Acute HCV Infection: Diagnosis, Epidemiology and Current Treatment Options

Abstract

Acute hepatitis C is traditionally defined as the first 6-month period after infection with hepatitis C virus (HCV). This acute phase is characterized by peculiar features: although it is commonly asymptomatic, HCV-RNA and transaminases peak to very high values; a spontaneous clearance of the infection is achievable in 25 % of the cases; if a standard treatment with pegylated interferon is undertaken, high rates of sustained virologic response may be obtained irrespective of the viral genotype. Even though an early diagnosis is not always easy, current epidemiology in Western countries is characterized by an ongoing outbreak among men who have sex with men, especially in the context of HIV infection. Screening with HCV-RNA should be performed in populations at risk—such as intra-venous drug users and men who have sex with men—in an effort to improve the diagnosis in either HIV-infected and uninfected individuals. HCV-RNA monitoring every 4 weeks should be performed for 12–16 weeks: if a viral decay is not observed within this time-point, treatment should be started. Pegylated interferon monotherapy for 24 weeks proved to be an effective approach; in subjects achieving a rapid virologic response, the treatment might be shortened to 12 weeks, while ribavirin should be added in patients difficult to treat such as HIV-infected individuals. Although there are no evidences to withhold a course with direct-acting agents, which proved to be a better option in chronic hepatitis C in terms of efficacy and tolerability, there are no data about interferon-free regimens in this setting. As a consequence, off-label use of such expensive drugs may represent an issue for regulatory authorities, national health systems and health insurances. European and American guidelines diverge substantially about this topic, but pegylated interferon probably remains the mainstay of treatment until data from ongoing clinical trials about direct-acting agents in this setting are available.