You can get hepatitis C (HCV) more than once. Let’s start with that.
This is weird and can be a little confusing, and it is a significant concern for people who have been cured of HCV. To date we haven’t done a great job of explaining this to people, and we haven’t provided them with the knowledge and tools to prevent it from happening. This article will give you an overview of what HCV reinfection is, how common it is and ways to prevent it from happening.
What is hepatitis C reinfection?
Hepatitis C reinfection is when a person has a detectable virus after they have been either cured through treatment or have spontaneously cleared the virus on their own.
Background
In many cases, when you are infected by a virus, your body will create antibodies and develop immunity that will fight off any future infection. This is true for hepatitis A (HAV) and hepatitis B (HBV). In other words, if you get it once you’re not going to get it again.
This is not the case with hepatitis C: With HCV you can get it and your body will clear it on its own or you can go get treated and cured, but then you can get it again.
About one in four people (25%) clear HCV in the first six months of infection. They will always have HCV antibodies, but there is no longer any virus that will damage their liver. Some people clear the virus multiple times but there’s always a chance that the next time will lead to a chronic infection.
This is different from hepatitis A or B. If you get HAV, you will feel very sick for a while, eventually clear the virus and feel better, and then you will never get it again. You will have antibodies that will protect you from further HAV infection no matter how many times you may get exposed to it. The same applies with HBV: People who acquired hepatitis B and clear it will never get it again. (Note: Some people will keep HBV chronically. For more information, SEE “Hepatitis B: An Overview” on here.) These differences from HCV can lead to confusion: If antibodies can protect an individual from HAV or HBV, it’s easy to think that the same is true for HCV. It’s not.
Fortunately, HCV reinfection is not inevitable. Overall, the risk of HCV reinfection is quite low: For people who don’t have any new risks for infection, especially drug use or condomless sex and HIV, the rate of reinfection is so low that there is little to nothing to be concerned about. For people with no ongoing vulnerabilities to HCV, once they are cured there is no need to retest and no need to worry about reinfection.
Hepatitis C reinfection in people who use drugs
Hepatitis C reinfection can and does occur among people who use drugs but it’s not as common as many people assume it to be. Some studies show higher rates of reinfection in areas where there are many people living with hepatitis C and have limited access to harm reduction supplies such as sterile injecting equipment; other studies have found rates of reinfection to be low. Overall reinfection rates are lower than the rates of first-time infections. So, people who get hep C once and then clear it or are cured of it are less likely to get reinfected again.
We also know that if more people are treated with curative hep C treatment they are less likely to come into contact with it if they share a syringe or other injecting equipment. We know that with U=U for HIV prevention, people with an undetectable HIV viral load do not transmit the virus to their sexual partners. For hepatitis C, U absolutely equals U: If there is no virus, there is no transmission. Thus, access to HCV treatment and cure is an essential component of HCV prevention and, by extension, means less reinfection over the long run.
Hepatitis C reinfection in MSM living with HIV
Sexual transmission of HCV is rare overall, but in people living with HIV it can be much greater. This is still not fully understood, but we know that with HIV, certain sexual practices may be associated with a greater chance of HCV transmission. This includes, but is not limited to, condomless receptive anal sex, fisting and sex toy play, group sex and drug use with sex. Similarly, certain sexually transmitted infections (STIs) may play a role in making someone more vulnerable to sexually transmitted HCV: A herpes sore or syphilis chancre can provide the opening for HCV to enter. Also, HCV has been found in the semen and non-bloody rectal fluids of men living with HIV. All these combined lead to increased risk of HCV transmission.
Research has also shown high rates of reinfection in men who have sex with men (MSM) who are living with HIV. Preventative measures like condoms, gloves for fisting and routinely testing for STIs can reduce the chances for reinfection; routinely testing for HCV is recommended. Getting at least one HCV RNA test (hepatitis viral load) a year is recommended, but feel free to test more frequently if you have concerns about reinfection. The sooner a person learns they have HCV, the sooner they can get treated and cured.
