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1244143 tn?1268497624

Can I still spread the Hep C

After 4 and a half years of treatment I have been virus free for almost 4 years, can I still infect others even tho I am in remission
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Avatar universal
Im not sure how contagious hep c is i was old 15 years ago i had it. I most certianly got it at least 12 years earlier before i got clean. I was married for 8 of those years and had regular unprotected sex.to hs day my ex is negitive. Since my divorce ive had 6 relationships one 3 years one 4 years all my partners were told that i have hep-c all after a time deceided not to use condoms..none have ever got it
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Avatar universal
thanks for correction Mike - also (not picking on you MB -but unlike hiv/hbv hcv is not a retrovirus. There's never an instance of hcv dna in its normal lifecycle; the NS5b polymerase  is an rna to rna machine).

I do think MB makes a very good point about the *choice* to be more careful, at least until this is better understood. The day-to-day equivalent of what Bill described regarding organ donation is a hypothetical like the following. You're having a bicycle race with your 7-year old grandchild, go down a hill hit sand/gravel and both go flying with resulting bloody palms, scraped arms and much wailing. As actively infected I assume everyone would take extreme care to avoid contact - but what about as an SVR?  In the same way that blood and organ banks might be losing out on Ab+ rna- donations it seems better to err on the  side of caution.
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Avatar universal
It is understandable that merryBe was under the wrong impression. At the time of this event many of us we discussing my situation in a persistent or occult context. And there was a notation stating something like <40 IU/ml. It was difficult for me to digest at the time because I had so much faith in my doctors. Any one who has read a biopsy report knows that there is a lot of information that may or not be relevant - disclaimers and the like. My report referenced laboratory in-house testing techniques that may not be FDA approved or something along those lines. Jim was active at that time and willing was also active in the discussion. Willing gave me the clearest context within which to look at this situation. All I wanted to know from my transplant team was precisely what test showed the presence of Hepatitis C. In fairness my coordinator truly believed that a test was performed - a molecular test. When I finally spoke to the pathologist - who is world renown by the way - and told my coordinator that no specific test was performed she was absolutely shocked. I blame the doctor who ordered the biopsy. He should have known that a PCR of tissue was indicated. Really, most of us would know to order a tissue PCR in the setting that I was in - SVR for 2 years. I could have only had few things going on - rejection or recurrence of HCV or enhanced immune response to low VL of HCV that had previously been overlooked by my immune system. A PCR would have cleared it up. I was tested monthly thereafter per Heptimax until last summer and I was UND every test.
That's the story.
Mike
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475300 tn?1312423126
All you new people and not so new.  Listen to what Mike Simon says!!  He is one of the most knowledgable people on the board.
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179856 tn?1333547362
Good that freaked me out I didn't think that Mike had a VL at all and that scared me alot. I thought I had lost my marbles.
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Avatar universal
Gee, I'm really confused now.
Trish - I guess I don't get your post at all.
Nevertheless, I am not concerned nor do I think I suggested that I was concerned about donor criteria vis a vis HCV SVR/HCV+ donor livers.

Merrybee
You said: "If you couple that notion with various instances....like MikeSimon, who has hovered at around 40 VL for years...."

This is incorrect. I have not tested detectable since April 2003. I had a liver biopsy in June 2006 which I misinterpreted as showing a low viral load. It is a long and probably boring story but in a nutshell here it is.
I was being weened off all anti-rejection meds - a quick tapering, if you will in the spring of 2006.
I got to the point where I was taking a low dose of 1 anti-rejection drug every other day and my enzymes began to elevate. I was biopsied in June 2006 and the report stated "Hep C" and contained some mention of VL. I questioned the results repeatedly asking specifically what test showed HCV. After over 18 months I finally spoke directly with the chief pathologist. He said there was no specific test performed to detect HCV. Apparently the doctor assigned to my case saw that I was transplanted for HCV and my current histology was consistent with HCV so he just assumed that was the cause of the activity. The chief pathologist said that typically that was the correct diagnosis but since I had been SVR since 2004 a PCR on my tissue sample should have been ordered. That test was not ordered. He then said that, in light of my SVR status, I could have had a minor component of rejection or an immune response to a very low VL triggered by the stimulation to my immune system caused the weening process. I told him I would bet my right arm that I suffered a minor component of rejection and he didn't argue the point.
I tested undetectable per Heptimax <5 IU/ml a week or two prior to that biopsy and again 2 weeks after the biopsy.
So, you cannot really use me in your argument.

Mike
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233616 tn?1312787196
Willing makes some good points that can be summed up in the simple statement "the clinical relevance is still under investigation".

that being said, I think it wise to realize the SVR can be best summed up by remembering what it stands for...Sustained Viral Response...not viral eradication but sustained response.

