A Hepatitis C Guide for Patients Plus a Liver-Friendly Breakfast Recipe

Credit: Adobe Stock/Lala

Hepatitis C (HCV) remains one of the most common and curable liver infections in the world. Despite the availability of safe and highly effective treatments, millions of Americans remain undiagnosed or untreated, often due to lingering myths and limited awareness.

In an interview with The Educated Patient, we spoke with David Wolf, M.D., a leading transplant hepatologist and medical director of the Liver Transplant Program at Westchester Medical Center, to help demystify HCV. Wolf breaks down the basics of the virus, how it spreads, who’s most at risk and what newly diagnosed patients should know about today’s life-changing therapies.

As a bonus, the American Liver Foundation (ALF) shares a liver-friendly recipe — Breakfast Couscous With Fruit — perfect for starting the day with nutrition in mind.

Breakfast Couscous With Fruit

Ingredients:

• 2 cups fresh raspberries
• ½ cup raisins
• ½ cup unsweetened shredded coconut
• ½ cup raw pumpkin seeds
• ¼ cup maple syrup (optional)
• 4½ cups cooked couscous

Instructions:

1. Cook couscous by following the instructions provided on the packaging.
2. Combine additional ingredients and optional maple syrup to warm, cooked couscous. Mix ingredients well and serve.

For someone newly diagnosed, what exactly is HCV and how does it affect the liver?

David Wolf, M.D.: HCV is a common virus infection that impacts over 50 million people around the world and more than 2.4 million Americans. We have had safe and highly effective treatments for HCV for over a decade, with the ability to cure more than 95% of patients who enter treatment. Unfortunately, the elimination of HCV remains an elusive goal.

Between 15% and 45% of individuals who become infected with HCV spontaneously clear the virus. The remaining 55% to 85% of patients develop chronic HCV infection.

Some patients with chronic HCV remain asymptomatic for the rest of their lives, with minimal impact of HCV infection on liver function or quality of life. Other patients develop symptoms, fatigue being patients’ most common complaint. Still others develop progressive liver inflammation, as well as the development of scar tissue (called fibrosis) within the liver. Between 10% and 20% of patients with untreated HCV infection — over the course of decades — develop a state of advanced fibrosis within the liver called cirrhosis.

It is important to remember that a diagnosis of cirrhosis is not “a death sentence.” The vast majority of individuals who are diagnosed with cirrhosis remain alive and well 10 years after diagnosis. However, the presence of cirrhosis does put patients at higher risk for developing liver failure or liver cancer. Successful treatment of HCV can prevent the development of cirrhosis. In some cases, the successful treatment of HCV can even lead to regression of fibrosis (i.e., scarring) in the liver.

Less commonly, untreated HCV infection can lead to kidney disease, skin and joint disease and even non-Hodgkin lymphoma.

How do people typically get infected with HCV — and what are the biggest myths about transmission?

DW: HCV is most commonly transmitted by contact with infected blood. At this time, the group of individuals who are at the highest risk for contracting HCV infection are persons who inject drugs (PWIDs). HCV-infected blood droplets may be present on needles and the other paraphernalia utilized in the preparation of injection drugs. Transmission occurs when people share needles and paraphernalia.

Other less common but still important means of transmitting HCV include the following:

• Sharing the paraphernalia related to intranasal drug use.
• Being born to an HCV-infected mother.
  • This occurs in about 6%-7% of pregnancies in HCV-infected women.
• Having sex with an HCV-infected individual.
  • It is uncommon for HCV to be transmitted through condomless sexual intercourse.
  • The Centers for Disease Control and Prevention (CDC) does not recommend routine condom use to prevent HCV infection among monogamous couples.
  • Still, sexual transmission can occur, particular related to activities that involve contact with blood.
• Undergoing either tattoo placement or a body piercing by someone who is utilizing HCV-contaminated equipment.
• Having contact with another individual’s HCV-infected blood droplet on a razor or a toothbrush.
• Receipt of HCV-infected blood, blood products and organs.
  • Transmission via blood transfusion has been rare since the advent of blood screening procedures in 1992.
• Needle stick injuries among health care workers.

There are many myths regarding the transmission of HCV.

HCV is not spread by the following:

• Kissing
• Social contact (e.g., hugging or holding hands)
• Coughing or sneezing
• Sharing kitchen utensils
• Sitting on a toilet seat

What does the HCV testing process involve?

