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Hepatitis C versus the Immune System: The Biology of Hepatitis C Transmission

September 5, 2018

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How Many People Can Clear the Virus on Their Own (Spontaneous Clearance)?

Based on six studies in a recent international meta-analysis, 19.8% of people cleared the virus from their body within three months; 27.9% within six months; and 36.1% within 12 months. After two years, the percentage of people who cleared the virus only increased by 1% (37.1%).31

One of the studies used in the analysis consisted of data from nine cohorts from Canada, Australia, the Netherlands and the USA. The combined 12-month clearance rate from this study was 27.4%, a lower rate than that found in the meta-analysis.29


Who Is More Likely to Clear the Virus on Their Own?

The international meta-analysis31 identified groups of people that are more likely to clear the virus on their own:

  • Women are 1.5 times more likely than men to clear the virus on their own.
  • Indigenous people are 2.1 times more likely than non-Indigenous people to clear the virus on their own.
  • People with a symptomatic infection are 2.6 times more likely to clear the virus than those with an asymptomatic infection.
  • Black people are 2.6 times more likely than non-Black people to clear the virus.
  • Younger people (less than 45) are 1.9 times more likely to clear the virus than older people.
  • People who do not have HIV are 2 times more likely to clear hepatitis C than people with HIV.
  • People with hepatitis B are 4.2 times more likely to clear hepatitis C than people who do not have hepatitis B.
  • Those with hepatitis C genotype 1 virus are 1.6 times more likely to clear the infection than individuals with other hepatitis C genotypes.
  • People who do not use excess alcohol are 1.5 times more likely to clear the virus compared to people who use excess alcohol.
  • People who have no history of injecting drug use are 1.7 times more likely to clear the virus compared to people who have a history of injecting drug use.


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What Happens During Chronic Hepatitis C Infection?

Having hepatitis C in the body causes liver cells to die. It is unclear whether the hepatitis C virus or the immune system kills the liver cells. It is likely a combination of both factors, with the immune system causing the most injury. Liver cells that are infected with hepatitis C virus release signals that tell immune cells to come to the liver cells. These immune cells kill the virus-infected cells, but the death of the liver cells results in an inflammatory response in the liver. The end result of this inflammatory process is scarring in the liver because damaged tissue is not able to repair itself properly.32

For most people, liver injury progresses slowly. People will develop scarring in their liver, and over time this scarring will increase and more of the liver will become injured. This is called fibrosis. Fibrosis can be measured using a scale of F0 to F4, with F0 being no liver fibrosis to F4 being an advanced level of liver injury known as cirrhosis. It can take 20 to 30 years to develop cirrhosis or liver cancer but in some people it can happen more quickly.33


Is There a Cure for Hepatitis C?

Hepatitis C treatment with direct-acting antiviral medications (DAAs) cures most people with the virus. Treatments are simple to take, have few side effects and are usually taken for 12 weeks or less. If a person is cured through treatment it means the virus is no longer in their body. The earlier that someone is treated, the less likely they are to develop advanced liver damage.

When a person is cured, the liver damage usually stops progressing and the liver will begin to heal in some people.34 This is less likely to happen for people who have advanced cirrhosis.35 For a small proportion of people who are cured of hepatitis C, the liver continues to become injured and progresses to cirrhosis. This is usually linked to other factors such as alcohol use or fatty liver disease.34 Being cured of hepatitis C decreases the likelihood of a person getting liver cancer, liver failure or dying from liver problems.36 People with advanced liver disease will need to be followed up with regular ultrasound scans after cure because there is still a risk of liver cancer developing. There are also many non-liver related health benefits from being cured of hepatitis C, including a reduced risk of diabetes mellitus, mixed cryoglobulinaemia (a blood disorder), glomerulonephritis (a type of kidney disease), porphyria cutanea tarda (a build up of chemicals that affects the skin and nervous system), and possibly non-Hodgkin lymphoma (a cancer that starts in blood cells).37

Being cured of hepatitis C does not give a person immunity. A person can become infected again if they are exposed to the hepatitis C virus.


Key Messages for Service Providers

Encourage People to Practise Safer Drug Use, Safer Sex and Other Prevention Strategies

Service providers can support people who inject, snort or inhale drugs to prevent them from getting hepatitis C by encouraging them to use new equipment every time they use drugs.

Service providers can support gay and bisexual men who are vulnerable to the sexual transmission of hepatitis C by encouraging them to:

  • use a new condom for each partner
  • use a new glove each time for fisting
  • use a new condom on sex toys for each partner
  • use individual lube containers
  • use their own drug use equipment and don't share it
  • get tested regularly for other STIs

Service providers can support people who get tattoos and piercings to use a professional studio with proper sterilizing equipment, such as an autoclave. For people who are getting tattoos and piercings outside professional studios encourage them to have the artist use a sterile tattoo machine and as much new equipment as possible.

Service providers can also encourage people to not share personal care items, such as razors, toothbrushes and nail clippers.


Encourage Oeople to Get Tested for Hepatitis C

People at ongoing risk for hepatitis C -- such as people who inject, snort or inhale drugs, and gay and bisexual men who have condomless sex -- should be encouraged to speak to their healthcare provider about how often they should get tested. Service providers can offer testing to immigrants and newcomers from countries where hepatitis C is endemic. The CCHIR tool can help determine if screening is appropriate.

Explain that testing requires two different tests, a hepatitis C antibody test for screening and a hepatitis C RNA test to confirm if someone has a hepatitis C infection. Two RNA tests separated by at least six months may be required to confirm a chronic infection.

If a baby is born to a pregnant person with hepatitis C, the baby can be tested for hepatitis C antibodies 12 to 18 months after they are born. If they are tested at 12 months a follow up test should be done at 18 months. Antibody testing prior to 18 months is not perfect because the test may detect antibodies from the parent that were transferred to the baby during pregnancy but are not the baby's own antibodies. If the parents are anxious about their child having hepatitis C, a hepatitis C RNA test can be done two months after the birth. If the child tests positive for RNA there is still a chance of them clearing the virus, so follow up RNA testing will need to be done every six months. If the child tests negative for hepatitis C RNA, an antibody test can be done at 12 or 18 months. Testing prior to 18 months does not change the management of hepatitis C in children.7


Link People With Chronic Hepatitis C to Treatment

If a client is diagnosed with chronic hepatitis C, share the good news about how effective, manageable and accessible hepatitis C treatment is. It cures over 95% of people who take it, causes few side effects, is usually taken for 12 weeks or less, and is simple to take. All provinces and territories have programs that cover all or most of the cost of treatment.

It is also important to let people know that if they have cleared the virus on their own or been cured through treatment, they can get infected again if they are re-exposed so it is still necessary to take steps to prevent getting hepatitis C again.

Service providers can play a key role in supporting individuals and communities most affected by hepatitis C through advocating for testing, treatment and prevention strategies.

Scott Anderson is currently studying to become a nurse. Prior to this he was CATIE's hepatitis C researcher/writer and a research coordinator at the Centre for Addiction and Mental Health.

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This article was provided by Canadian AIDS Treatment Information Exchange. It is a part of the publication Prevention in Focus: Spotlight on Programming and Research. Visit CATIE's Web site to find out more about their activities, publications and services.

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