If you couple that notion with various instances....like MikeSimon, who has hovered at around 40 VL for years, or the cases Willing just gave, a kidney TP patient for whom immunosuppressants caused a relapse of a previously SVR state...add enough of these and you come away not knowing for certain what it all means.

Since recent tests showed as few as 20-40 virons infecting healthy tissue, I'd be inclined to say take care always. I wouldn't want anyone getting any virus I carried, be it polio, herpes, hcv, menigitis, chicken pox, or a whole host of others that they now understand we may carry in small quantity for life. The more we learn about these viruses, the more reason for concern. Some disease have all but been wiped out, only to emerge in more virulent forms because a few carriers passed it on, and because viruses do mutate.
HCV, like HIV, is a retrovirus, the most virulent types they have been observed in laboratories mutating as often as every 20 minutes. Those are some tough bugs!

I think we would all love to think SVR means 100% gone, not one viron floating around...but the verdict isn't in on this, it's still out.
SVR is considered a cure because less than 1% relaspe after reaching that goal...but 99% is not 100% now is it?

Ergo, I'd take the D for donor off the driver's licenses, or at the very least wear a medical ID bracelet, and let it be known to everyone, so that if someone takes your organ they at least know that the risk exists.

I'd also see advantage to being careful with toothbrushes and razors ever more...not because you have to, but because you GET to...and being cautious will allow you to know you are doing your best not to ever pass HCv to a loved one, not even a "little virus" because in this case a little is still a dangerous thing.
Were this not the case, would so much effort have gone into inventing machines that detect parts per million?
Machine that detect 1 or 2 virons in a drop of blood...a drop that could hold a million virons...would these be neccessary? I think not.

mb
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Avatar universal
This is an area in which there may continue to be some question or argument.  I think one has to define terms and intents so that all understand what is being asked and answered.

So far as an SVR person infecting another person thru day to day normal events; no.  In normal situations it should not present itself.  For all practical intents and purposes the person does not have the virus and cannot transmit it.

Even so, they are finding that post SVR does not mean the total absence of HCV RNA (please correct me if I am wrong).  That is an area in which there is still study and speculation as to the ramifications of what that means.  The *presence* the HCV RNA may exist in small amounts, it may even replicate, but remain at very low and or unquantifiable amounts.  Keep in mind that the ability to detect HCV keeps improving. The absence of HCV RNA in blood does not assure that it is not in tissue.

There is a simple common sense provision of transplants that if they can eliminate the chance of using infected tissue they will.  Their refusal to use antibody positive tissues does not mean that it is infective, it's simply a quick screening mechanism.  Regarding whether an liver from an SVR patient could infect somebody, I'm not certain that it is known, nor the effect of transfusing many units of an SVR patients blood into a non-infected patient.  Even so, these are more theoretical questions that I'm not sure that the answers are known 100%, but they do not effect the normal SVR patients life or quality of life and do not pertain to normal transmission methods.

For all practical intents, no you cannot transmit the virus you no longer have.

I don't intend this as a change of topic, but if what I have written is true, then what mode of transmission is somewhere in between the two extremes of normal day to day living with a SVR non-infective patient and receiving a liver from one?  

(answer) Sharing needles with one.

I would think that if a SVR person could transmit the virus, this mode of transmission would have already proven itself to be a transmission vector.  Once again this could be dicey claiming that one knows, but it would not surprise me if this has been tested more than once "in the field".  One supposes that the numbers would be small or that reporting might be limited.  Even so, if it were possible I think that we might have heard about it by now.  I think that it would be good to know but I've never heard of any discussion or trials in this area.  We HAVE heard of SVR patients becoming infected again, so people DO share needles, or so I believe.  If so, I would think that there would be a few people who had shared needles with a SVR'ed patient.  This is something that would be very easy to prove, but one that might be considered inhumane to test the hypothesis in some sort of trial.

By the way, when treatments improve getting an HCV infected liver will not be as big of an issue.  There should also be a reduced need for livers since people will be cured, and not progress to needing a TP, so I assume that both issues could change in the near future.

My 2 cents, and acknowledging that it is in a somewhat speculative area, I could be wrong.

best,
Willy

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87972 tn?1322661239
Thanks as well, Willing, for taking time to dig this up. The time frame required for NAT assay never crossed my mind; of course organ degradation would occur while waiting for test results.

Anecdotally, I was trying (in advance :o))to make a whole body donation to science several years ago. I have a letter of denial from UC Davis based on my being HCV antibody positive; when I followed up, I was told the same; they won’t take antibody positive or seropositive donations, either for tissue harvest or research. The doctors at CPMC didn’t offer any options or alternatives either.

Bill
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419309 tn?1326503291
Wow, really gives cause for both emotional and ethical questions to ponder.
I think if my husband relapsed and became seropositive, it would not be at issue whether or not to receive either an anti-body positive or seropositive liver, if he needed transplant to stay alive -- with survival rates for those on the tp list barely above 10% it'd be a gift of life.  