Follow-up HCV testing after a cure or spontaneous clearance
If you have been cured of HCV or are one of the 25% of people who clear it naturally and you don’t have any factors that could lead to reinfection—primarily substance use or condomless sex while living with HIV—then you don’t need to continue to test for reinfection.
Individuals who use drugs or are living with HIV and are sexually active should keep testing for HCV. Remember, once you are HCV antibody-positive, you’ll always have HCV antibodies, so make sure to inform the test site so that they can run a hepatitis C viral load test to look for infection (SEE Understanding your hepatitis C results). An HCV viral load test is recommended at least once per year, but you can test more frequently, especially if you believe you’ve had an HCV exposure. The sooner you can detect HCV acquisition, the sooner you can get treated and cured. Talk with your medical provider or an HCV test counselor to discuss how frequently you should test.
HCV treatment for people who get reinfected
The good news is that people who are reinfected with HCV can be treated and
cured at the same high rates as those who get HCV the first time. The recommendations for treating HCV reinfection are the same as treating the first infection. Although there are no medical reasons to delay treatment for HCV reinfection, there may be some barriers around insurance coverage of multiple treatments for the same person. In cases like these, medical providers and benefits navigators can help work through such challenges and find alternatives to getting treatment covered.
Conclusions
Acquiring hepatitis C should not be viewed as a failure. We should accept and normalize HCV reinfection as a standard part of our lives: We are not testing and treating everyone who is vulnerable to HCV, so as a result, there are millions of people living with HCV who don’t know it. Consequently, HCV transmission occurs without people knowing it. The more we test and treat, the fewer infections—both new and repeated—will happen.
SEE Preventing HCV for People who Use Drugs, including a step-by-step guide to handling and cleaning works, online. GO TO positivelyaware.com. Also check out the Harm Reduction Coalition’s “Getting Off Right” booklet for more safe injecting info; GO TO http://bit.ly/4ck0kBO.
Two examples of HCV reinfection
JOE SHARED a syringe with a friend who was living with hepatitis C, and he tested positive for both the antibodies and viral load. He waited six months to see if he is chronically infected. His viral load test result is negative, meaning he is among the 25% of people who clear the virus on their own. Recently, Joe shared a cooker that had blood with hep C in it and he became infected again. Again, he waits to see if he’s chronically infected; his follow-up test indicates he is positive for the virus. Joe was reinfected with hepatitis C and will only be able to clear the virus now through treatment and cure.
A YEAR AGO, Amy shared a cooker with a friend living with HCV, and acquired the virus. She waits six months to see if she is chronically infected and her test results tell her that she is. She goes on treatment and gets cured. One year later she shares a syringe with a friend, and her HCV viral load test is positive. She waits six months to see if she’s chronically infected again, and when she tests her viral load test comes back negative. Amy was reinfected with hepatitis C but cleared the virus on her own without the need for treatment.
Preventing HCV reinfection for people who use drugs
Although it might seem that substance use and HCV go hand in hand, HCV can be prevented and so too can reinfection. The key is having access to the tools to stay HCV-negative—new and unused injection equipment, new pipes and smoking equipment—and the knowledge of certain practices that can help a person stay negative.
The first and most effective way to prevent both primary HCV infection and reinfection is to not use drugs. This is easier said than done and quitting is not always easy. For people who use opioids, exploring medications like burprenorphine or methadone to prevent painful withdrawal symptoms can be an option. Drug treatment programs, therapy and other behavioral interventions may also be effective. It can sometimes be hard to get into a treatment program; there may not be one that is a good fit for you, or you may not be ready to stop right now.
In the absence of stopping using drugs, there are harm reduction interventions that can be used to reduce or eliminate a chance of reinfection. Accessing new injecting and smoking equipment and never sharing these items is essential to preventing HCV.