Hepatitis C

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Last reviewed: 3 Jun 2025

Last updated: 10 Mar 2025

Hepatitis C virus transmission is through percutaneous exposure to infected blood, most commonly through injection of illicit drugs or transfusion of unscreened blood and blood products in developed countries, or via unsafe injection practices in resource-poor countries.

Following acute exposure to hepatitis C virus, many patients develop chronic hepatitis C. Most infections are asymptomatic; however, hepatic inflammation is often present and can lead to progressive hepatic fibrosis.

The goal of treatment is to eradicate the virus, achieve a sustained virological response, and prevent disease progression. Oral direct-acting antiviral therapies are standard treatment.

Long-term complications of chronic infection include cirrhosis or hepatocellular carcinoma.

Definition

Hepatitis C is an inflammation of the liver caused by the hepatitis C virus (HCV).[1] Infection may present as an acute illness (e.g., fatigue, arthralgia, jaundice) in approximately one third of patients; however, the majority of patients are asymptomatic. Patients with acute infection may spontaneously clear the virus. Chronic infection causes liver inflammation and fibrosis, and a significant number of these patients will develop cirrhosis and liver failure or liver cancer over a period of approximately 20 to 50 years. The infection rarely resolves spontaneously in patients with chronic infection.

History and exam

Key diagnostic factors

presence of risk factors

Full details

Other diagnostic factors

constitutional symptoms
jaundice
ascites
signs of hepatic encephalopathy
extrahepatic manifestations

Full details

Risk factors

unsafe medical practices
intravenous or intranasal drug use
blood transfusion or organ transplant
heavy alcohol use
interleukin (IL)-28B gene polymorphism
HIV
incarceration/institutionalisation
dialysis
healthcare work
tattoos/body piercing
acupuncture
multiple sex partners
infected mother (for fetus)
male sex
vitamin D deficiency

Full details

Diagnostic investigations

1st investigations to order

hepatitis C virus (HCV)-antibody enzyme immunoassay (EIA)
hepatitis C virus (HCV) RNA polymerase chain reaction (PCR)
serum aminotransferases

Full details

Investigations to consider

viral genotyping
hepatitis C virus (HCV) core antigen assay
non-invasive tests of liver fibrosis or elasticity
aspartate aminotransferase-to-platelet ratio index (APRI)
liver biopsy
testing for co-infection

Full details

Treatment algorithm

INITIAL

recent infection

ACUTE

chronic infection suitable for simplified treatment: any genotype

chronic infection not suitable for simplified treatment and treatment-naive: genotype 1a

chronic infection not suitable for simplified treatment and treatment-naive: genotype 1b

chronic infection not suitable for simplified treatment and treatment-naive: genotype 2

chronic infection not suitable for simplified treatment and treatment-naive: genotype 3

chronic infection not suitable for simplified treatment and treatment-naive: genotype 4

chronic infection not suitable for simplified treatment and treatment-naive: genotype 5 or 6

chronic infection not suitable for simplified treatment and treatment-experienced: all genotypes

ONGOING

decompensated cirrhosis

Contributors

Authors

Jawad Ahmad, MD, FRCP, FAASLD

Professor of Medicine

Division of Liver Diseases

Mount Sinai Hospital

New York

Disclosures

JA declares that he has no competing interests.

Acknowledgements

Dr Jawad Ahmad would like to gratefully acknowledge Dr Brian L. Pearlman, the previous contributor to this topic.

Disclosures

BLP is on the speakers' bureaus and serves as an advisor to Merck, Gilead, J&J, and AbbVie, and does contracted research with Boehringer Ingelheim, Tibotec/Janssen, Bristol-Myers Squibb, Gilead, and Merck. BLP is also an author of a number of references cited in this topic. BLP wishes to acknowledge Chaithanya Mallikarjun, MD, for her help in writing the original version of the manuscript.

Peer reviewers

AnnMarie Liapakis, MD

Assistant Professor

Digestive Disease and Liver Transplant

Yale University

Disclosures

AL has participated in an advisory board meeting with Gilead and Janssen, and is a primary investigator for Merck’s C-Surfer trial.

Benedict Maliakkal, MRCP

Director of Hepatology and Medical Director of Liver Transplantation

Associate Professor of Medicine

Strong Memorial Hospital

University of Rochester

Disclosures

BM belongs to the paid speaker’s bureau for pharmaceutical companies Gilead (maker of ledipasvir/sofosbuvir), AbbVie (maker of Viekira Pak® - ombitasvir/paritaprevir/ritonavir and dasabuvir), Merck, and Salix.

Sulleman Moreea, FRCS (Glasg), FRCP

Consultant Hepatologist

Bradford Teaching Hospitals Foundation Trust

Bradford

Disclosures

SM has received sponsorship and has sat on advisory boards for BMS, Gilead, AbbVie, and Merck.

Steve Ryder, DM, FRCP

Consultant Hepatologist

Nottingham University Hospitals NHS Trust

Disclosures

SR is an advisory board (paid) member for AbbVie, Gilead, Janssen, and MSD.

References

Our in-house evidence and editorial teams collaborate with international expert contributors and peer reviewers to ensure that we provide access to the most clinically relevant information possible.

Key articles

American Association for the Study of Liver Diseases; Infectious Diseases Society of America. HCV guidance: recommendations for testing, managing, and treating hepatitis C. Dec 2023 [internet publication].Full text

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

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- Hepatitis B
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- Hepatitis E
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Guidelines
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More Patient information
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Hepatitis C

Summary

Definition

History and exam

Key diagnostic factors

Other diagnostic factors

Risk factors

Diagnostic investigations

1st investigations to order

Investigations to consider

Treatment algorithm

recent infection

chronic infection suitable for simplified treatment: any genotype

chronic infection not suitable for simplified treatment and treatment-naive: genotype 1a

chronic infection not suitable for simplified treatment and treatment-naive: genotype 1b

chronic infection not suitable for simplified treatment and treatment-naive: genotype 2

chronic infection not suitable for simplified treatment and treatment-naive: genotype 3

chronic infection not suitable for simplified treatment and treatment-naive: genotype 4

chronic infection not suitable for simplified treatment and treatment-naive: genotype 5 or 6

chronic infection not suitable for simplified treatment and treatment-experienced: all genotypes

decompensated cirrhosis

Contributors

Authors

Jawad Ahmad, MD, FRCP, FAASLD

Disclosures

Acknowledgements

Disclosures

Peer reviewers

AnnMarie Liapakis, MD

Disclosures

Benedict Maliakkal, MRCP

Disclosures

Sulleman Moreea, FRCS (Glasg), FRCP

Disclosures

Steve Ryder, DM, FRCP

Disclosures

References

Key articles

Reference articles

A full list of sources referenced in this topic is available to users with access to all of BMJ Best Practice.

Differentials

Guidelines

Patient information

Log in or subscribe to access all of BMJ Best Practice

Log in or subscribe to access all of BMJ Best Practice

Log in to access all of BMJ Best Practice