I guess the complexities and uneasiness would come into play if he were to need tp after SVR and presented with the option of seropositive hiv and/or hcv liver.  My instincts tell me I would consent, but I'm not sure everyone would automatically feel that way.  Some might feel like just it's buying poor quality time rather than extending longevity.  Guess that's what informed consent is all about...

Great info, thanks for posting it -- much food for thought. ~eureka
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Avatar universal
Trish : agreed this is a  complicated area. Here are some guidelines regarding organ screening in a transplant setting
"Screening of donor and recipient prior to solid organ transplantation."
http://www.ncbi.nlm.nih.gov/pubmed/20070698

"Antibody to HIV Exclude from organ donation
Antibody to HTLV I/II Generally exclude from organ donation (may be used in life-threatening situations, with informed consent)
Antibody to HCV If used, usually reserve organ for recipient with antibody to HCV or severely ill recipient"

(HTLV is Human T-cell lymphotropic virus (HTLV)-I/II)

Where NAT has been implemented , I believe it is in addition to rather than in place of antibody screens, but am not sure. To make things more complicated, NAT testing is not even an option for cadaver donors because degradation is so quick

"Using our hospital laboratory as a reference, we found that the most rapid turnaround time for HIV antibody is 1 hour with the OraQuick Advance HIV-1/2 antibody test (Orasure Technologies, Bethlehem, PA). The turnaround time is 24 hours for HIV-RNA NAT, 4 hours for HCV antibody, and 24 hours for HCV-RNA NAT. Given these turnaround times, the additional delay of waiting for NAT would be impractical as donor organs show deterioration of function with increasing ischemic times, which translates into overall inferior graft and recipient outcomes. The incremental cost associated with NAT would also be considerably higher."
from
http://www.ncbi.nlm.nih.gov/pubmed/18975294

(and you'd think after you were dead, people would finally stop rushing you..)

Mike : haven't seen any data there either. I would think most recipients would be pretty happy with  an svr donor.  Apparently the woman in the case above was very unhappy about getting both hiv and hcv along with the new liver, but that's an extreme case.

Here's more from the guidelines review above

"Hepatitis C antibody-positive donors have traditionally been considered a dilemma, because of the high risk of transmission of HCV through transplantation of any organ. A positive donor HCV-RNA, indicative of active viral replication, has been associated with a higher risk of transmission, but often this information is not available in the time frame required to utilize a deceased donor. The risks of transmission from HCV-RNA negative, HCV antibody positive donors have not yet been fully defined. In the future, rapid molecular testing will likely be increasingly performed in the time frame needed for donor evaluation.

The 2001 Crystal City Meeting reported that there was no increase in 1- or 5-year mortality or morbidity in transplanting a liver or kidney from an HCV-positive donor versus an HCV-negative donor into an HCV-positive recipient (10). However, a large 2003 study by Abbott and colleagues of over 36 000 adult deceased-donor renal transplant recipients demonstrated an independent risk for increased mortality with HCV-positive donors, even in the subgroup of HCV-seropositive recipients (62). When compared with remaining on the waiting list, there was a survival advantage to receiving a kidney from an HCV+ donor (63). Thus, survival with a kidney from an HCV+ donor, while less than that seen in the setting of an HCV negative donor, appears to be associated with better survival than remaining on dialysis (64).

In recent years, the use of HCV+ organs for life-saving transplants in HCV-negative recipients has also been studied, sometimes with acceptable results. In a survey of lung transplant programs, 55% reported utilizing HCV seropositive donors, in many cases restricted to HCV seropositive recipients (65). A survey of heart transplant programs revealed that most centers use HCV+ donors for status 1 and/or HCV+ transplant candidates; only 26% of centers reported never using HCV seropositive donors. In that survey, 64% of centers reported listing HCV+ candidates for heart transplantation (66). However, one series identified an excess of rapidly progressive cholestatic hepatitis and an increased mortality overall for HCV– recipients of HCV+ donor hearts on mycophenolate-based immunosuppression (67). Whether specific immunosuppressive regimens are preferred in such situations requires further study. In any event, whenever an HCV seropositive donor is utilized, stringent informed consent is advisable.

As recent transmission events have proven, HCV can be transmitted to multiple organ and tissue transplant recipients from a seronegative donor (19,20). The time between infection and antibody production can vary in HCV-infected individuals, although viral RNA may be present much earlier after acute infection. The efficacy and feasibility of NAAT and other confirmatory HCV RNA testing is being investigated in the hope of decreasing the risk of transmission from donors to recipients."
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419309 tn?1326503291
jdwithhcv:
And sorry about your friend, too sad :|.
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419309 tn?1326503291
gary95:  
'Remission' is a misleading word... could mean a number of things, which makes your question ambiguous and difficult to answer.  Bottom line, though: If you do not have active virus, you would not be contagious.

