Hepatitis C

• IVDU (most common- 80-90%, THINK- past users)
• Recurrent blood donation receivers (e.g. haemophiliacs, esp before 1991)
• health care workers
• migrants/travellers
• offspring of HCV mother
• sexual partner of HCV pt (MSM)

therefore prevention:

• education of IVDU
• needle exchange
• good sharps managment
• blood donor screening

Contaminated healthcare injections WHO, 200):

• reusing euiqpment for injections, esp SE asia and middle east
• cause 2 million HCV infecctions (40% of all new)
• also 21 mil HBV 

• single stranded RNA virus 
• infection through contaminated blood
• discovered 1989

• highest in north africa
• high in asia
• high in sub-saharan africa

• 6 main genotypes
• detemine reponse to treatment (GN3 hardest to treat ATM)
• geographical variation 
  • GN1 and 3 in UK 
  • GN1 in US
  • GN3 in Indo-Pakistani pts
• little effect on natural history

• 20% initial clearence
• if not= chronic hepatitis
  • 20% cirrhosis at 20 years
  • 50% cirrhosis at 30 years

Increase

• hIgh alcohol intake
• co-infections (HBV/HIV)
• age of infection >40
• insulin restistance 
• GT3 infection
• steatosis

Decrease

• coffee intake(>3  cups/day)
• female
• age of infection <30
• black ethnicity
• normal ALT

NB HCV also increases risk of CV death

Depends on:

• genotype
• amount of fibrosis (use fibroscan to assess)
• presence of co-mrobidities

Previously:

• interferon and ribavirin
• triple therapy
  • telaprevir or boeprevir with interferon and ribavirin for 24-48 wks
• interferon associated with s/e
  • "flu"
  • exacerbated psych conditions
  • not safe for pt w/ cirrhosis
  • some pt not sensitive 

STR (single tablet regimen)

• Ledipasvir/Sofosbuvir 90/400mg
  • once daily, oral
  • 12 week treatment (compliance)
  • 90% cure at 12 weeks

Ledipasvir

• NS5A inhibitor
• effective against GN1a and GN1n

Sofosbuvir

• NS5B nucleotide polymerase inhibitor
• effective against GN1-6