hepatitis c in primary care: screening, interpretation, and referral

Hepatitis C (HCV) is curable with direct-acting antivirals, but many people are undiagnosed. Primary care can add real value by opportunistic testing of at-risk groups, correct interpretation (antibody vs RNA), and rapid referral to local viral hepatitis services.

• Current/past injecting drug use (including image/performance-enhancing drugs); sharing any injecting equipment.
• Blood transfusion before early 1990s (country-dependent), recipients of blood products historically.
• Prison history, homelessness, or high-risk settings.
• Born/raised in high-prevalence countries, or healthcare exposure overseas.
• HIV or HBV infection; MSM with high-risk behaviour; sexual exposure risk.
• Unexplained LFT abnormalities with risk factors.

• HCV antibody positive = exposure at some point (past or current infection).
• Confirm current infection with HCV RNA (PCR).
• Antibody positive + RNA negative usually indicates cleared or treated infection (no active viraemia) — follow local advice; may not need referral unless ongoing risk, immunosuppression, or liver disease concerns.
• Antibody positive + RNA positive = active infection → refer for treatment.

Baseline practical set (often helpful before referral): FBC/platelets, LFTs, U&E/eGFR, INR/albumin if concerns, and co-infection screen (HIV, HBV). Use local pathways (some services prefer referral without delay).

• Refer: anyone with confirmed active HCV (RNA positive) to local viral hepatitis/hepatology/ID service.
• Assess alcohol and metabolic risk (co-factors for fibrosis progression).
• Urgent referral: decompensated liver disease (ascites, encephalopathy, GI bleed) or jaundice with systemic illness.

Public health note: discuss harm reduction (needle exchange, avoiding sharing equipment) and partner notification routes via specialist services.