Hepatitis C Virus (HCV) Infection
HCV infection is the most common chronic bloodborne infection in the United States, with an estimated 2.4 million persons living with chronic infection (1332). HCV is not efficiently transmitted through sex (1333–1335). Studies of HCV transmission between heterosexual couples and MSM have yielded mixed results; however, studies have reported either no or minimally increased rates of HCV infection among partners of persons with HCV infection compared with partners of those without HCV (1334,1336–1338). However, data indicate that sexual transmission of HCV can occur, especially among persons with HIV infection. Increasing incidence of acute HCV infection among MSM with HIV infection has been reported in multiple U.S. (96,236,239,1339) and European cities (237,1340–1342). A recent systematic review reported an HCV incidence of 6.35 per 1,000 person years among MSM with HIV infection (1343). An association exists with high-risk and traumatic sexual practices (e.g., condomless receptive anal intercourse or receptive fisting) and concurrent genital ulcerative disease or STI-related proctitis (237,1342). HCV transmission among MSM with HIV infection has also been associated with group sex and chemsex (i.e., using recreational drugs in a sexual context) (1344–1348). Shedding of HCV in the semen and in the rectum of men with HIV infection has been documented (1349,1350). Certain studies have revealed that risk increases commensurate with increasing numbers of sex partners among heterosexual persons (1337,1338,1351–1353) and MSM with HIV infection (1349,1354–1357), especially if their partners are also coinfected with HIV (237,1340,1354–1356,1358). More recently, acute HCV infections have been reported among MSM on PrEP, increasing concerns that certain MSM might be at increased risk for incident HCV infection through condomless sexual intercourse with MSM with HCV infection (1359,1360).
Persons newly infected with HCV typically are either asymptomatic or have a mild clinical illness. HCV RNA can be detected in blood within 1–3 weeks after exposure. The average time from exposure to antibody to HCV (anti-HCV) seroconversion is 4−10 weeks, and anti-HCV can be detected among approximately 97% of persons by 6 months after exposure (1361–1364) (https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#section3).
Chronic HCV infection develops among 75%–85% of persons with HCV infection (1365,1366), and 10%–20% of persons with chronic infection develop cirrhosis in 20–30 years of active liver disease (1367). The majority of infected persons remain unaware of their infection because they are not clinically ill. However, infected persons are a source of transmission to others and are at risk for cirrhosis and hepatocellular carcinoma decades after infection.
HCV is primarily transmitted parenterally, usually through shared drug-injecting needles and paraphernalia. HCV also can be transmitted through exposures in health care settings as a consequence of inadequate infection control practices (1314). Transmission after receipt of blood from donors and from transplantation of tissues and organs with HCV infection has occurred only rarely since 1992, when routine screening of these donated products was mandated in the United States (1367,1369). Tattoos applied in regulated settings have not been associated with HCV transmission, although those obtained in certain settings have been linked to such transmission (1336). Occupational and perinatal exposures also can result in transmission of HCV; however, such transmission is uncommon.
Acute HCV infection is a reportable condition in 49 states. Matching viral hepatitis and HIV surveillance registries, and molecular epidemiologic assessments, can facilitate early detection of social networks of HCV transmission among MSM with HIV infection.
CDC recommends hepatitis C screening at least once in a lifetime for all adults aged ≥18 years and for all women during each pregnancy, except in settings where the prevalence of HCV infection is <0.1% (156). One-time hepatitis C testing is also recommended regardless of age, setting, or recognized conditions or exposures (e.g., HIV infection, history of injecting drug use, or children born to women with HCV infection). Routine periodic HCV testing is recommended for persons with ongoing risk factors (e.g., injecting drug use or hemodialysis).
Diagnosis
Testing for HCV infection should include use of an FDA-cleared test for antibody to HCV (i.e., immunoassay, EIA, or enhanced CIA and, if recommended, a supplemental antibody test) followed by NAAT to detect HCV RNA for those with a positive antibody result (1370). Persons with HIV infection with low CD4+ T-cell count might require further testing by NAAT because of the potential for a false-negative antibody assay.
Persons determined to have HCV infection (i.e., positive for HCV RNA) should be evaluated for treatment. Antibody to HCV remains positive after spontaneously resolving or successful treatment; therefore, subsequent testing for HCV reinfection among persons with ongoing risk factors should be limited to HCV RNA. Persons who have spontaneous resolution or who have undergone successful treatment are not immune to reinfection.
Treatment
HCV infection is curable, and persons with diagnosed HCV infection should be linked to care and treatment. Providers should consult existing guidelines to learn about the latest advances in treating HCV infection (https://www.hcvguidelines.orgexternal icon) and with hepatitis specialists, as needed. Persons at high risk for transmitting HCV to others should be treated both for individual benefit and to prevent HCV transmission.
Management of Sex Partners
Because incident HCV has not been demonstrated to occur among heterosexual couples followed over time (1334,1371–1373), condom use might not be necessary in such circumstances. Persons with HCV infection with one long-term, steady sex partner do not need to change their sexual practices. However, they should discuss the risk for transmission with their partner and discuss the need for testing (234) (https://www.cdc.gov/hepatitis/hcv/index.htm). Heterosexual persons and MSM with HCV infection and more than one partner, especially those with concurrent HIV infection, should protect their partners against HCV and HIV acquisition by using external latex condoms (237,1358,1374) and HIV PrEP. Partners of persons with HCV and HIV should be tested for both infections.
Other Management Considerations
All persons with HCV infection for whom HIV and HBV infection status is unknown should be tested for these infections. Those who have HIV or HBV infection should be referred for or provided with recommended care and treatment. Persons without previous exposure to HAV or HBV should be vaccinated.
