This post explains Hepatitis C tests and their results. It explains the ideal sequence of Hepatitis C tests from the first Hep C test through to end of treatment testing.
This page will explain Hepatitis C tests and how to read them. Below is the normal sequence that Hepatitis C testing is done in. Please move down the page for more information.
There is an ideal world where all Hep C testing is paid for by a health insurance company or by a government health service. Unfortunately, only about 30% of the world’s population have access to this “ideal world”. For the rest of the human population with Hep C who live in countries or circumstances where the cost of testing is impossible to afford, there are other ways to approach Hepatitis C testing, which I discuss in a separate post. If you are in a country, or situation, where the cost of Hepatitis C testing is beyond your means please use this link to read about Hepatitis C testing options in low-income situations.
But here is the “ideal” testing sequence:
Antibody test (if positive) > Viral Load test (if positive) > Liver Function test and Fibroscan > Genotype test [ TREATMENT] End of treatment Viral Load test > Liver Function test> 12 weeks after end of treatment another Viral Load or PCR test.
I will now explain the different tests. Please remember that if you do not understand any of this I am happy to talk to you via email. Also please remember that the sequence just described is the “ideal” if it is not possible for you to follow the ideal, which is also the most expensive, I will explain other testing options further along. If you want to talk to me use the contact form at the bottom of this page.
The Hepatitis C Antibody test is the first test on the path to confirming that you may have Hep C. The HCV antibody test does not prove that you are currently infected with the Hepatitis C virus, only that you have come in contact with Hep C. If you test positive for Hep C antibodies there is about a 75% chance that you are infected with Hepatitis C.
If you test positive for the Hep C antibody then you should get a viral load test. The cost for a viral load test will be between US$90 and US$250 depending on which country you live in.
The VIRAL LOAD TEST (also known as the quantitative HCV RNA test). The viral load test measures the amount, or number, of hepatitis C virus particles in the blood. The result will be an exact number, such as “1,378,980 IU/L.” This number is “the load” of virus a patient is carrying in their blood. The higher the number the more virus in the blood and in the liver. Numbers can range from 200,000 to 10 million or more. Ranges between 1 million and 5 million are common.
If the viral load test result gives a result such as “<15 IU/L,” (under 15) this means that the quantitative test used cannot measure the hepatitis C virus below that number. It may mean that there is no Hepatitis C virus in the patient at all, but it may also mean that the level of virus is just too low for the test to pick it up.
Generally speaking if a person has had Hep C and completed treatment and a viral load test shows no detectable virus 12 weeks after the End Of Treatment (EOT) then the patient is considered cured. Some doctors like to perform a second test 24 weeks after EOT but for many the cost of viral load test is a lot of money. In most countries the cost of a viral load test is between US$90 and US$250.
If the viral load test result at EOT 12 weeks shows “Undetected” is almost universally considered to be a 100% cure.
Please also remember that the viral load measurement does not tell anything about the severity of a patient’s liver disease or the degree of fibrosis (liver scarring). A person may have a viral load of 5 million or more but have very little liver damage. Conversely, a person may have a low viral load and a lot of liver damage. For example in my case my viral load never went above 800,000 but I had extreme and severe liver damage.
Also worth noting is that viral load is not relevant to treatment outcomes. That is to say, having a high HCV viral load of 5 million or a viral load of 1 million will not make a difference to cure rates. The factors that affect Hepatitis C cure rates are more to do with the level of liver fibrosis, how long the person has had Hep C and previous treatment history.
The Qualitative HCV RNA test is another test that detects the presence of the Hepatitis C virus in your blood. Its is usually slightly cheaper than the viral load test.
The qualitative test does not measure the number of hepatitis C virus but simply confirms that the Hep C virus is present in the bloodstream or not. The result is reported as either “detected” or “not detected.”
If a qualitative RNA test is positive (detected), then it is certain that the patient has Hepatitis C DNA in their blood. If it shows “undetected” then there is no virus.
The “qualitative” test is more accurate than the “quantitative” test because qualitative tests are able to detect very low levels of the virus. But is does not give exact numbers of Hep C virus.
Once it is confirmed that you are infected with the Hepatitis C virus the next step is to work out the best treatment option.
To understand Hep C genotypes, and to put it simply, the different genotypes are different varieties, or races, of Hep C virus. Think of Hep C genotypes in terms of types of dogs (sorry if this offends any dog lovers). You would need a different weapon to kill a Great Dane than what you would need to kill a Chihuahua.
