Natural History of HCV Disease

Acute HCV disease is usually asymptomatic, but 25%-35% of patients develop some constitutional symptoms or jaundice. Serum alanine aminotransferase (ALT) levels frequently rise, fluctuate, and fall again, suggesting recovery from the acute phase. Following acute infection, however, HCV is not easily cleared by the immune system, and 75%-80% of acute HCV infections become chronic, as evidenced by persistent or intermittent HCV viremia.

Patients infected with HCV should be advised to minimize or preferably discontinue intake of alcohol. Chronic HCV infection can cause inflammatory infiltration, particularly of the portal tracts, as well as focal liver cell necrosis and fibrosis that bridges between portal tracts. Hepatitis C is the leading cause of liver transplantation in the United States. About 10%-20% of patients progress to cirrhosis within 20-30 years of infection, and among those with cirrhosis, 1%-4% per year will develop hepatocel-lular carcinoma.

Immunosuppression associated with HIV appears to significantly alter the natural history and clinical course of HCV, with HCV-associated cirrhosis occurring more frequently in patients with HCV-HIV co-infection (33%) than in HCV alone (11%). People with HCV do not tolerate HAART as well, which can interfere with effective HIV treatment. Data indicate that liver failure due to HCV is the leading non-AIDS cause of death in HIV-infected individuals (Community Research Initiative on AIDS 2000; Vento et al. 1998). All patients co-infected with HCV and HIV, or infected with either virus alone, should be screened for immunity to hepatitis A and B; and if not immune, they should be immunized with both hepatitis A vaccine and hepatitis B vaccine. Acute infection with hepatitis A virus, normally a relatively benign and self-limited disease, is more likely to result in fulminant hepatic necrosis in the presence of HCV infection or any other chronic liver disease (Vento et al. 1998). Hepatitis A vaccine is safe for HIV-infected patients, and more than two-thirds of HIV-infected patients immunized with hepatitis A vaccine develop a protective antibody response. Patients without antibody protection for hepatitis A and B viruses can receive a combined vaccine that confers protection against both viruses.

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