Cured of Hepatitis C: Is There Potential to Infect Others?

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Those lucky enough to be cured of Hepatitis C have much to celebrate, but remain unsure of what being cured actually means. Does ‘cured’ of Hepatitis C mean that all viral particles are 100 percent absent forever, or does it mean the virus has gone into remission? More importantly, does being cured completely eliminate all chances of infecting others in the case of blood-to-blood contact?

In general, we are more comfortable living in a world of absolutes than acknowledging several shades of grey. Unfortunately, the potential for infectivity following a Hepatitis C cure lies somewhere in the grey category. It would be easy to assume that being cured of Hepatitis C totally removes any likelihood of being infectious, but experts’ opinions on this matter vary.

In order to be declared by a physician as ‘cured of Hepatitis C,’ the person’s viral load must be non-detectable six months after the completion of treatment. Known as achieving a sustained virologic response (SVR), this is the goal of Hepatitis C therapy. There are earlier indicators that treatment is going well, such as:

• Rapid virologic response – undetectable Hepatitis C RNA one month into treatment
• Early virologic response – undetectable Hepatitis C RNA three months into treatment
• End-of-treatment response – undetectable Hepatitis C RNA at the end of treatment

Even if any of these earlier results of undetectable Hepatitis C occur, physicians only consider the patient cured if the virus is undetectable at six months post treatment. Many physicians believe that once SVR is attained, the person is cured of Hepatitis C – meaning they no longer harbor the virus and therefore pose no threat of transmitting the infection.

A physician who claims that SVR is absolute is Lynn E. Taylor, MD, FACP, AAHIVS – an HIV specialist focusing on prevention and care of HIV/viral hepatitis co-infection. Taylor is an assistant professor of medicine in the division of infectious diseases at Brown University, and attending physician at the Miriam Hospital in Providence, Rhode Island. According to Dr. Taylor, “Once a person has cleared Hepatitis C, either through treatment leading to cure, or spontaneously (without medication), the infection is gone. There is no virus to spread. The person is not contagious.”

The rare instance of a person testing positive for Hepatitis C RNA after attaining SVR is typically attributed to re-infection. Especially for individuals who partake in high risk activities, such as intravenous drug use or receiving a tattoo with a used needle, re-infection is possible because Hepatitis C’s antibodies do not protect against future infection. However, there is some evidence that Hepatitis C can recur – even after six months of undetectable virus post treatment. Such a recurrence would mean that exposure to their blood could potentially be a route of infection for someone else.

Emergin research refutes Dr. Taylor’s position. According to a study published in a May 2009 issue of the journal Hepatology, research led by Tomasz I. Michalak of Memorial University of Newfoundland, Canada found that trace quantities of Hepatitis C persisting in the circulation for a long time after therapeutically induced resolution can remain infectious.

As published in the October 2013 edition of The Journal of Infectious Diseases, American researchers found that the reappearance of Hepatitis C RNA years after an SVR can be from relapse of the initial viral infection rather than re-infection from a different virus. According to one of the study’s authors, Theo Heller, MD, chief of the translational hepatology unit at the Liver Diseases Branch of the National Institute of Diabetes & Digestive & Kidney Diseases at the NIH, “In a few people, Hepatitis C has found a sanctuary site and can remain dormant for a length of time. This is important both biologically and clinically, even in the approaching era of direct-acting antivirals, where relapse may still be a problem. We already know it can and does occur.”

Careful evaluation of the information available shows that the medical community is torn on declaring SVR to be an absolute cure that renders the person no longer infectious. Before sighing in frustration, it is important to remember that the era of improved Hepatitis C therapy has just begun – and it will be many more years before we can eliminate many Hepatitis C uncertainties. In the meantime, Dr. Melissa Palmer, MD, author and internationally-renowned hepatologist suggests the following three scenarios for a return of Hepatitis C after SVR:

1. The original diagnosis of being cured after therapy was incorrect due to either inaccurate blood testing or miscommunication.
2. There has been a re-infection with a new strain of Hepatitis C.
3. Truly relapsing after years of being virus-free must be reported to your physicians in order to alert other physicians.

A relapse of Hepatitis C after SVR is extremely rare, but not unheard of. Because of this possibility, those who have been cured of Hepatitis C are urged to take precautions so as not to accidentally expose anyone to their blood. Until more is known to eliminate this gaping grey area of infectivity, it is advised to err on the side of caution and assume that even those who have been cured may still spread Hepatitis C.

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