Evaluation of the Hepatitis C Virus–Infected Patient: The Initial Encounter
CID
Evaluation of the Hepatitis C Virus-Infected Patient: The Initial Encounter
Camilla S. Graham
Section Editor
Norbert Bräu 0 1
0 Bronx VA Medical Center , Bronx , New York
1 Divisions of Liver Diseases and Infectious Diseases, Mount Sinai School of Medicine , New York , USA
Deaths from hepatitis C virus (HCV)-related disease are increasing, now exceeding those from human immunodeficiency virus. Up to 7 million Americans (2.3%) may be infected with HCV, and more than half are undiagnosed. Proposed expansion of hepatitis C screening to include all persons born between 1945 and 1965 will lead to many new diagnoses, and infectious diseases physicians have a unique opportunity to be part of managing these patients. Apart from a liver-focused history and examination, the initial evaluation includes determination of the liver function via serum tests and assessment of liver fibrosis and necroinflammation through biopsy or noninvasive means. Patients with cirrhosis require screening for esophageal varices and for liver cancer. Nonimmune patients need vaccinations against hepatitis A and B, and alcohol abstinence is critical. Initial counseling on therapy emphasizes viral cure rates of currently 70%-80% as well as expected side effects. New treatments with fewer side effects and potentially higher cure rates are currently in development.
chronic hepatitis C; screening; clinical assessment; counseling
Chronic hepatitis C is the most common etiology of
chronic liver disease in the Western world. In the third
National Health and Nutrition Examination Survey
(NHANES III), conducted by the Centers for Disease
Control and Prevention (CDC) in sentinel counties, the
prevalence of chronic hepatitis C virus (HCV) infection
in the United States. has been estimated at 1.33% or about
4 million persons [
1
]. A subsequent study that adjusted
for the omission of institutionalized persons in NHANES
III estimated the HCV prevalence in the United States at
1.7%–2.3%, or 5.2–7.0 million persons [
2
]. Many
HCVinfected patients are undiagnosed, and in one study
50% of HCV-infected patients were unaware of their
diagnosis [
3
] Progression to cirrhosis occurs in about 25%
of HCV-infected patients, but this process is slow and
on average takes 20–30 years. Once cirrhosis has
developed, 29% of patients develop liver failure over 10 years
and 14% develop hepatocellular carcinoma (HCC). The
5-year survival rate for compensated cirrhosis is still fair
at 91%, but after the onset of liver decompensation
begins, the 5-year survival rate declines to 50% [
4
].
In the United States and other Western countries, a
sharp rise in deaths from HCV-related disease has
been observed over the last decade (Figure 1) [
5
], and
since 2007, deaths related to HCV infection have even
exceeded deaths from human immunodeficiency virus
(HIV) disease [
6
]. This is the consequence of a large
cohort of patients who were infected in the 1960s and
1970s, mainly through injection drug use, that now,
3–4 decades later, reaches the time point when HCV
infection has progressed to liver failure and HCC.
Most of these patients were born between 1945 and
1965 and are now the target of the CDC’s universal
HCV screening recommendation as described below.
Infectious diseases physicians with their long
experience of managing the complexities of HIV disease
are in a unique position of taking on a growing role in
the care of patients with chronic hepatitis C.
DIAGNOSIS
Chronic hepatitis C is largely asymptomatic, with
perhaps chronic fatigue as one nonspecific complaint
affecting some patients [
7
]. However, timely intervention with
antiviral therapy and lifestyle counseling even in the absence
of symptoms is critical to prevent advanced and fatal liver
disease. Therefore, an active screening program is necessary to
identify patients with HCV infection. Until recently, the CDC
has recommended testing all persons who have 1 or more risk
factors for HCV. However, it has been recognized that this
approach still leaves a large number of HCV-infected individuals
undiagnosed. On 17 August 2012, the CDC published a new
recommendation to expand HCV testing from risk groups to a
birth cohort, namely, to test all persons born between 1945
and 1965 regardless of risk factors (Table 1) [
8
]. In the United
States, 75% of cases of chronic hepatitis C fall within this
cohort, so universal testing in this group is likely to yield a
significant number of new diagnoses. In a prior study, this
approach has been found to be cost-effective [
9
]. This change
in screening method is similar to the previous implementation
of universal screening for HIV infection in 2006 [
10
].
Initial testing for HCV is performed by HCV antibody testing
via enzyme-linked immunosorbent assay, which in its current
generation has a sensitivity of close to 100% to detect chronic
HCV infection. Chronic HCV infection is confirmed by plasma
HCV RNA testing, which also gives quantitation of (...truncated)