Hepatitis C overview

Last updated May 16, 2024, by Marisa Wexler, MS
Fact-checked by Marta Figueiredo, PhD

Hepatitis C is a viral infection spread through contact with bodily fluids and causes liver inflammation. The initial acute infection rarely causes problematic symptoms, but more than half of infected people will develop a chronic, or long-term, infection that can cause serious complications such as irreversible liver scarring (cirrhosis) and liver cancer.

In contrast to hepatitis A and hepatitis B, two other common types of hepatitis, there is no vaccine to prevent hepatitis C. However, a number of antiviral medications can resolve the infection in the vast majority of patients. Understanding hepatitis C causes, risk factors, and symptoms is therefore essential for early detection and timely treatment to help mitigate complications of hepatitis C.

What is Hepatitis C?

Discovered in 1989, hepatitis C is a viral infection that, similar to other forms of hepatitis, is marked by liver inflammation.

The first six months after the hepatitis C virus (HCV) has entered the body is defined as the acute infection period. Symptoms are rare during an acute hepatitis C infection, and about one in four of patients will spontaneously clear the virus without treatment. The remaining people, however, will develop a long-lasting hepatitis C virus infection that can lead to serious liver complications.

About 50 million people worldwide are living with hepatitis C, with approximately one million new cases occurring each year, according to the World Health Organization (WHO). While hepatitis C can develop anywhere around the world, its highest incidence is in the Eastern Mediterranean Region, where 12 million people are estimated to have chronic hepatitis C.

The WHO estimates hepatitis C was responsible for more than 240,000 deaths in 2022, mainly due to cirrhosis and hepatocellular carcinoma, the most common type of liver cancer.

Causes

What causes hepatitis C is an infection with the hepatitis C virus. This virus has a high mutation rate that results in many different genotypes, or genetically different forms of the virus. Currently, there are eight known HCV genotypes, with more than 80 subtypes identified — and the number continues to increase.

The HCV is spread via exposure to blood from an infected person. Before 1992, this virus was commonly transmitted through blood transfusions or organ transplants from infected people. With modern screening practices implemented in the early 1990s, however, the risk of hepatitis C transmission from blood transfusion or organ donation is extremely low.

Currently, most people become infected with HCV by sharing contaminated needles, syringes, or any other equipment that’s used to prepare and inject recreational drugs.

Hepatitis C may also be spread by contaminated equipment in healthcare facilities and non-sterilized instruments used for tattoos or piercings, though this is rare when appropriate precautions are taken.

Another uncommon way for the virus to spread is from an infected pregnant person to their newborn baby: about 6% of babies born to mothers with hepatitis C will be infected with the virus.

Other risk factors for an HCV infection include:

• sharing personal items that can break the skin, such as razors or toothbrushes, with an infected person
• having a job where there’s a risk of exposure to contaminated blood, bodily fluids, or open sores, including in healthcare
• being incarcerated in a jail, prison, or other detention setting where there is a higher exposure to people who engage in high-risk behaviors
• undergoing or having been previously on maintenance dialysis, a medical procedure that seeks to replace kidney function by removing waste products and excess fluid from the blood
• engaging in unprotected sexual interplay where there is a high risk of exposure to blood through tiny tears in the skin, such as anal sex, with someone who is infected with HCV.

Hepatitis C cannot be spread through casual contact such as hugging, kissing, or sharing food with an infected person. The virus also does not spread via breast milk, although infected women with cracked or bleeding nipples are advised to pause breastfeeding until their nipples have healed.

A previous infection with hepatitis C does not confer immunity against hepatitis C, meaning that someone who has previously been infected can be infected again if they are exposed to the same or a different HCV genotype at a later date. This is due to a generally ineffective immune response against the virus as a result of its high mutation rate during infection.

Symptoms

When HCV first enters the body, it undergoes an incubation period that can last anywhere from two weeks to six months. During this time, the person won’t show obvious signs of hepatitis C, but may already be contagious and able to spread the virus to others.

Acute hepatitis C doesn’t usually cause noticeable symptoms. When it does, symptoms are often nonspecific, resembling those of the common cold. While some patients will spontaneously clear the hepatitis C virus in the first six months, most will go on to develop a chronic infection that causes chronic hepatitis C symptoms and complications.

