Chronic Hepatitis C

Chronic hepatitis C is a long-lasting liver infection caused by a virus that can damage your liver over many years, but modern medicines can cure more than 95% of people with the condition.

Table of contents

• What is chronic hepatitis C
• How common is chronic hepatitis C
• Symptoms and signs
• How chronic hepatitis C spreads
• Possible complications
• Diagnosis and testing
• Treatment options
• Living with chronic hepatitis C

What is chronic hepatitis C

Chronic hepatitis C is a long-lasting infection of the liver caused by the hepatitis C virus (HCV). The virus causes inflammation, which is swelling that happens when tissues of the body become injured or infected^[1]. This ongoing inflammation can damage your liver over time.

When someone first gets infected with the hepatitis C virus, they can either have a very mild illness with few or no symptoms, or a more serious condition. This early stage is called acute hepatitis C and lasts for the first six months after infection. Less than half of people who get hepatitis C are able to clear the virus naturally during this time without treatment^[1].

Most people who get infected will develop chronic hepatitis C, meaning the infection lasts more than six months and becomes lifelong if not treated^[3]. About 75% of people with acute hepatitis C go on to develop the chronic form^[3]. The remaining 70% (55 to 85%) of infected persons will develop chronic HCV infection^[4].

Left untreated, chronic hepatitis C can cause serious health problems including liver disease, liver failure, liver cancer, and even death^[1]. However, it’s important to know that chronic hepatitis C can be cured with proper treatment.

How common is chronic hepatitis C

Chronic hepatitis C affects millions of people around the world. Globally, an estimated 50 million people have chronic hepatitis C virus infection, with about 1 million new infections occurring each year^[4]. In 2022, approximately 242,000 people died from hepatitis C worldwide, mostly from cirrhosis (scarring of the liver) and liver cancer^[4].

In the United States, researchers estimate that more than 2.4 million people had hepatitis C from 2017 to 2020, though some estimates suggest the number could be as high as 4 million^[1]. From 2013 to 2016, about 2.4 million people in the United States had chronic hepatitis C infection^[3].

People born between 1945 and 1965, known as baby boomers, are five times more likely to have hepatitis C than other adults. This group accounts for 75% of those living with the disease^[25]. The hepatitis C virus didn’t have a name or screening test until 1989, which means people born before this time grew up when health care facilities didn’t take the same safety precautions they do today^[25].

Symptoms and signs

One of the most challenging aspects of chronic hepatitis C is that many people don’t have any symptoms at all. You can have hepatitis C even if you don’t look or feel sick^[1]. Many people with chronic hepatitis C have no symptoms and feel well, though some may experience a feeling of being generally unwell, loss of appetite, extreme tiredness, and vague discomfort in the upper part of the belly^[3].

People with chronic hepatitis C are usually asymptomatic, meaning they do not have symptoms, or they may have general symptoms like chronic tiredness or depression^[1]. Yet even people without symptoms can spread the virus to others.

If you do develop symptoms during the early stages of infection, you will typically notice them 2 to 12 weeks after being infected with the virus. These signs can include^[1]:

• Dark urine or clay-colored stools
• Feeling tired
• Fever
• Joint pain
• Loss of appetite
• Nausea, stomach pain, or throwing up
• Yellow skin or eyes, a condition called jaundice

Often, the first specific symptoms are those of cirrhosis or complications from cirrhosis. These symptoms can include an enlarged spleen, small spider-like blood vessels visible on the skin, redness of the palms, buildup of fluid within the belly, a tendency to bleed, bleeding in the digestive tract, jaundice, and deterioration of brain function due to malfunction of the liver^[3].

Because symptoms may not appear until the infection has extensively damaged the liver—which can take decades after people are first infected—regular testing is crucial, especially for people who are at higher risk^[8].

How chronic hepatitis C spreads

Hepatitis C is spread when blood from a person infected with HCV enters the body of someone who is not infected^[1]. Even microscopic amounts of blood can transmit the virus. The hepatitis C virus is a bloodborne virus, and most infection occurs through exposure to blood from unsafe injections and procedures in health care, unscreened blood transfusions, sharing of needles and syringes among people who inject drugs, and sexual practices that lead to exposure to blood^[4].

