Hepatitis C

The word hepatitis refers to inflammation of the liver. While liver inflammation is often associated with heavy alcohol use, autoimmune disease, drug use, and exposure to toxins, viruses are the most common cause of hepatitis.

Hepatitis C, also known as hep C, is one such viral disease that causes liver inflammation. The condition develops when you contract the hepatitis C virus (HCV). Viral infection can be acute (short-term) or chronic (long-term), depending on how long liver inflammation lasts.

Acute hepatis C infection

The acute phase of hepatitis C occurs during the first six months of infection. Most people remain free of symptoms during this time. In fact, fewer than 30 percent of people infected with the virus experience hep C symptoms during this period. This is why many people who carry HCV might never know they’ve been infected.

Because infection triggers various responses from the immune system, up to 50 percent of people who test positive for hepatitis C clear the virus from their bodies without the need for treatment. When you have a viral infection like hepatitis C and your body clears it, your immune system produces certain white blood cells (WBCs) called memory T cells.

These memory T cells remain in your system for long periods of time. Because of the presence of memory T cells from an earlier infection, your chances of clearing the hepatitis C virus again may go up by about 80 percent if you’re reinfected, according to a 2023 review of studies published in Viruses.

If you’re reinfected with HCV, memory T cells rapidly lower your viral load (the amount of the virus you have in your blood). They also help clear the virus from your blood at a faster rate.

Acute HCV infection isn’t usually life-threatening. But in some cases, acute hepatitis can lead to acute liver failure, also called fulminant hepatic failure (FHF).

Chronic hepatitis C infection

Around 55 to 85 percent of people with acute hepatitis C go on to develop chronic hepatitis C, which is when the infection lasts longer than six months. During this chronic phase, HCV replicates (makes copies of itself) in liver cells called hepatocytes. As liver inflammation persists, hepatocyte damage can harm your liver, leading to several health issues such as liver stiffness and gradual loss of liver function, which can become life-threatening.

What are the differences between hepatitis A, B, and C?

The most prevalent types of viral hepatitis found in the U.S. are hepatitis A, B, and C. Collectively, these account for 90 percent of acute viral hepatitis infections across the country.

HCV causes hep C while the hepatitis A virus (HAV) causes hep A and the hepatitis B virus (HBV) causes hep B. Symptoms for each can range from mild to severe, although some people might not experience any symptoms, especially during the acute phase.

While they share common features, there are important differences between hepatitis A, B, and C.

Transmission of hepatitis A, B, and C

Hepatitis A is transmitted mainly through the fecal-oral route; that is, by ingesting food or water that’s contaminated with the feces of a person who carries HAV. It can also be contracted through direct contact with a person who has the infection. Hep A is linked to unsafe water or food, inadequate sanitation, poor personal hygiene, and oral-anal sex.

Hepatitis B is most often spread via perinatal transmission, also called vertical transmission. That means the virus is passed to a baby during pregnancy and childbirth.

Other modes of hep B transmission (called horizontal transmission) occur when people come into direct contact with infected blood or other body fluids (such as menstrual, seminal, or vaginal fluid) during sex, while getting tattoos or body piercings, or via an injury involving a contaminated sharp object such as a needle or syringe. While getting infected from kissing is highly unlikely, the risk is increased if large amounts of saliva are exchanged, if there are cuts or abrasions in the mouth of the infected person, or if that person has an especially high viral load.

Hepatitis C is most often contracted through direct contact with HCV-infected blood. The most common transmission modes include:

• Reusing needles or medical equipment that haven’t been properly sterilized
• Sharing and using contaminated drug-injection equipment such as syringes and needles
• Transfusing infected blood and blood products, which may occur due to inadequate screening of these products

Hepatitis A, B, and C incubation and duration

The incubation period of an infectious disease describes the time that passes between one’s initial exposure to the disease and the first appearance of symptoms. The duration can be a few hours, days, or months, depending on the disease.

