Hepatitis C - clinical fact sheet and MCQ

Overview

Hepatitis C virus (HCV) infection remains a significant public health issue in Australia, with approximately 118,000 people living with chronic infection. Transmission predominantly occurs by contact with infected blood, usually by sharing needles or syringes for injecting drugs. It can also occur with unsafe piercing, tattooing and medical or dental procedures. Mother-to-child transmission can occur during pregnancy and delivery. Sexual transmission may occur if there is blood exposure during sexual activity.

Chronic HCV infection can lead to progressive liver fibrosis, cirrhosis, hepatocellular carcinoma (HCC) and liver failure. Fortunately, HCV is curable in most cases with direct-acting antivirals (DAAs), leading to improved quality of life, reduced transmission, and reduced mortality.

Diagnosis of hepatitis C

1. Screening

Testing is recommended for individuals with identifiable risk factors, including:

• people who inject drugs (PWID)

• those with a history of incarceration

• recipients of blood products before 1990

• individuals from high-prevalence regions (eg Africa, Middle East, South Asia, Eastern Europe, the Mediterranean)

• men who have sex with men (particularly if HIV-positive)

Point-of-care testing using the TGA approved Xpert® HCV RNA assay provides rapid and reliable diagnosis, particularly in high-prevalence settings.

2. Differential diagnoses

Consider other causes of liver dysfunction such as:

• hepatitis B virus (HBV)

• alcohol-related liver disease

• metabolic dysfunction-associated steatotic liver disease (MASLD) (previously termed non-alcoholic fatty liver disease)

3. Red flags

Urgent referral to a specialist is warranted if:

• cirrhosis is suspected (eg clinical signs, APRI ≥1.0 (explained below) or Fibroscan® >12.5 kPa as discussed below)

• co-infection with HIV or HBV

• significant renal impairment (eGFR <50 mL/min)

• previous unsuccessful HCV treatment

Management of hepatitis C

Acute viral hepatitis C is a notifiable disease in Australia. 

1. Pre-treatment assessment

Key assessments include:

• liver function tests, full blood count, and renal function

• evaluation for liver fibrosis using non-invasive methods (APRI score or FibroScan®)

• the AST to platelet ratio index (APRI) score is a simple, widely available tool to estimate fibrosis stage

• an APRI score of less than 1.0 indicates that cirrhosis is unlikely, whereas a score of 1.0 or greater suggests possible cirrhosis 

• FibroScan® is a non-invasive imaging technique (transient elastography) that measures liver stiffness

• FibroScan® values > 12.5 kPa are consistent with cirrhosis and require specialist evaluation​

• screening for HBV and HIV co-infections

• review of medications for potential drug interactions

Counselling should address adherence, lifestyle factors (eg alcohol reduction), and prevention of reinfection.

2. Treatment for hepatitis C

All adults with detectable HCV RNA should be considered for treatment, regardless of fibrosis stage. In the absence of contraindications, treatment choice may be guided by patient preference.

The primary regimens are:

• sofosbuvir/velpatasvir (SOF/VEL): one tablet daily for 12 weeks

• contraindicated with concomitant use of amiodarone

 OR

• glecaprevir/pibrentasvir (GLE/PIB): three tablets daily for 8 weeks (or 12 weeks if cirrhosis present)

• contraindicated in moderate or severe hepatic impairment

GPs experienced in HCV management can prescribe DAAs independently; otherwise, consultation with a specialist is advised. Referral of the patient for treatment is not necessary except in the presence of cirrhosis, co-infections, or complex comorbidities.

Monitoring during treatment is usually minimal, focused on adherence and managing any side effects. Testing during treatment is not required.

3. Follow-up

• Confirm cure with HCV RNA testing at or beyond 4 weeks post-treatment (SVR4)

• Continue liver disease surveillance if cirrhosis is present, including 6-monthly ultrasound for HCC screening

4. Special considerations

• Treatment is not recommended during pregnancy and breastfeeding

• Incarcerated individuals, Aboriginal and Torres Strait Islander peoples, and rural populations may benefit from tailored models of care

• Annual screening is recommended for individuals with ongoing risk factors

5. Contact tracing 

 Contact tracing is high priority for the following:

• needle-sharing partners of HCV Ab+ individuals

• current blood donors, who have donated within 12 months prior to testing positive 

• blood donor recipients who received donated blood products before 1990

• children of infected mothers 

• sexual partners of gay, bisexual, and other men who have sex with men if HIV-positive

Contact tracing for sexual partners of people with hepatitis C is otherwise low priority. 

More guidance on contact tracing can be found here.

References

Hepatitis C Virus Infection Consensus Statement Working Group. Australian recommendations for the management of hepatitis C virus infection: a consensus statement (2022). Melbourne: Gastroenterological Society of Australia, 2022.

Muller K, Hasan M. Treating chronic hepatitis C in general practice. AJGP. 2021;50(10):697-701.

Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Decision Making in Hepatitis C. 2024. (last accessed May 2025).

Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Hepatitis C. 2022. (last accessed May 2025).

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