Hepatitis C: Testing and Cure with Direct-Acting Antivirals

Hepatitis C is a liver infection caused by the hepatitis C virus (HCV), an RNA virus spread mainly through blood. Pakistan has one of the highest burdens of hepatitis C in the world. Most infections become chronic and silent, but modern direct-acting antiviral (DAA) tablets cure the vast majority of patients in 8–12 weeks.

Transmission

• Unsafe injections and reuse of syringes or needles — a major driver in South Asia.
• Unscreened blood transfusions and unsterilised medical, dental or surgical instruments.
• Sharing razors, and unsafe barbering or tattooing.
• Injecting drug use.
• Less commonly, mother to baby and sexual contact.

There is no vaccine against hepatitis C.

Clinical features

Acute infection is usually silent. About 70% (most estimates fall between 55 and 85%) of infected people develop chronic hepatitis C, which can progress silently over decades to:

• liver fibrosis
• cirrhosis
• liver failure
• hepatocellular carcinoma

Extrahepatic features:

• fatigue
• mixed cryoglobulinaemia
• glomerulonephritis
• porphyria cutanea tarda
• an association with type 2 diabetes

Diagnosis

1. Anti-HCV antibody: shows exposure, but stays positive after cure or spontaneous clearance.
2. HCV RNA (PCR) or HCV core antigen: confirms current infection.

Further assessment:

• liver function tests
• full blood count (low platelets suggest cirrhosis)
• a fibrosis assessment, such as elastography or the APRI and FIB-4 scores
• ultrasound
• tests for hepatitis B and HIV

Treatment

• Treatment is recommended for almost everyone with chronic infection.
• Pan-genotypic DAA regimens, such as sofosbuvir with daclatasvir or sofosbuvir with velpatasvir, are given for 12 weeks (sometimes 8 or 24 weeks depending on the regimen and on cirrhosis). Cure rates are above 95% in most studies.
• Cure (sustained virological response) means undetectable HCV RNA 12 weeks after finishing treatment.
• Check drug interactions before starting. In patients with past or current hepatitis B, monitor for hepatitis B reactivation.
• Patients with cirrhosis still need liver cancer surveillance (ultrasound about every 6 months) after cure.
• Cure does not protect against reinfection.

Prevention

• Safe injection practices, and single-use or auto-disable syringes.
• Screening of all blood for transfusion.
• Sterilisation of instruments.
• Harm reduction for people who inject drugs.
• Testing and treatment programmes to find undiagnosed infections ("test and treat").

Exam pearls

• A positive antibody test alone does not mean current infection. Confirm with HCV RNA.
• DAAs have transformed hepatitis C into a curable disease.
• Hepatitis C is a leading cause of cirrhosis and liver transplantation in many countries.

See also Hepatitis B, Liver Cirrhosis and our Medicine Companion.

Test yourself

5 exam-style single-best-answer questions. Choose your answer, then tap “Show answer”.

1. Anti-HCV positive. What confirms current infection?

   1. HCV RNA (PCR)
   2. ALT level
   3. Repeat antibody
   4. HBsAg
   5. Liver ultrasound
   Show answer

   Answer: A. HCV RNA (PCR)
   Antibodies remain after cure or clearance; HCV RNA shows active infection.

2. Which statement about hepatitis C is true?

   1. Direct-acting antivirals cure most patients
   2. Cure prevents reinfection
   3. A vaccine is available
   4. It spreads mainly by droplets
   5. It never becomes chronic
   Show answer

   Answer: A. Direct-acting antivirals cure most patients
   DAAs cure over 95% of patients in most studies, but there is no vaccine and reinfection is possible.

3. A major driver of hepatitis C spread in Pakistan is:

   1. Handshakes
   2. Unsafe injections and reused syringes
   3. Mosquitoes
   4. Contaminated water
   5. Coughing
   Show answer

   Answer: B. Unsafe injections and reused syringes
   Unsafe medical injections and reuse of equipment are major routes of transmission.

4. Cure (SVR) is defined as:

   1. Normal ALT at end of treatment
   2. Weight gain
   3. Undetectable HCV RNA 12 weeks after treatment ends
   4. Negative antibody test
   5. Normal ultrasound
   Show answer

   Answer: C. Undetectable HCV RNA 12 weeks after treatment ends
   Sustained virological response = undetectable RNA 12 weeks after finishing therapy.

5. After cure, a patient with cirrhosis still needs:

   1. Monthly biopsies
   2. No follow-up
   3. Liver cancer surveillance about every 6 months
   4. Annual antibody tests
   5. Lifelong antivirals
   Show answer

   Answer: C. Liver cancer surveillance about every 6 months
   Cirrhosis carries ongoing HCC risk even after viral cure.

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• Hepatitis B: Transmission, Serology and TreatmentHepatitis B explained: how it spreads, interpreting HBsAg, anti-HBs and anti-HBc, chronic infection, tenofovir/entecavir and birth-dose vaccination.
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Disclaimer

For education and exam preparation only. This is not medical advice and must not be used to diagnose or treat patients. Always follow current clinical guidelines and the advice of qualified senior colleagues.