The natural history of HCV infection has been difficult to assess, primarily because of the often silent onset of the acute phase, the paucity of symptoms in the early stages of chronic infection, and the relatively short time that has elapsed since the discovery of the disease. The acute phase of hepatitis C is generally defined as lasting six months after the time of original infection. During this period, a minority of people (about 15-30%) are able to clear the virus themselves. Once someone has been infected for six months or more, they are defined as having chronic hepatitis C. From this point on, it is an exception for them to overcome the infection without treatment. (Hoofnagle, 2002) Although chronic hepatitis C may not be accompanied by obvious symptoms, damage can be accumulating in the liver. Clinically “silent” disease does not necessarily mean inactive disease. People with hepatitis C vary greatly in how quickly their liver health worsens, and this cannot be accurately predicted. Some people show little change over 20 or even 30 years, while others may reach cirrhosis within 10 years. (Marcellin, 2002, p.S50) (Hoofnagle, 2002, p.S23( (See Figure 1-5)
Figure 1-5. Adapted from Hoofnagle, JH. Course and Outcome of Hepatitis C. Hepatology, 2002. V36, Issue 5, p. S23.
Experts now recognise that there are some factors that may be linked with faster progression:
Figure 1-6: Progression of Hepatitis C
Click image to enlarge
Chronic hepatitis C is associated with significant morbidity and mortality and is a major cause of progressive liver damage. If left untreated, chronic hepatitis C can evolve through increasingly severe fibrosis to cirrhosis. (Marcellin et al, 2002) Hepatocellular carcinoma (HCC) can eventually appear, often after decades of infection and usually in people with established cirrhosis.
Late diagnosis of patients with chronic hepatitis C may mean advanced stage of fibrosis or cirrhosis has been reached. By this time, it is likely that patients will already experience clinical symptoms and have developed complications. In view of the serious outcomes of late-stage disease, it is very important to try to diagnose and treat chronic hepatitis C before cirrhosis is reached. The NIH 2002 consensus document states: “All patients with chronic hepatitis C are potential candidates for antiviral therapy. Treatment is recommended for patients with an increased risk of developing cirrhosis”
The decision to treat should take into account the risk-benefit ratio for the individual. The motivation of the patient and family/friends must also be carefully assessed before initiating treatment. (French Consensus Guidelines)