In the United States, the most common way people get hepatitis C is through sharing drug needles or other drug materials with someone who has the virus^[1]. Other possible ways the infection can spread include^[6]:

• Being born to a mother with hepatitis C
• Getting an accidental stick with a needle that was used on someone with HCV, which can happen in health care settings
• Being tattooed or pierced with tools or inks that were not properly cleaned after being used on someone with HCV
• Having contact with the blood or open sores of someone who has HCV
• Sharing personal care items that may have come in contact with another person’s blood, such as razors or toothbrushes
• Having unprotected sex with someone who has HCV

Before 1992, hepatitis C was also commonly spread through blood transfusions and organ transplants. Since then, there has been routine testing of the U.S. blood supply for HCV, making it very rare for someone to get the virus this way^[5].

It’s important to know that hepatitis C is contagious even if you don’t have symptoms or know that you have it. However, it only spreads through blood, not through other bodily fluids or casual contact^[6]. There is no evidence that hepatitis C spreads from food handlers, teachers, or other service providers without blood-to-blood contact. You cannot spread the virus by sharing eating utensils, hugging, kissing, holding hands, coughing, sneezing, or through food or water^[1].

People who have cleared or been cured of the virus can be re-infected if they are exposed to the virus again^[1].

Possible complications

Without treatment, chronic hepatitis C can cause serious health problems over many years. Left untreated, chronic hepatitis C can cause serious health problems including liver disease, liver failure, liver cancer, and even death^[1].

Chronic hepatitis C progresses to cirrhosis in 20% to 30% of patients, though this scarring of the liver often takes decades to appear^[8]. Of those with chronic HCV infection, the risk of cirrhosis ranges from 15% to 30% within 20 years^[4].

Cirrhosis is serious scarring of the liver that interferes with its functioning. When cirrhosis becomes severe, it can lead to liver failure, which is the end stage of chronic liver disease^[6]. Cirrhosis and liver failure bring risks of other complications, including high blood pressure in the veins that carry blood to the liver (portal hypertension) and liver cancer^[6].

Liver cancer can result from HCV-induced cirrhosis but occurs only rarely from chronic infection without cirrhosis^[8]. Chronic hepatitis C is a leading cause of liver cancer and the leading cause of liver transplants in the United States^[1].

Chronic hepatitis C is occasionally associated with other conditions outside the liver, including a skin condition called lichen planus, blood vessel inflammation affecting the skin, kidney problems, a condition called porphyria cutanea tarda, mixed cryoglobulinemia, and possibly non-Hodgkin B-cell lymphoma^[8].

Diagnosis and testing

Providers diagnose chronic hepatitis C based on your medical history, a physical exam, and blood tests^[5]. Doctors may suspect chronic hepatitis C when people have typical symptoms, blood tests show abnormally high liver enzymes, or people have been previously diagnosed with acute hepatitis C^[3].

Testing for chronic hepatitis C usually begins with blood tests to determine how well the liver is functioning and whether it is damaged. These are called liver tests or liver function tests. They involve measuring the levels of enzymes and other substances produced by the liver^[3].

If tests suggest hepatitis, doctors do other blood tests to check for the hepatitis C virus. These blood tests can identify parts of the virus, specific antibodies your body produces to fight the virus, and genetic material (RNA) of the virus^[3]. If a screening test shows hepatitis C, other blood tests can measure the quantity of the virus in the blood (called the viral load) and show the type or genotype of the virus^[10].

There are six major genotypes of hepatitis C virus, which vary in their response to treatment. Genotype 1 is more common than genotypes 2, 3, 4, 5, and 6 in the United States, accounting for 70% to 80% of cases of chronic hepatitis C^[8].

Your doctor will also want to assess your liver for damage or scarring. Tests to check for liver damage can include^[10]:

• Magnetic resonance elastography (MRE): This test mixes magnetic resonance imaging technology with patterns formed by sound waves bouncing off the liver to create a map showing where the liver is stiff. Stiff liver tissue means scarring.
• Transient elastography: This is a type of ultrasound that sends vibrations into the liver and measures how fast they travel through the liver tissue.
• Liver biopsy: This involves putting a thin needle into the liver to remove a small sample of liver tissue to be examined in a lab.
• Blood tests: A series of blood tests can show the amount of scarring in the liver.