Prevention
Reducing the burden of HCV infection and disease in the United States requires implementing both primary and secondary prevention activities. Primary prevention reduces or eliminates HCV transmission, whereas secondary prevention identifies persons through screening and then provides treatment to reduce chronic liver disease and other chronic diseases and HCV transmission. No vaccine for hepatitis C is available, and prophylaxis with IG is not effective in preventing HCV infection after exposure. PEP using direct-acting antivirals is not recommended.
Persons with HCV infection should be provided information about how to protect their liver from further harm (i.e., hepatotoxic agents); for instance, persons with HCV infection should be advised to avoid drinking alcohol and taking any new medicines, including over-the-counter or herbal medications, without checking with their clinician. In addition, a need for hepatitis A and B vaccination should be determined; persons who are not immune should be vaccinated.
To reduce the risk for transmission to others, persons with HCV infection should be advised not to donate blood, body organs, other tissue, or semen; not to share any personal items that might have blood on them (e.g., toothbrushes or razors); and to cover cuts and sores on the skin to keep the virus from spreading by blood or secretions. Women with HCV infection do not need to avoid pregnancy or breastfeeding, although children born to women with HCV also should be tested for HCV.
Persons who use or inject drugs should be counseled about the importance of prevention and provided access to substance misuse treatment, including medication-assisted treatment, if indicated. Persons who inject drugs should be encouraged to take the following additional steps to reduce personal and public health risks:
- Never reuse or share syringes, water, or drug preparation equipment.
- Only use syringes obtained from a reliable source (e.g., a syringe services program or a pharmacy).
- Use a new, sterile syringe to prepare and inject drugs each time.
- If possible, use sterile water to prepare drugs; otherwise, use clean water from a reliable source (e.g., fresh tap water).
- Use a new or disinfected container (i.e., cooker) and a new filter (i.e., cotton) to prepare drugs.
- Clean the injection site with a new alcohol swab before injection.
- Safely dispose of syringes after one use.
Postexposure Follow-Up
No PEP has been demonstrated to be effective against HCV infection. Testing for HCV is recommended for health care workers after percutaneous or perimucosal exposures to HCV-positive blood. Prompt identification of acute infection is vital because outcomes are improved when treatment is initiated early during the illness course.
Special Considerations
Pregnancy
All pregnant women should be screened with each pregnancy for HCV antibodies at the first prenatal visit in settings where the HCV prevalence is >0.1% (https://www.cdc.gov/hepatitis/hcv/index.htm) (154,155). Although the rate of transmission is highly variable, more than six of every 100 infants born to women with HCV infection become infected; this infection occurs predominantly during or near delivery, and no treatment or delivery method (e.g., cesarean delivery) has been demonstrated to decrease this risk (1375). However, the risk is increased by the presence of maternal HCV viremia at delivery and is twofold to threefold greater if the woman has HIV infection. Although no recommendations are available for HCV treatment during pregnancy, discussion about the individual risks and benefits of postpartum treatment can be considered in accordance with existing guidance (https://www.hcvguidelines.org/unique-populations/pregnancyexternal icon).
HCV has not been reported to be transmitted through breast milk, although mothers with HCV infection should consider abstaining from breastfeeding if their nipples are cracked or bleeding. Infants born to mothers with HCV infection should be tested for HCV infection; children should be tested for anti-HCV no sooner than age 18 months because anti-HCV from the mother might last until that age. If diagnosis is desired before the child reaches age 18 months, testing for HCV RNA can be performed at or after the infant’s first well-child visit at age 1–2 months. HCV RNA testing can be repeated at a subsequent visit, independent of the initial HCV RNA test result (1376) (https://www.cdc.gov/hepatitis/hcv/hcvfaq.htm#section3).
HIV Infection
All persons with HIV infection should undergo serologic screening for HCV at initial evaluation (98) (https://www.hcvguidelines.orgexternal icon). Providers should be aware of the likelihood that MSM with HIV infection can acquire HCV after initial screening. Because acute HCV infection acquisition among persons with HIV infection can occur, especially among MSM, and regular screening of those with HIV is cost-effective (238,239,1377), periodic HCV screening should be conducted (1378–1380). For persons with HIV infection, hepatitis C screening with HCV antibody assays (followed by HCV RNA if antibody positive) can be considered at least yearly, for those at high risk for infection, and more frequently depending on specific circumstances (e.g., community HCV infection prevalence and incidence, high-risk sexual behavior, and concomitant ulcerative STIs and proctitis). Antibody to HCV remains positive after spontaneously resolved infection or successful treatment; therefore, subsequent testing for potential HCV reinfection among persons with ongoing risk should be limited to HCV RNA testing only. Indirect testing (e.g., alanine aminotransferase [ALT]) is not recommended for detecting incident HCV infections because such testing, especially if performed once a year, can miss persons who have reverted after acute HCV infection to a normal ALT level at the time of testing (239) (https://www.hcvguidelines.orgexternal icon). Conversely, ALT can be elevated by antiretroviral and other medications, alcohol, and toxins. If ALT levels are being monitored, persons with HIV infection who experience new or unexplained increases in ALT should be tested for acute HCV infection and evaluated for possible medication toxicity or excessive alcohol use.
Continued unprotected sexual contact between partners with HIV can facilitate spread of HCV infection because the virus can be recovered from the semen of men with HIV infection (1349,1381). Specific prevention practices (e.g., barrier precautions that limit contact with body fluids during sexual contact with other MSM) should be discussed.
Because a minimal percentage of persons with HIV infection do not develop HCV antibodies, HCV RNA testing should be performed for persons with HIV infection and unexplained liver disease who are anti-HCV negative. The course of liver disease is more rapid among persons with HIV and HCV, and the risk for cirrhosis is higher than that for persons with HCV infection alone.