During the incubation period, the source of the infection (such as a virus or bacteria) replicates and multiplies in your body. Knowing the incubation period of a disease can help you and your healthcare provider (HCP) determine whether you’re still within the timeframe when you’re likely to develop the first symptoms of the disease.

This helps your HCP pinpoint when certain diagnostic tests are more likely to produce accurate results, such as tests to detect markers in your blood that indicate disease. It can also help you figure out when and where you were likely exposed to the infection.

The incubation period for HAV ranges from 15 to 50 days with an average of 28 days. For HBV, it’s 60 to 150 days with an average of 90 days. For HCV, the incubation period ranges from 14 to 182 days with an average range of 14 to 84 days.

Hepatitis A infection tends to be short-lived, with most people recovering within a few weeks or months. Some people experience a relapse, meaning their symptoms flare up again after they’ve recovered from the initial acute episode, although this relapse period also tends to last for a short while.

On the other hand, hepatitis B and hepatitis C can be acute or chronic.

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HCV infection may not produce any symptoms. In fact, many people don’t experience any symptoms, although they carry the virus.

When present, hep C symptoms might include the following:

Acute hep C symptoms

Acute hep C symptoms tend to be mild if they occur at all. These might include:

• Abdominal pain
• Clay- or gray-colored stool
• Fatigue
• Fever
• Jaundice, which causes the skin and whites of the eyes to turn yellow due to a high level of bilirubin, a yellow-orange pigment produced by the liver when red blood cells (RBCs) break down
• Joint pain
• Nausea and/or vomiting
• Poor appetite
• Urine that’s dark, which may also point to excess bilirubin being released when you urinate

Chronic hep C symptoms

Chronic hepatitis C often stays silent for years. This means you may slowly develop chronic liver disease and damage without showing any symptoms for years or decades.

You may not know you’ve been infected with HCV until you test positive for the virus as part of a blood-donation screening process or unless a blood test shows elevated levels of the alanine aminotransferase (ALT) liver enzyme. Checking your ALT levels may be part of blood tests such as a comprehensive metabolic panel or liver panel, which may be included with a routine physical exam.

In addition to those experienced with acute infection, chronic hep C symptoms associated with long-term or advanced liver disease may include:

• Ascites (fluid buildup in your abdomen)
• Bruising easily
• Coagulopathy (impaired ability of the blood to clot, leading to prolonged or excessive bleeding)
• Bleeding in the digestive tract due to esophageal varices (enlarged veins), which form when blood flow to the liver is blocked by a clot or scar tissue in the organ
• Brain function deterioration called hepatic encephalopathy, which causes symptoms such as confusion, drowsiness, slurred speech, and mood or personality shifts
• Edema (swelling), especially in your lower legs and feet
• Pruritis (itchy skin)
• Spider angiomas, which resemble spider veins, except they have a red or purple spot in the center and reddish to purplish extensions which radiate outward like a spider's web
• Unintended weight loss

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Hepatitis C is caused by HCV, a blood-borne pathogen that infects you when it enters your bloodstream. Hepatitis C transmission mainly occurs through contact with the blood of someone infected with the virus, whether they have hepatitis symptoms or not.

You may contract or spread the disease through other body fluids such as:

• Amniotic fluid (which surrounds a baby during pregnancy)
• Cerebrospinal fluid (which flows in and around the brain and spinal cord)
• Saliva
• Semen
• Vaginal secretions

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Around 1.5 million new HCV infections occur each year worldwide. In the U.S., an estimated 66,700 acute hepatitis C infections occurred during 2020, and more than 100,000 cases of chronic hepatitis C were newly reported.

The routes of acute hepatitis C transmission include:

Sharing contaminated drug-injection equipment

People who inject drugs (PWIDs) have the highest rate of hepatitis C in the U.S., according to the Centers for Disease Control and Prevention (CDC). People who share HCV-contaminated needles, syringes, and other equipment used to prepare and inject drugs are at high risk of contracting and spreading hep C. In fact, more than 52 percent (around 8.2 million) of PWIDs considered in a 2022 review of studies published in the International Journal of Drug Policy contracted hepatitis C in this manner.  