DW: Getting tested for HCV is simple. The key to making a diagnosis of HCV is a blood test called an HCV antibody test. There can be false positive and false negative results. For that reason, the finding of positive HCV antibody test warrants the performance of an HCV RNA (ribonucleic acid) blood test. If an HCV RNA test is positive, there is a very high likelihood that the patient is infected with hepatitis C virus.

Typically, the results from an HCV RNA blood test take a few days to come back from the lab. Beginning in 2024, some health care practitioners (HCPs) have had access to a new HCV point-of-care test that provides HCPs and patients with HCV RNA tests result in under an hour.

If a patient is found to have HCV RNA positivity, two important things need to occur:

• First, the patient needs testing for exposure to the human immunodeficiency virus (HIV) and the hepatitis B virus (HBV).

The following tests should be checked by the patient’s HCP:

• HIV antibody
• HBcAb (hepatitis B core antibody, the total antibody)
• HBsAg (hepatitis B surface antigen)
• HBsAb (hepatitis B surface antibody)

• Secondly, the patient needs to be linked to care. Although the treatment of HCV infection is usually straightforward, some HCPs do not feel comfortable treating this viral illness. Patients who are informed of HCV infection should be referred for treatment of HCV infection immediately.

There’s been a lot of progress in treating HCV — can you explain how today’s treatments work and how effective they are?

DW: The introduction of highly effective antiviral agents in the mid-2010s is one of the great scientific advances of the 21st century. In the U.S., two combinations of oral drugs are in common clinical use. Sofosbuvir/velpatasvir (also known as Epclusa) received FDA approval in 2016. Glecaprevir/pibrentasvir (also known as Mavyret) received FDA approval in 2017. Both drugs are capable of curing upward of 95% of patients who undergo treatment.

Typically, a course of sofosbuvir/velpatasvir lasts for 12 weeks. Typically, a course of glecaprevir/pibrentasvir lasts for eight weeks. Both drugs can cause side effects that include fatigue and headache. Fewer than 1% of patients who start these agents find it necessary to discontinue them due to undesired side effects. Other drugs are available to treat and cure the fewer than 5% of patients who do not respond to first-line treatment.

Once HCV is cured, it is common for patients to feel better almost right away. Furthermore, the cure of HCV helps to prevent the progression of liver disease from early stages of fibrosis to cirrhosis.

What lifestyle changes or habits can help support liver health for someone with HCV?

DW: Patients who are infected with hepatitis C, as well as all other patients with chronic liver disease, are encouraged to do the following:

• Eat nutritious foods
• Exercise
• Maintain a healthy weight
• Avoid alcohol
• Practice safe sex
• Get vaccinated against infection with hepatitis A and B

Patients who are active or recent injection drug users are encouraged to get tested and, if positive for HCV RNA, get treated for hepatitis C immediately. It is important to note that active drug use or alcohol use do not contraindicate treatment for HCV infection.

Drug users are encouraged to avoid sharing needles and other drug paraphernalia. This will help to prevent reinfection with HCV.

What advances in HCV research or care are you most excited about right now?

DW: A wide variety of anti-HCV drugs with novel mechanisms of action are undergoing active research. Efforts are still underway to develop a safe and effective vaccine to protect at-risk individuals from contracting HCV infection.

The elimination of HCV infection remains one of our great public health challenges. The FDA approval of a technology to provide rapid, point-of-care HCV testing goes a long way to speeding our ability to diagnose hepatitis C and link patients to care.

Another important development was the CDC’s decision in 2020 to recommend at least once in a lifetime testing for HCV infection in all U.S. adults aged at least 18 years, as well as testing for all pregnant women during each pregnancy and children born to HCV-infected mothers. The CDC also recommended periodic testing for patients with ongoing risk factors for HCV infection: e.g., injection drug users, patients undergoing maintenance hemodialysis.

What’s one piece of advice you would give to someone newly diagnosed with HCV?

DW: The most important thing that a newly diagnosed patient can do is to get treatment. There is nothing that should prevent treatment:

• Not the patient’s age (provided that the patient is older than 3 years of age)
• Not the presence or absence of symptoms
• Not the presence of cirrhosis
• Not the presence of co-infection with either HIV or hepatitis B
• Not the patient’s history of drug or alcohol use
• Not the presence of other serious medical problems

None of these conditions should prevent treatment against HCV.

The second most important thing a patient can do is to get testing to exclude co-infection with either HIV or HBV.

Our ability to encourage patients to get tested and treated (as needed) will improve our ability to eliminate HCV infection over the next decade.