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Epidemiology and natural history of HCV infection

Abstract

Worldwide, an estimated 130–170 million people have HCV infection. HCV prevalence is highest in Egypt at >10% of the general population and China has the most people with HCV (29.8 million). Differences in past HCV incidence and current HCV prevalence, together with the generally protracted nature of HCV disease progression, has led to considerable diversity in the burden of advanced liver disease in different countries. Countries with a high incidence of HCV or peak incidence in the recent past will have further escalations in HCV-related cirrhosis and hepatocellular carcinoma (HCC) over the next two decades. Acute HCV infection is difficult to detect because of the generally asymptomatic nature of the disease and the marginalization of at-risk populations. Around 25% of patients with acute HCV infection undergo spontaneous clearance, with increased rates among those with favourable IL28B genotypes, acute symptoms and in women. The remaining 75% of patients progress to chronic HCV infection and are subsequently at risk of progression to hepatic fibrosis, cirrhosis and HCC. Chronic hepatitis C generally progresses slowly in the initial two decades, but can be accelerated during this time as a result of advancing age and co-factors such as heavy alcohol intake and HIV co-infection.

Key Points

  • Although many countries in Asia have a low-to-intermediate prevalence of HCV, around half of the global population of patients infected with HCV reside in this region

  • Many countries have 'ageing cohorts' of people with HCV owing to peak HCV incidences in the recent past (2000 in Australia, 1980s in the USA) or distant past (1920–1940s in Japan)

  • Changes in levels of HCV RNA during acute HCV infection might guide early therapeutic intervention, with levels in patients with viral clearance or persistence diverging after 3–4 months of infection

  • The disease progression of chronic HCV infection often accelerates after 20 years of infection, with lifestyle factors key drivers of hepatic fibrosis

  • Direct-acting antiviral therapies should provide a paradigm shift in treatment over the next few years

  • However, unless rates of diagnosis of HCV and access to treatment improve dramatically, direct-acting antivirals will have a limited effect on global disease burden

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Figure 1: The estimated prevalence of HCV infection and the distribution of HCV genotypes across the world.
Figure 2
Figure 3: Dynamics of acute HCV infection from 2 months after infection, split by infection outcome.
Figure 4: The disparity between potential HCV treatment efficacy and projected HCV treatment effectiveness.

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Acknowledgements

The Kirby Institute is funded by the Australian Government Department of Health and Ageing and is affiliated with the Faculty of Medicine, The University of New South Wales. B. Hajarizadeh is an Australian Postgraduate Award PhD scholar. J. Grebely is supported by a National Health and Medical Research Council Career Development Fellowship. G. J. Dore is supported by a National Health and Medical Research Council Practitioner Research Fellowship. The authors would also like to thank Dr Homie Razavi (Center for Disease Analysis) for contributing epidemiological data for the figures included in this manuscript.

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B. Hajarizadeh researched data for the article, contributed to discussion of content, wrote the article and reviewed/edited the manuscript before submission. J. Grebely and G. J. Dore researched data for the article, contributed to discussion of content and reviewed/edited the manuscript before submission.

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Correspondence to Behzad Hajarizadeh.

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J. Grebely is a consultant/advisor for Merck. G. J. Dore is a consultant/advisor and has received research grants from AbbeVie, Bristol Myers Squibb, Gilead, Janssen, Merck and Roche. B. Hajarizadeh declares no competing interests.

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Hajarizadeh, B., Grebely, J. & Dore, G. Epidemiology and natural history of HCV infection. Nat Rev Gastroenterol Hepatol 10, 553–562 (2013). https://doi.org/10.1038/nrgastro.2013.107

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