Perinatal (vertical) transmission of hepatitis C

An HCV-positive mother can transmit the virus to their baby during pregnancy or childbirth. This happens around 6 percent of the time, although the risk goes up if the mother also has a high HCV viral load or is HIV-positive. Note that hep C isn’t transmitted through breast milk, according to the CDC. But since it is spread through blood, as a precaution, women with cracked or bleeding nipples should temporarily stop nursing until their nipples have healed.

Sharps injuries among healthcare workers

Healthcare professionals who use needles during patient care are at higher risk of needlestick injuries (NSIs) and other percutaneous injuries (PIs). PIs are caused by sharp instruments used in healthcare settings such as hypodermic needles, scalpels, suture needles, wires, surgical pins, and saws.

Those at the highest risk of these injuries include nurses, physicians, surgeons, emergency department workers, and lab professionals such as phlebotomists. Around 600,000 to 800,000 NSIs and other PIs occur each year among healthcare workers in the U.S. Healthcare workers are also exposed to blood-borne pathogens through blood and bodily fluid splashes, as well as direct contact with mucous membranes and open wounds.

It’s a worldwide issue. Of nearly 51,000 healthcare workers from 31 countries tracked in a 2020 research analysis published In Annals of Global Health, 45 percent reported sustaining NSIs. The authors of the review noted that every year NSIs cause around 16,000 cases of HCV, 66,000 cases of HBV, and 1,000 cases of HIV around the world.

Needle-sticking causes stress for healthcare workers and exposure to infectious diseases compounds this stress. Around 42 to 60 percent of healthcare workers experience stress and depression associated with NSIs.

Sexual contact with a person who has hepatitis C

Hepatitis C isn’t spread by holding hands, hugging, kissing, or coughing and sneezing on someone. It often requires direct or intimate sexual contact with the blood or bodily fluid of a person who has HCV.

While having unprotected sex with multiple sexual partners amplifies this risk for anyone, hepatitis C infection has been reported more often among men who have sex with men (MSM). Multiple studies and reviews say that the higher rates of hep C among MSM may be associated with high-risk sexual behaviors such as:

• Decreased precautionary measures, such as unprotected anal intercourse, which can lead to anal injuries such as lacerations, abrasions, and small tears called anal fissures—all of which can cause bleeding and provide a way for HCV to enter the body
• Brachioproctic insertion (commonly referred to as anal fisting), which can also lead to anal injury
• Having a high number of sexual partners
• Recreational drug use before or during sex (commonly referred to as chemsex)

Semen also carries a high HCV viral load. Greater amounts of it may be deposited onto the rectum when MSM have unprotected anal intercourse, notes a 2021 analysis of studies published in Frontiers in Medicine.

Unregulated tattooing and body piercing methods

You’re more likely to contract hepatitis C if you get tattoos or body piercings from businesses or people who don’t clean and sterilize their needles and equipment properly. These might include people who provide these services in unlicensed, unregulated, or informal settings.

Organ transplants, blood transfusions, and clotting injections

People who received an organ transplant or blood transfusion before July 1992 or clotting factor concentrates before 1987 are more likely to contract hepatitis C. This includes people who received blood transfusions for sickle cell anemia and clotting factor injections for hemophilia. Today, the risk of hepatitis transmission through these means is extremely low thanks to widespread adoption of organ transplant and blood supply screening protocols.

Sharing household items and personal care products

Hepatitis C isn’t usually spread by sharing eating utensils or drinks and food, but it can be transmitted by sharing other household and personal care items contaminated with HCV. These include items that touch an open, infected wound or hold microscopic amounts of infected blood, such as nail clippers, razors, glucose monitors, and toothbrushes.