Trish77:
My understanding of the blood donor screening process as it relates to hcv is simply based on 'efficiency' -- it is both costly and timely to screen blood for the presence of active virus (PCRs are pricey, whatever the method).  Furthermore, since both the scientific and medical communities (and ours as well!) still debate the specifics of 'cure' and 'transmission', most blood-donation centers (for the most part non-profit organizations) take the route of least resistance.  As for liver transplants, I believe that for the hcv-positive population on the TP list, some centers have clearance to transplant hcv positive livers if it means saving one life as opposed to none at all (presuming the liver cleared all other criteria) -- but I believe protocol would change if the the recipient patient were actually SVR.

mikesimon:
Interesting thought.  I would presume that positive hcv antibodies wouldn't exclude someone from organ donation, but I'd never really given that question much consideration until now, and it raises a number of questions in my mind.  I'll have to explore that a little... if I find anything of note I'll definitely get back on this.

~eureka
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Avatar universal
No, Mike.  I haven't seen any statistics or studies on transplanted livers from a donor who has HCV and is not SVR.

There's a certain leap of logic that I'm making here.  I'm thinking that the professionals who do liver transplants already have some sort of screening criteria for donor livers.  They also seem to have some criteria for who gets a liver.  I would find it hard to believe that they would blindly accept a liver from a donor who was positive  for HCV antibodies, let alone someone who has HCV (or is the order of that the other way around?) if they had sufficient concerns about it.  I'd find it hard to believe they wouldn't have put at least some time, if not considerable time, into considering whether that was a medically wise approach to take, along with the kind of approach that would open them up to lawsuits and the like. I tend to think there are certain requirements and hospital boards and legal opinions and all sorts of things that go into a decision on what organ, not just livers, gets transplanted into a patient. While I have not personally seen studies on this, I am assuming that a certain amount of research and diligence went into the decision of the medical professionals in a transplant centre to take a liver from a person who has antibodies but not Hep C, who cleared on their own or is SVR.

Perhaps if this concerns you, you should start writing letters to these centres that they should not do this until there are studies to back up this practice.
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Avatar universal
I had a old friend who received an SVR organ, but sorry tosay  he never stopped drinking and partying.  He died several years ago.  
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Avatar universal
In certain cases at some centers HCV+ livers are transplanted too. What's that tell you? Not much as I see it.
What I would like to see is how the recipient of an SVR organ does - HCV+ or not. I've not see any information about that.
Have you?
Mike
.
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Avatar universal
"Bottom line is no one's sure yet. Blood and organ banks  consider presence of HCV antibody a risk, even post-SVR. "

willing ... are you sure you're interpreting that correctly?  Isn't it possible that the presence of antibodies is enough for blood banks to simply turn down that blood donation as it would require them to then send someone for a PCR...for what?  A pint of blood?  I think it's simply cutting their losses at that point.  Do you actually have some data that states that blood banks find antibodies a risk for contagion?  I submit it's possible that the risk they see is what else could also exist due to antibodies.

As for organ banks, if presence of antibodies was a problem then why do they accept liver donations from those who are SVR but who would have antibodies?  That would be incongruous with your contention that organ banks have an issue with the presence of HCV antibodies, don't you think?

Regards,

Trish
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Avatar universal
There's pretty much universal consensus that you are cured.

However the question of whether you are still can infect others is less clear. This is a complicated area without clear guidelines. Examples documenting virus after SVR are common, for example:
http://www.ncbi.nlm.nih.gov/pubmed/18712814

If you're interested in researching the topic, a recent review by Zeuzem has collected much of the evidence for and against post-svr virus:
http://www.ncbi.nlm.nih.gov/pubmed/19105211

See also a very recent overview by Pham,Coffin, Michalak
http://www.ncbi.nlm.nih.gov/pubmed/20070513

Bottom line is no one's sure yet. Blood and organ banks  consider presence of HCV antibody a risk, even post-SVR. Being reasonably prudent about possible blood-borne infection until the question is finally resolved seems the safer way to go.
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476246 tn?1418870914
If you have been virus free for almost 4 years, I would conclude that you are SVR = cured!!!  You cannot transmit something you do not have.

So no, you cannot infect others!
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Avatar universal
Were you undetecable 6 months after your last shot?
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87972 tn?1322661239
Unfortunately, the term remission is rather vague, and isn’t used to describe one’s HCV status. It doesn’t differentiate between HCV RNA and HCV antibodies.

If you can tell us more about you, we might be able to help answer your questions—

Bill
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Avatar universal
There is no such thing as remission. You either have the virus or you don't. If you treated and became cured (SVR). Then no, you are not contagious.
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