Hepatitis C — Who Should Get Tested

Hepatitis C is a viral infection that affects the liver and is one of the most common bloodborne infections in the United States. An estimated 4 million individuals in the United States and over 58 million people worldwide are infected with the hepatitis C virus (HCV). This condition is particularly concerning because many people with hepatitis C don't look or feel sick and do not know they are infected.

What makes hepatitis C especially challenging is that people can have hepatitis C for years without any symptoms, and all that time, it might be quietly damaging the liver. More than half of people who become infected with HCV will develop chronic infection, which can cause serious health problems, including liver damage, cirrhosis (scarring of the liver), liver cancer, and even death. However, the condition is now highly treatable, with curative treatments available and safe and effective treatments that can cure most people in 8–12 weeks.

HCV is transmitted via direct percutaneous exposures to infectious blood and is most efficiently transmitted through blood-to-blood contact. Injection drug use (IDU) is the most common risk behavior reported for HCV infection, accounting for a significant portion of new infections.

Populations at highest risk for having hepatitis C include people who inject drugs, HIV-positive men who have sex with men, people with a history of incarceration, and people born during 1945–1965 (baby boomer birth cohort). Certain people who received blood transfusions, clotting factor concentrates before 1987, blood or other transfusions before July 1992, or organ transplants before July 1992 are also at risk. Other potential routes of transmission include sharing personal items that may have blood on them, getting tattoos or body piercings with unsterile equipment, and occupational exposure in healthcare settings.

The CDC recommends that all adults aged 18 and older should be screened for hepatitis C at least once, and all pregnant patients during each pregnancy. Testing becomes particularly important for individuals with specific risk factors or exposures. People with certain risk factors or exposures are at higher risk for hepatitis C and should be tested at least once, and periodically if exposure persists, including people who inject drugs or have previously injected drugs, people with HIV, and children born to people infected with HCV.

Anyone experiencing unexplained symptoms such as persistent fatigue, abdominal pain, or changes in urine or stool color should consider testing. People who have ever received maintenance hemodialysis and those with persistently abnormal alanine aminotransferase (ALT) levels are also considered at increased risk. Since hepatitis C can remain silent for years while causing liver damage, testing may be appropriate even without symptoms if risk factors are present.

Hepatitis C testing typically involves multiple markers to determine infection status. A positive hepatitis C antibody test indicates exposure to the virus at some point, but additional RNA testing is needed to confirm active infection. Clinicians should initiate hepatitis C testing with an FDA-approved HCV antibody test with reflex to nucleic acid test (NAT) for HCV RNA if the antibody test is positive/reactive. Active infection requires prompt medical attention and treatment.

Liver function tests may show elevated enzymes even when hepatitis C symptoms are absent. A high ALT level often means there is some liver damage, but it may not be related to hepatitis C, and the ALT level does not indicate how much scarring (fibrosis) is in the liver. Many patients with hepatitis C will have a normal ALT level, and patients can have very severe liver disease and cirrhosis and still have a normal ALT level. These results should always be interpreted by a healthcare provider who can recommend appropriate follow-up care and treatment options.

While awaiting test results or during treatment, maintaining liver health becomes particularly important. Avoiding alcohol consumption is crucial, as it can accelerate liver damage in people with hepatitis C. A balanced diet rich in fruits, vegetables, and whole grains supports overall liver function. Regular exercise can help manage fatigue and improve overall well-being.

Preventing transmission to others is also essential. This includes not sharing personal items that might have blood on them, such as razors or toothbrushes, and ensuring any tattoos or piercings are done with sterile equipment at licensed facilities. Healthcare providers should be informed of hepatitis C status to ensure appropriate precautions during medical procedures.