High-risk behaviors during incarceration

Nearly 11 million people worldwide are incarcerated (or held in jail or prison), according to a 2022 analysis of studies published in BMC Public Health. Nearly 2 million of those are in the United States. People who are incarcerated are more likely to engage in behaviors that increase the risk of hepatitis C transmission, including:

• High-risk sexual behavior such as unprotected sex
• Using unsterile equipment for tattoos
• Sharing injected-drug equipment and other paraphernalia

As a result, rates of HCV infection among the prison population worldwide have risen. Although the World Health Organization (WHO) recommends that all people who are incarcerated be tested at least once while in custody, this guideline is not often followed.

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HCPs diagnose or rule out hepatitis C based on a patient’s:

Medical history

Your HCP will ask about your personal medical history and symptoms to see if these align with hep C symptoms. They’ll assess whether you’re at higher risk of HCV infection based on your history of drug use, blood transfusions, sexual behaviors, and other events or behaviors that raise your risk.

Physical exam

A thorough physical exam looks for signs and symptoms that may indicate hepatitis C and liver damage, such as:

• Skin pigment changes, including jaundice
• Edema in the lower legs, ankles, or feet
• Abdominal tenderness and bloating or swelling

Blood tests

Based on your medical history and physical exam, your HCP may order one or more blood tests to screen for hepatitis C:

HCV antibody test

The HCV antibody test, also called the anti-HCV test, shows whether you’ve developed antibodies to HCV. Antibodies are proteins your immune system releases into your bloodstream when a disease-causing organism or substance invades your body. These antibodies may still be produced even after the virus has been cleared from your bloodstream.

An enzyme immunoassay (EIA) test is often used to screen for HCV antibodies, but other antibody screening tests include:

• Chemiluminescence microparticle immunoassay (CMIA)
• Enhanced chemiluminescence immunoassay (CLIA)
• Electrochemiluminescence immunoassay (ECLIA)
• Immunochromatographic assay (rapid test)
• Microparticle immunoassay (MEIA)

Results from your HCV antibody test can be:

Non-reactive (negative): This can mean HCV has never been in your blood or your immune system has yet to produce HCV antibodies in response to infection. This may be a false-negative result because it may take up to six months before you test positive for hepatitis C antibodies. Most likely, however, you’ll test positive for these antibodies within 8 to 11 weeks following HCV exposure. If your HCP suspects a false-negative result, they may recommend retesting again a few months later. (A false-negative test result is one that incorrectly indicates you don’t have a health condition.)

Reactive (positive): This means you had an HCV infection at some point, although the virus may no longer be present if your immune system cleared it naturally or you received treatment that cured the hepatitis C infection.

Hepatitis C ribonucleic acid (RNA) test

A positive HCV antibody test doesn’t always mean you have hepatitis C. To confirm your infection status after your antibody test comes back positive, your HCP will order a nucleic acid test (NAT) to detect the presence or absence of hepatitis C genetic material known as RNA in your blood, as well as your HCV viral load.

This test is also referred to as a polymerase chain reaction (PCR) test. PCRs detect genetic material from various organisms that cause disease. HCV is one example, but PCR tests can also detect pathogens that cause other diseases such as Ebola, HIV, influenza, and tuberculosis.

The result of your NAT test for HCV RNA can be:

Negative: This means you were infected with HCV, but it’s no longer in your body because you received treatment that cured your hepatitis C or your immune system cleared it from your body on its own.

Positive: This means you currently have HCV in your blood and can infect or transmit it to others. This PCR test can confirm the presence of the virus within one to two weeks following exposure.

If you are HCV-positive, your HCP may repeat this test during your treatment to find out if the amount of the virus in your blood is going up or down. This can help determine how well your hepatitis C treatment is working.

Hepatitis C genotypes

Scientists have identified at least seven main hepatitis C genotypes and more than 67 subtypes. These are genetically distinct HCV strains that have evolved over the years.

HCV genotypes tend to be distributed around the world by region:

• Genotype 1 is the most common strain in the U.S. (and worldwide), accounting for 60 to 70 percent of the country’s hepatitis C cases.
• Genotype 2 is common worldwide but most often seen in central and West Africa.
• Genotype 3 is also widely distributed but most often found in people with hepatitis C in Asia.
• Genotype 4 is usually found among people with HCV in the Middle East and Northern Africa.
• Genotype 5 is most often identified in South Africa.
• Genotype 6 is most often found in Southeast Asia.
• Genotype 7 is most often seen in the Republic of the Congo in Central Africa.