Acute hepatitis C symptoms

About one in five people with an HCV infection experience acute hepatitis C symptoms, which usually appear two to 12 weeks after the initial infection and can last up to six months.

Acute hepatitis C symptoms can include:

• fever
• fatigue
• loss of appetite
• joint pain
• abdominal pain, especially in the upper right part of the belly
• nausea
• vomiting
• jaundice (a yellowish tint to the skin and the whites of the eyes)
• dark-colored urine
• pale stools.

Chronic hepatitis C symptoms

People whose immune system is not able to clear the hepatitis C virus after more than six months are generally considered to have chronic hepatitis C.

The chronic infection itself typically does not cause any noticeable symptoms, and some people may be symptom-free for years or even decades. Some people with chronic hepatitis C may also experience nonspecific symptoms such as chronic fatigue or depression. However, for most patients, obvious chronic symptoms only appear once the disease has progressed to cause notable liver function problems.

Some signs of liver damage that can occur in people with acute hepatitis C — such as jaundice, dark urine, pale feces, and loss of appetite — may occur in those with chronic disease. Other signs of severe liver damage may include:

• enlarged spleen
• spider-like blood lesions on the skin
• red palms
• excess fluid in the abdomen
• swelling in the legs, ankles, and feet
• itchy skin
• unexplained weight loss
• easy bruising and bleeding
• cognitive issues such as confusion and memory problems (hepatic encephalopathy).

In some people, chronic hepatitis C can lead to other conditions outside the liver. These may include:

• diabetes
• glomerulonephritis, or inflammation of the kidneys’ filtering units
• mixed cryoglobulinemia, a condition marked by blood vessel inflammation, which can cause a range of symptoms, including skin rash
• lichen planus, a skin condition that can also cause rash in different parts of the body
• porphyria cutanea tarda, a condition characterized by skin damage upon exposure to sunlight
• non-Hodgkin’s lymphoma, a type of blood cancer.

Diagnosis

Given that most people infected with the hepatitis C virus do not develop symptoms until the disease has already progressed to substantial liver damage, a hepatitis C diagnosis is rarely achieved in the early phases of the infection.

Because hepatitis C symptoms are not specific, the only way to confirm a diagnosis is through blood tests, which are generally done in two steps.

The first test checks for the presence of antibodies produced by the immune system to fight off the hepatitis C virus. If this HCV antibody test is positive, it means the person has been exposed to HCV at some point, even if the infection naturally resolved or was eventually cured with treatment. Still, the antibody test results may be negative for up to six months following exposure to the virus, so it’s possible that an infection may not yet be evident with this test.

If the test comes back positive, an additional blood test is needed to discriminate between past and current HCV infection. This test is called a nucleic acid test (NAT) or a PCR test that measures a person’s viral load — the amount of RNA, a type of genetic material, from HCV in the blood.

HCV’s RNA is detectable as early as one to two weeks after infection, and generally reaches its highest levels within six to 10 weeks, remaining near peak levels for up to two months. During the acute phase of the infection, these RNA levels may fluctuate significantly and even drop below detection. However, they are consistently detected at symptom onset, and become undetectable when the infection is resolved.

If this hepatitis C test is negative, it means the person has been infected with HCV in the past, but either cleared the infection or was cured with treatment. In turn, if the NAT test is positive, it indicates a current infection, and treatment is warranted in most patients.

In these cases, additional blood tests may also be used to assess liver function and determine the virus’ specific genotype to guide treatment decisions. NAT may also be performed at regular intervals to monitor a person’s response to hepatitis C treatment.

As hepatitis C often doesn’t cause any noteworthy symptoms, the U.S. Centers for Disease Control and Prevention (CDC) recommends that all adults be tested for HCV at least once in their lifetime. Anyone who is pregnant should also be screened for hepatitis C, with a new test for each pregnancy.

Exceptions for these recommendations include people living in regions where the prevalence of HCV infection is lower than 0.1%, although screening in these regions can still be performed at the discretion of providers and patients.

The agency also recommends hepatitis C testing should be performed regularly in people who are at increased risk of contracting the virus, including those using injection drugs or undergoing dialysis.