Knowing the genotype is helpful for choosing the best medication to treat your Hepatitis C infection with. This is something that should be discussed with your doctor or health professional. But to give an indication here are some different Hep C treatment options showing which genotypes of Hep C they will treat.
Harvoni is used to treat Hep C genotype 1.
Epclusa is used to treat Hep C genotypes 2 and 3 and 4 and 5 and 6
Sofosbuvir + Daclatasvir is used to treat all genotypes.
Mavyret is used to treat all genotypes
Whilst knowing which genotype of Hep C you have is very useful for choosing the best treatment options a LOT of people around the world cannot afford the cost of a genotype test or do not have access to a genotype test because this test is not available in their country.
If you can not access a genotype test (for whatever reason) you should discuss with your doctor the option of using a drug combination that treats all genotypes. This is a called a pan-genotype drug; examples of pan-genotype Hep C drugs are Mavyret and Sofosbuvir + Daclatasvir and Epclusa. Sofosbuvir + Daclatasvir is the cheapest pan-genotype drug and it is also highly effective. Most testing shows that it is equal to or better than Mavyret.
The Liver Function Test is a cheap Hepatitis C test that tests a range of enzymes and other substances that are produced by the liver. Amongst these enzymes there are what is called “marker” enzymes, or “indicators”. These enzymes indicate the general health of your liver or, conversely, how much damage is being done to your liver by the Hepatitis C virus. Elevated liver enzymes usually indicate high levels of liver fibrosis or cirrhosis.
The main indicator enzymes are:
If all, or any, of these enzymes are high it is an indication of liver damage. Put simply the higher the numbers the higher the level of liver damage. To read more about the liver function test and its interpretation click on this link.
As a rule of thumb these liver enzymes (and liver function) will return to normal levels within 4 to 6 weeks of treatment. If you get a Liver Function Test before you start treatment it is a very good base line to use to assess how your treatment is going. For example if you have high enzyme levels prior to starting treatment and they have returned to normal levels four weeks into treatment then this is a very good indicator that the treatment is working and your liver is healing.
Another test that is a good base line pre-treatment test and is also helpful for deciding the length of treatment time is the Fibroscan. The Fibroscan measures the amount of liver fibrosis. If caused by Hepatitis C, liver fibrosis is basically a measure of the damage that the Hep C virus has done to your liver. If you have a high level of liver fibrosis or cirrhosis you may need to do a longer treatment time, which should be discussed with your doctor.
There is actually no critical reason that you need to have any testing done during treatment unless you have other serious health issues that might be effected during treatment. For most people the there will be no need for testing during Hepatitis C treatment with DAAs.
However if you are in a situation where you can access blood tests for free, or can afford them, it is interesting to get a viral load test and a liver function test after four weeks of treatment. The reason for this is that it will confirm that the treatment is working.
By week four of treatment your viral load should be at undetectable levels and your liver function test should show liver enzymes at normal levels, or at least significantly improved levels.
It is reassuring to get these tests done but not necessary at all.
Once your Hep C treatment is completed there is only one test that is absolutely needed and that is a viral load test (or PCR test) 12 weeks after the end of treatment.
The term “End of Treatment” is commonly shortened to EOT.
The international norm is that a person who has undergone treatment and has an undetectable viral load 12 weeks after the end of treatment is cured of Hepatitis C. Some countries and some doctors like to follow up with another viral load test 24 weeks after the end of treatment. But the international standard is that if you have no detectable virus level 12 weeks after the end of treatment then you are cured. This stage is commonly called SVR 12. (Sustained Viral Response). If you reach SVR12 you are cured.
At EOT it is common to have a liver function test. If the liver function test shows normal levels it confirms that your liver is healing well. If one or more liver enzyme remains above normal levels this may indicate other liver-related problems and further testing would be needed.
Generally it is a good idea to get a liver function test every year or so after clearing the virus just to be sure you liver has completely healed and there are no complication caused by the damage done by the Hep c infection.
If it is possible then it is worth having a Fibroscan some time after the end of treatment, particularly if you have had a Fibroscan prior to treatment and your fibrosis levels were high, or if you have cirrhosis.
Generally speaking the liver heals very well after treatment and fibrosis levels improve. Most people with cirrhosis will find that the cirrhosis disappears within a year of completing treatment. For more information on how the liver heals after the Hep C virus is removed please click this link.
The important thing to remember is that the sooner you cure yourself of Hepatitis C the better. The longer you have Hepatitis C the greater the damage that the virus does and the more chance there is of you of developing serious, long-term, possibly fatal, health problems.