Your HCP will order a blood test to determine your HCV genotype as part of the diagnostic process. The strain you contract at the time you’re infected doesn’t change over time, nor is it thought to play a role in how the disease progresses.

Rather, your genotype helps identify the hepatitis treatment type, dose, and duration that will likely work best for you. Although “superinfection” with more than one HCV genotype is possible, this doesn’t usually influence treatment decisions further.

Additional tests for hepatitis C

Other tests may be ordered by your HCP to determine the extent of damage to your liver. These help guide hepatitis C treatment decisions.

Liver function test (LFT)

LFTs are a panel of blood tests performed at the same time to assess whether:

Liver enzymes are elevated: This can be a sign of liver or bile duct damage. The enzymes tested include ALT along with aspartate transaminase (AST), alkaline phosphatase (ALP), and gamma-glutamyl transpeptidase (GGT).

Liver proteins are low or high: Globulin and albumin are two main proteins found in your blood and made by the liver. Prothrombin is a protein produced by the liver that helps with blood clotting. Low globulin and albumin levels and a high prothrombin time (a test that measures how many seconds it takes your blood to clot) may indicate liver damage.

Bilirubin is elevated: Higher than normal bilirubin levels suggest that your liver isn’t breaking down or clearing red blood cells properly, which can also be a sign of liver damage.

Liver elastography

Liver elastography is an imaging scan that helps your HCP assess the degree of liver tissue elasticity and fibrosis (scarring). This scar tissue forms when collagen proteins and other liver cell components collect or build up between liver cells as the organ tries to heal the damage caused by chronic inflammation.

Fibrosis usually starts off mild. Over time, liver inflammation and fibrosis lead to progressive loss of tissue elasticity and widespread scarring. This causes your liver tissue to harden or stiffen, which can restrict blood flow to the organ. As your liver’s internal structure and ability to regenerate itself are damaged, liver function is impaired.

Types of liver elastography used to assess liver damage and fibrosis caused by hepatitis C include:

• Ultrasound (or transient) elastography: The imaging test uses a handheld wand called a transducer and sound waves to create an image called an elastogram.
• Magnetic resonance elastography (MRE): This test combines magnet and radio waves from magnetic resonance imaging (MRI) technology with sound waves from an ultrasound to produce a visual map of your liver.
• Shear wave elastography: This newer imaging technology delivers high-intensity ultrasound pulses to produce a higher-quality image of your liver.

Elastography may be the only imaging test needed to assess the extent of liver damage. Your HCP may still opt to combine one of these tests with another imaging test such as a conventional abdominal ultrasound or MRI to look for other signs or types of liver disease, including liver cancer.

Liver biopsy

A liver biopsy may be conducted if blood and imaging tests aren’t sufficient to diagnose or rule out hepatitis C. This involves removing a small tissue sample from your liver, which will then be viewed under a microscope for signs of liver damage or disease.

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Worldwide, around 290,000 people died from hepatitis C in 2019, per WHO statistics. Nearly 15,000 people in the U.S. died from hepatitis C in 2020, according to the CDC. Most of these deaths were due to two main complications of hepatitis C: cirrhosis and hepatocellular carcinoma. Long-term liver damage caused by chronic hepatitis C can progress through the different stages of fibrosis, cirrhosis, and hepatocellular carcinoma over the course of 5 to 30 years.

Cirrhosis

The advanced stage of liver fibrosis is known as cirrhosis. Severe scarring can crowd out healthy tissue in the liver and can block the flow of blood, eventually causing cell death, profound liver damage, and loss of liver function, which can be life-threatening.

According to the WHO, the risk of cirrhosis ranges from 15 to 30 percent within 20 years among people with chronic hepatitis C.

