Clinical Review

Managing hepatitis C virus infection

BMJ 2009; 338 doi: (Published 26 June 2009) Cite this as: BMJ 2009;338:b2366
  1. Kathryn L Nash, consultant hepatologist1,
  2. Ian Bentley, general practitioner2,
  3. Gideon M Hirschfield, assistant professor of medicine3
  1. 1Southampton University Hospitals NHS Trust, Southampton
  2. 2Hill Lane Surgery, Southampton
  3. 3Liver Centre, Toronto Western Hospital/Department of Medicine, University of Toronto, Toronto, Ontario M5T 2S8, Canada
  1. Correspondence to: G M Hirschfield gideon.hirschfield{at}

    Summary points

    • Chronic hepatitis C infection is a substantial global health problem

    • Strategies to prevent infection through provision of safe blood products and targeting intravenous drug users are essential

    • Many people are unaware that they carry the virus and are at risk of liver disease

    • Complications of liver disease related to hepatitis C infection are expected to increase over the next 10 years

    • Sustained viral eradication and prevention of disease progression is possible through antiviral therapy

    • Optimal treatment is peginterferon alfa and ribavirin tailored to genotype and response to therapy

    • New specific targeted antiviral therapies are being developed

    Chronic infection with the RNA flavivirus hepatitis C is a major cause of liver disease.1 The Department of Health estimates that in the United Kingdom, chronic infection is present in 200 000 people—of whom 50% are unaware that they carry the virus—with variations in prevalence between different groups (0.04% in blood donors, 1% in people attending genitourinary clinics, and up to 50% in intravenous drug users). A general practitioner with an average list of 1800 can expect to have eight to 20 patients with hepatitis C infection. If such patients are identified and treated, the virus can be eradicated in more than half of them. We outline this area of hepatology, highlighting risk factors for acquisition, groups to screen, and specialist management of patients with chronic infection.

    What is the natural history of hepatitis C infection?

    In the UK the main mode of acquisition is recreational intravenous drug use; in developing countries transfusion of blood products and exposure to unclean or unsterilised objects remains important —for example, during circumcision, scarification, and tattooing (box 1). Outcomes of infection are not uniform (fig 1).2 Acute infection is usually unrecognised, and 60-85% of patients progress to chronic infection with persistent detection of hepatitis C virus RNA.

    Fig 1 Natural history of hepatitis C …

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