Synopsis
Detect active hepatitis C with RNA testing, link every viraemic person to curative therapy, manage exposure safely, and prevent reinfection and advanced liver complications.
- HCV is blood-borne; injecting equipment is the principal UK route, while needlestick, unscreened historical blood, tattooing and sexual blood exposure also matter.
- Antibody shows exposure, not current infection. Detectable HCV RNA confirms active viraemia and is the result that triggers treatment linkage.
- A negative antibody test can miss very recent acquisition or immune suppression; request HCV RNA when clinical or exposure suspicion remains high.
- Most acute infections are asymptomatic, yet chronic infection can silently progress to fibrosis, cirrhosis and hepatocellular carcinoma.
- All people with active HCV should be offered specialist assessment for curative direct-acting antiviral therapy without stigma or an abstinence prerequisite.
- Common pangenotypic adult regimens include glecaprevir 300 mg plus pibrentasvir 120 mg once daily with food for eight weeks in suitable compensated treatment-naive disease, or sofosbuvir 400 mg plus velpatasvir 100 mg once daily for 12 weeks.
- Protease-inhibitor regimens such as glecaprevir-pibrentasvir are unsuitable in decompensated cirrhosis; treatment duration and choice change with liver stage, prior therapy, genotype and interactions.
- Confirm cure with an undetectable HCV RNA at least 12 weeks after treatment, then continue harm reduction because cure does not create immunity.
Key red flags
Haematemesis, melaena, hypotension or syncope in known or possible cirrhosis requires immediate variceal-bleeding management and endoscopy planning.
New confusion, fever, ascites, jaundice, oliguria or rising INR suggests decompensation, spontaneous bacterial peritonitis or acute-on-chronic liver failure.
A new focal liver lesion, weight loss or rising alpha-fetoprotein in chronic HCV needs urgent hepatocellular-carcinoma assessment.
HCV RNA positivity during pregnancy requires coordinated hepatology and maternity review, infant testing planning and avoidance of unsupported antiviral prescribing.
Needlestick or blood exposure needs prompt baseline assessment and follow-up RNA testing; no vaccine or immunoglobulin can prevent HCV.
Direct-acting antiviral treatment with severe bradycardia, jaundice, drug toxicity or virological rebound requires immediate specialist and interaction review.
Ascites, variceal bleeding, encephalopathy, jaundice and renal dysfunction signal advanced disease and constrain antiviral selection.
Investigation priorities
Screen for previous exposure in people beyond the antibody window period.
Management branches
A person has a past or current blood exposure, belongs to a higher-prevalence group or has unexplained liver disease.
- Ask non-judgementally about injecting and equipment sharing, prison, tattoos, transfusion era and country, healthcare exposure, sexual blood exposure and previous testing or treatment.
- Request anti-HCV with laboratory reflex RNA testing whenever possible, or request RNA directly if exposure is recent or antibody formation may be impaired.
- Test HBV and HIV, assess HAV and HBV vaccination needs and obtain baseline liver, renal and pregnancy information in the same episode.
- Communicate both antibody and RNA results explicitly so a reactive antibody is neither mistaken for active disease nor falsely described as immunity.