Hepatocellular carcinoma (HCC)

HCC is one of the main types of adult primary liver cancer. Primary liver cancers are those where malignant (cancerous) cells first develop in liver tissue. HCC comprises 90 percent of primary malignant liver tumors. It’s the third leading cause of death due to cancer worldwide.

Globally, around 18 percent of HCC cases are associated with HCV infection. Every year, around 1 to 5 percent of people with hepatitis C are at risk of developing HCC.

Liver failure

When chronic hepatitis C leads to cirrhosis it may cause liver failure, also called end-stage liver disease (ESLD). When ESLD occurs, the liver loses most or all of its ability to function properly.

HCV/HIV co-infection

Around 2.3 million people worldwide are co-infected with HCV and HIV, according to a 2021 review of studies published in Frontiers in Immunology. People who inject drugs comprise 1.3 million of those co-infected.

Because the immune systems of people with HCV/HIV co-infection may be compromised, the chances that their bodies will clear the virus on their own is less likely. The infections combine to cause more serious harm than either infection alone.

More than 6 percent of people living with HIV are also co-infected with HCV, according to the Frontiers in Immunology authors. (An estimated 21 percent of people in the U.S. with HIV also have HCV.) Moreover, people with HIV are six times more likely to contract HCV, compared to people who are HIV-negative.

HIV speeds up the damage caused by liver disease, including the progression from fibrosis to cirrhosis, HCC, ESLD, and death—even when HIV is controlled with antiretroviral therapy (ART). Among people with HIV, HCV co-infection is a major cause of illness and death not due to AIDS.

HCV co-infection hastens HIV’s progression to AIDS and raises the risk of developing AIDS-defining illnesses, including those caused by bacterial and fungal infections such as pneumocystis pneumonia, HIV-related encephalopathy, and mycobacterium tuberculosis.

Extrahepatic (non-liver) complications of HCV

Chronic HCV also raises the risk of certain non-liver diseases. These are termed extrahepatic manifestations.

Around 38 percent of people with chronic hepatitis C develop at least one of the following issues, according to a 2023 review of studies published in Biology:

• Autoimmune diseases such as Sjogren’s syndrome and thyroiditis
• Cardiovascular disease
• Stroke
• Diabetes
• Lymphomas such as non-Hodgkin’s lymphoma, follicular lymphoma, and large B-cell lymphoma
• Mixed cryoglobulinemia (also called immune-mediated disorder)
• Heart attack
• Kidney diseases, including chronic kidney disease and renal insufficiency
• Skin conditions such as the chronic inflammatory skin disorder lichen planus and blistering skin lesions called porphyria cutanea tarda, the most common type of cutaneous porphyria

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Joint guidelines from the American Association for the Study of Liver Diseases and the Infectious Diseases Society of America recommend starting HCV medicines before spontaneous viral clearance occurs. Because it can take up to six months for clearance to take place, early HCV treatment can help prevent further hepatitis C transmission and liver damage.

It's important to discuss the benefits and risks of starting or delaying treatment with your HCP based on your health profile. You can decide together if starting a course of HCV medicines would be best for you. Instead of or in addition to medicine, your HCP might also recommend these lifestyle strategies to help you manage your hepatitis C:

• Getting plenty of rest
• Hydrating well with healthy fluids such as water
• Eating nourishing, nutrient-rich whole foods that support your liver and total health such as fruits, vegetables, whole grains, and lean proteins such as poultry or fish
• Avoiding alcohol, which speeds up fibrosis and the progression of liver disease
• Avoiding certain medicines, herbs, and dietary supplements, as some can be toxic to your liver or damage it further. Examples include medicines such as acetaminophen and amoxicillin-clavulanate and herbs and supplements such as aloe vera, black cohosh, cascara, chaparral, comfrey, kava, and ephedra. Talk to your HCP about whether you may need to adjust your intake during treatment for hepatitis C.