One-time routine screening is recommended for all people 18 years old or over, regardless of risk factors^[8]. Such testing is important because symptoms may not develop until the hepatitis C has extensively damaged the liver, years after the initial infection^[8].

Treatment options

The good news is that chronic hepatitis C can be cured. Treatment for chronic hepatitis C involves tablets to fight the virus, a test to see if your liver is damaged, and lifestyle changes to prevent further damage^[11].

Hepatitis C is treated using direct-acting antiviral (DAA) tablets. These are the safest and most effective medicines for treating hepatitis C^[11]. DAA tablets are highly effective at clearing the infection in more than 90% of people, and they can cure more than 95% of persons with hepatitis C infection^[4]. Direct-acting antiviral medicines can cure more than 95% of people in just 8 to 12 weeks^[12].

The medicines are easy to take and have very few side effects compared to older treatments^[12]. DAA tablets cure 9 out of 10 patients with hepatitis C^[11]. Most people find these tablets very easy to take, with side effects that are typically mild and may include feeling a little sick and having trouble sleeping at first^[11].

The tablets are taken for 8 to 12 weeks, and the length of treatment depends on which type of hepatitis C you have^[11]. Some types of hepatitis C can be treated using more than one type of DAA medicine. Treatment now focuses on direct-acting antiviral drugs without the need for older medicines like interferon, which had more difficult side effects^[10].

During treatment, you should have blood tests to check that your medicine is working. If it’s not working, you may be advised to try another medicine, though this affects only a small number of people^[11]. At the end of your treatment, you’ll have a blood test to see if the virus has been cleared, and a second blood test 12 or 24 weeks after treatment has stopped. If both tests show no sign of the virus, this means treatment has been successful^[11].

Successful treatment does not give you any protection against another hepatitis C infection. You can still catch it again^[11]. There is currently no effective vaccine against hepatitis C^[4].

If you don’t get treated right away, chronic hepatitis C can cause severe liver damage, liver cancer, and even death^[12]. Early treatment can prevent serious complications like liver scarring, liver cancer, and death^[12].

Living with chronic hepatitis C

If you are diagnosed with chronic hepatitis C and receiving treatment, or if you don’t have access to treatment right now, there are several things you can do to help keep your liver healthier and prevent the infection from spreading to others.

To protect your liver and overall health^[12][22]:

• Eat a well-balanced diet with plenty of fruit and vegetables, fiber, and protein
• Exercise regularly
• Control your weight with a healthy diet and regular exercise
• Avoid excessive alcohol intake or eliminate all alcohol, as it is harmful to your liver
• Quit smoking
• Talk to your doctor before taking prescription drugs or nutritional supplements, as some medications can be toxic for your liver
• Get vaccinated against hepatitis A and hepatitis B to prevent other viral infections that can harm your liver
• Get tested for HIV and hepatitis B
• Have your liver checked regularly if you have been diagnosed with cirrhosis

Drinking alcohol can increase the damage to your liver. If you have hepatitis C, you should try to cut out alcohol or limit your intake^[23]. All illicit drugs are also harmful to your liver and should be eliminated^[22].

To prevent spreading the infection to others^[1][18]:

• Keep personal items, such as toothbrushes or razors, for your own use
• Clean and cover any cuts or grazes with a waterproof dressing
• Clean any blood from surfaces with household bleach
• Do not share needles or syringes with others
• Do not donate blood, body organs, other tissue, or sperm
• If you want to lower the small chance of spreading HCV to your sex partner, you may decide to use barrier protections such as latex condoms

If you have one long-term steady sex partner, you do not need to change your sexual practices, as there is a very low chance of giving hepatitis C to that partner through sexual activity^[18].

You don’t have to tell your employer that you have hepatitis C unless you’re a healthcare worker. However, if hepatitis C is affecting your performance at work and your employer knows about your condition, they may be required to make allowances for you^[23].

You can travel abroad if you have hepatitis C, but you should speak to your doctor in advance. You may need to have vaccinations, and special arrangements may need to be made to ensure you’re able to transport and store your hepatitis C medication safely^[23].

Friends and family can provide important emotional support while you manage the disease. You may also find it helpful to connect with support groups where you can meet other people living with hepatitis C^[21].