Testing is also advised for anyone with an unexplained and persistent increase in blood levels of liver enzymes, indicative of potential liver damage, and for babies at age 2 to 6 months who were born to pregnant women with hepatitis C.

As some HCV risk factors carry stigma, the CDC notes that healthcare providers should offer hepatitis C testing to anyone who asks for it.

Treatment

A range of medications are available for hepatitis C, and most of the time they can successfully lead to a hepatitis C cure for the patient. Modern hepatitis C medications such as direct-acting antivirals (DAAs) — which target the virus itself to stop it from growing — can cure hepatitis C in 95% to 98% of cases within two to six months.

First-line treatment typically consists of one or more of these oral DAAs:

• Sovaldi (sofosbuvir)
• Harvoni (ledipasvir/sofosbuvir)
• Zepatier (elbasvir/grazoprevir)
• Epclusa (sofosbuvir/velpatasvir)
• Mavyret (glecaprevir/pibrentasvir)
• Vosevi (sofosbuvir/velpatasvir/voxilaprevir).

Treatment with DAAs, which have few side effects, usually lasts 12 weeks, or about three months.

A few DAAs for hepatitis C — namely Epclusa, Mavyret, and Vosevi — are considered pangenotypic, meaning they are usually effective against all known HCV genotypes. The remaining DAAs mostly work for one or a few specific genotypes.

Hepatitis C treatment depends on a number of factors, including which HCV genotype a person is infected with. Still, WHO recommends that all adults, adolescents, and children as young as 3 years with chronic hepatitis C be treated with pangenotypic DAAs.

In addition to DAAs, some hepatitis C patients may also receive older hepatitis C medications, including ribavirin (sold as generics only) and Pegasys (peginterferon alfa-2a).

Each of the various hepatitis C medications available has a unique side effect profile and safety considerations. Patients should discuss their specific situation with a healthcare provider to determine which specific treatment regimen is most appropriate for them.

While undergoing treatment, patients are typically advised to take certain steps to help the body stay healthy while fighting the infection. Hepatitis C self-care tips include getting plenty of rest, staying hydrated, eating a well-balanced diet, and avoiding substances like alcohol that can stress the liver.

In cases where hepatitis C progresses to cause liver failure or liver cancer, a liver transplant may be required.

Complications

When left untreated, hepatitis C can cause damage to the liver that results in long-term complications, such as:

• cirrhosis
• portal hypertension, or increased pressure in the liver’s main blood vessel due to cirrhosis
• hepatocellular carcinoma
• liver failure, where the liver is no longer able to function properly.

About one out of every five people with chronic hepatitis C will develop cirrhosis within two decades of being infected. Up to 5% (one in 20) will develop liver cancer within three decades of infection.

Men, people 50 years and older, and those consuming alcohol are all more likely to develop cirrhosis after HCV infection. The risk is also higher for those receiving immunosuppressive treatment and those with certain liver diseases, such as hepatitis B, nonalcoholic fatty liver disease — now known as metabolic dysfunction-associated steatotic liver disease — and co-infection with HIV.

Still, early detection of hepatitis C, prompt treatment, and regular monitoring of liver health can help to reduce the risk of these serious complications.

Prevention

No hepatitis C vaccine is available that can provide hepatitis C immunity, a notable distinction between this type of hepatitis and hepatitis A or B. The main reason for the lack of a vaccine to date is the virus’s high mutation rate that results in the many different genotypes and subtypes identified so far. An effective vaccine would have to protect against all or most of those genotypes and subtypes, which is more difficult to achieve.

The only way to reduce the risk of contracting HCV is to avoid contact with bodily fluids from people who are already infected. As such, risk mitigation mainly focuses on hepatitis C prevention and taking precautionary steps such as avoiding sharing syringes or needles, using barrier methods like condoms during sex, and ensuring sterile practices in healthcare facilities.

Liver Disease News is strictly a news and information website about the disease. It does not provide medical advice, diagnosis, or treatment. This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of your physician or other qualified health provider with any questions you may have regarding a medical condition. Never disregard professional medical advice or delay in seeking it because of something you have read on this website.