection of exposure to HCV. The patient collects a few drops of blood and mails the sample to a laboratory. The laboratory will then analyze the sample of blood by looking for the presence of HCV antibodies. Results of the test can be obtained within four to ten days by calling a toll free number and using a personal identification number to maintain privacy. If the results of the home test are positive, the patient needs to notify his or her doctor and schedule an appointment to discuss the results. The home HCV tests are available in local pharmacies and on the Internet. The cost can range from $70 to $80. While the home test is convenient, it only determines if the patient has been exposed to the virus. Making an appointment to see the doctor is essential if the patient tests positive.

If your doctor suspects that you have HCV based on a screening test, he may recommend that you have a liver biopsy. This sounds frightening, but if you are familiar with the procedure and know exactly what to expect and how to prepare for it, everything should go very smoothly.

*This section is adapted from Melani C and Heron B. What you need to know about the silent epidemic: Hepatitis C. Lifetimes 2001;1:15-17.

What is the natural course of HCV?
One of the hallmark features of HCV is a long latency period. Essentially what this means is that a majority of people who are infected do not know they are infected and harbor the virus for many years, until they begin experiencing symptoms and signs of the infection. It is probably easiest to describe the course of HCV by outlining acute and chronic hepatitis.

Acute hepatitis - Acute hepatitis can occur after a patient is exposed to HCV. They may develop flu-like symptoms or specific signs of hepatitis such as dark urine and light-colored stools (see What are the symptoms of HCV?). About 15-30% of patients who are exposed to HCV will recover spontaneously and "clear" the virus, however the remaining 70-85% will develop chronic HCV infection.

Chronic hepatitis - Patients who do develop chronic infection can harbor the virus for as long as 15-20 years. Not all patients with chronic infection will have problems down the road, however, cirrhosis has been reported to develop in 15-30% of patients. Cirrhosis is a condition that causes scarring and fibrosis (hardening) of the liver. It prevents the liver from functioning normally and can eventually lead to various complications including fluid in the abdomen, blood clotting disorders, brain function abnormalities (encephalopathy), elevated pressure in blood vessels (portal hypertension), and liver cancer (hepatocellular carcinoma or HCC). If liver damage becomes very extensive, a liver transplant may be warranted. In fact hepatitis C is the leading cause for liver transplants in the United States.

Patients who do not develop cirrhosis may still go on to have manifestations of mild/moderate disease. In other words, they may still have symptoms and an impairment in liver function, but not as severe as cirrhosis or cancer.

• Male sex
• Co-infection with HIV (see "What about HIV?HCV co-infection?")
• Co-infection with Hepatitis B virus
• Exposure to the virus later in life (>40 years old)
• Alcohol use (see "What else can I do?")

• ALT level (see "How is HCV detected?")
• Genotype (see "What is genotype?")
• The way in which the virus was acquired (see "How is HCV contracted?")
• HCV RNA number (see "How is HCV detected?")

This information is provided for educational purposes only. It is not intended to be a substitute for medical advice or treatment from a health care provider or to cover all possible uses, actions, precautions, side effects or interactions. Like any printed material, it may become out-of-date over time. If you have other questions, you should discuss them with your physician or PharmaCare Pharmacist.

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