Management of Special Groups: Patients with Acute HCV Infection

• HCV infection is seldom apparent or diagnosed during its acute phase.
• Spontaneous viral clearance occurs in as many as 50% of patients with acute HCV infection, but many acutely infected persons develop chronic infection.
• Early treatment of acute HCV infection is worthwhile, but the optimal timing of therapy and treatment regimen remain to be defined. Until further data are available, this panel considers it reasonable to initiate treatment of persistent infection by 12 weeks after acute infection is documented.

Rarely is HCV infection diagnosed during its acute phase. A minority of patients with acute HCV infection have symptoms; the most common symptoms during acute infection are jaundice, reported in 20% to 30% of patients, and nonspecific symptoms (eg, anorexia, malaise, abdominal pain), reported in 10% to 20%.¹⁷⁸ The average time from HCV exposure to symptom onset in these patients is 6 to 7 weeks.¹⁷⁸ Symptoms resolve on their own after several weeks in most symptomatic patients with acute HCV infection.

Spontaneous viral clearance is observed in as many as 50% of patients with acute HCV infection.^178-180 Several characteristics have been associated with spontaneous clearance of HCV after acute exposure, including younger age, female sex, white race, absence of an immune deficiency state, and the presence of symptoms or jaundice.¹⁸⁰

Because of the high rate of progression of acute HCV infection to chronic infection, treatment of persons with acute infection can be justified.⁷² Some studies have shown that IFN therapy initiated during the acute phase of infection is associated with higher rates of end-of-therapy and sustained virologic response, on the order of 80% to 100%.²² For instance, a recent study showed a sustained virologic response in 42 of 43 patients (98%) with acute HCV infection who received 5 million IU of IFN alfa-2b daily for 4 weeks and then three times weekly for another 20 weeks.¹⁸¹ Moreover, the rate of progression to chronic disease may be minimized by early therapy. However, these studies have been limited by their heterogeneity, small sample sizes, and lack of randomization.²²

The optimal timing of therapy and type of regimen remain to be determined. This panel recommends that treatment be initiated no later than 12 weeks after acute infection is documented. PEG-IFN has not yet been evaluated in patients with acute hepatitis C, but it is likely to be associated with outcomes similar to or better than those in patients treated with standard IFN.