Hepatitis C treatment goals

The goal of hepatitis C treatment is to cure the disease. The WHO has set a goal to eliminate viral hepatitis as a public threat by 2030, which is defined as a 90 percent reduction in new chronic hepatitis infections along with a 65 percent reduction in deaths caused by them, compared to rates from 2015.

In terms of individual hepatitis C treatment, the aim is to suppress your HCV viral load to the point where it can’t be detected in your bloodstream with follow-up PCR testing. This means HCV can’t be detected during treatment and after it has ended. Treatment is considered successful if the virus remains undetectable 12 weeks after you’ve finished taking your hepatitis C treatment regimen. This is called a sustained virologic response (SVR).

You will be given specific dates for getting your blood tested during and after treatment.

Hepatitis C treatment factors

Your HCP will work with you to develop the best strategy for treating hep C based on factors such as your:

• HCV genotype
• Viral load
• Amount of fibrosis and liver damage sustained and health complications you might have such as cirrhosis or HCV/HIV co-infection
• Other health conditions or health concerns (such as pregnancy), as well as medications you may take to treat and manage them
• Response to previous hep C treatments
• Treatment preferences

Direct-acting antiviral (DAA) medicine for hepatitis C

Medicines called direct-acting antivirals bolster cure rates, even among people who haven’t been successfully treated with other HCV therapies. Because of these hepatitis C treatment innovations, around 95 percent of people with HCV infection can now be cured, according to the CDC. These medicines have brought hope to the many people living with chronic HCV infection.

DAAs have become the primary treatment for hepatitis C infection. They stop HCV from reproducing, allowing your immune system to clear the infection faster. They have fewer side effects and support SVR more effectively compared to older HCV medicines, even in people with advanced liver disease.

Because HCV is an RNA virus, it doesn’t integrate into your genome (the complete set of genetic instructions your DNA provides to every cell in your body). This allows your body to fully eradicate HCV following treatment with DAA therapy.

Your HCP will likely prescribe a combination of several types of DAAs as part of your treatment regimen. Each DAA type targets different stages of the HCV life cycle to help treat your infection more effectively.

DAAs are classified based on which mechanism they use to treat hepatitis C infection, with each class attacking HCV differently. The three classes recommended for HCV include:

• NS3/4A protease inhibitors
• NS5A polymerase inhibitors
• NS5B polymerase inhibitors

To achieve and maintain SVR, it’s important to take these medicines as discussed with your HCP, which will likely be every day until you’ve finished your treatment course.

Treatment usually lasts between 8 to 24 weeks, although this can vary depending on which DAAs you’re taking, the extent of damage to your liver, and your HCV genotype, viral load, and other health conditions you have.

DAAs have few side effects and they tend to be mild. Common side effects include:

• Insomnia
• Fatigue
• Headache
• Nausea

Ribavirin with interferon/peginterferon for HCV infection

Prior to the development of DAAs, chronic hepatitis C infection was treated with ribavirin and peginterferon. Although these medicines are no longer the first line of treatment for HCV, they may still be prescribed in conjunction with DAAs for advanced liver disease or as an alternative treatment if DAA therapy isn’t effective for you.

The side effects from ribavirin and peginterferon range from mild to moderate, and include:

• Acid or sour stomach and belching; heartburn or indigestion; stomach discomfort or pain
• Blurred vision
• Bone pain
• Change in taste or bad, unusual, or unpleasant aftertaste
• Cracked, scaly skin, crusting, irritation, itching, rash, or discolored skin
• Difficulty moving
• Dizziness, lightheadedness, or a feeling of spinning or constant movement
• Forgetfulness
• Hair loss or thinning
• Lack or loss of strength
• Menstrual changes
• Pain or tenderness around the eyes and cheekbones
• Stuffy nose and sneezing
• Swollen joints
• Weight loss

Liver transplant

Many people with hepatitis respond well to DAA therapy. But for some who have extensive liver damage, a liver transplant may be the best option for survival.

Although you’ll receive a healthy, functioning liver, a liver transplant doesn’t cure hepatitis. The infection may return because HCV could still be circulating in your bloodstream. Your HCP might recommend a course of DAA therapy after liver transplantation to help eliminate the virus from your body.

Treatment during pregnancy

Hepatitis C treatment isn’t usually started during pregnancy due to the lack of well-controlled human studies to determine whether it’s safe for the fetus. The American Association for the Study of Liver Diseases and the Infectious Diseases Society of America caution that DAAs should be used during pregnancy only if the potential benefit of therapy outweighs the potential risk to the fetus.

If you’re trying to get pregnant, it’s best to wait several weeks after completing your hep C treatment before trying to conceive. If you’re assigned female at birth and using ribavirin to treat hep C, it’s recommended that you use contraception and wait at least four months before trying to conceive. If you’re assigned male at birth, it’s important that you use a condom for the duration of treatment and for an additional seven months after finishing treatment with ribavirin if you’re trying to conceive, as semen can contain the drug.

HCV treatment monitoring

Your HCP will check with you during and after treatment to review how well you’re tolerating and responding to your regimen and to discuss any follow-up test results they might have ordered. This will likely include additional PCR testing for HCV RNA to help track your viral load and to determine whether SVR has been achieved and maintained. Your HCP will let you know when to get tested while you’re being treated for hepatitis C and after you’ve completed your full course of treatment.

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Scientists are working to develop an effective vaccine for hepatitis C. Some vaccines have reached human clinical trials, but none have been approved by the U.S. Food and Drug Administration (FDA) for public use.

In the meantime, you can take measures to protect yourself from HCV infection and prevent spreading it to others.

• Talk with your HCP about getting help to quit using recreational drugs and other substances, especially those that are injected. If you’re unable to stop, avoid sharing any equipment to prepare, use, or inject drugs such as needles, syringes, filters, water, water containers, cookers, cottons, ties, snorting straws, or pipes.
• Get the hepatitis A and hepatitis B vaccines to protect your liver and overall health.
• Practice good personal hygiene such as washing your hands thoroughly with soap and clean water.
• If you have multiple sex partners, always use condoms or dental dams (latex or polyurethane sheets placed between the mouth and vagina or anus during oral sex). Try to avoid sexual activities that might cause bleeding.
• Avoid using other people’s personal care items such as razors, toothbrushes, toothpicks, and nail clippers.
• Get tattoos and piercings only from professional, regulated businesses that display state-issued certificates for each staff member.
• Always use clean needles and syringes to give yourself medicine injections.
• Always use new and clean lancets and glucometer test strips to check your blood sugar if you have diabetes.
• Only get injections used for medical or cosmetic purposes from a properly trained and licensed HCP such as a physician, registered nurse, or nurse practitioner.
• Get appropriate vaccinations when traveling to areas of the world with poor sanitation. Consider drinking bottled water while traveling to these locations.

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You may also want to talk to your HCP to learn more about your hepatitis C treatment plan and how to protect yourself and others from contracting or spreading the disease. The answers to these questions may help you live healthier with hepatitis C.

• What does it mean to practice safe sex and what are the best ways to do this?
• If I get injured and have a wound that’s open or bleeding, how should I clean and care for it properly to help avoid exposing others to HCV?
• What foods should I eat and avoid to support my liver health?
• Do I need to avoid alcohol completely or just limit how many drinks I have each week?
• How much rest and sleep should I get each day to help with recovery?
• How much exercise should I get each week and which types are best for my specific health needs?
• Which vaccinations should I get?
• Can I get a tattoo or body piercing?
• Is it safe to become pregnant or breastfeed if I have hepatis C? If not, how long must I wait to conceive or to nurse my baby?
• Can you recommend a good wellness program or support group for people living with hepatitis C?
• I think I may have a substance abuse problem. Where can I get help?
• What other actions can I take to stay as healthy as possible with hepatitis C?

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• Hepatitis C: What Are the Warning Signs and Should You Get Tested?
• What Happens When Hep C is Left Untreated
• 5 Things That Make Hepatitis C Worse