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Hepatitis – Signs and Symptoms

Signs and Symptoms

Initial infection with HBV or HCV may cause acute symptomatic disease, but many patients will be asymptomatic.1,2

If symptoms do occur, they will be similar regardless of the type of hepatitis. The only definitive way to determine the type of viral infection is to carry out serological analyses.3

  • When they occur, symptoms of acute HBV or HCV infection may include:3–6
    • fever
    • fatigue
    • decreased appetite
    • nausea
    • vomiting
    • abdominal pain
    • dark urine
    • grey-coloured faeces
    • joint pain
    • jaundice
  • Since infection with hepatitis viruses are often asymptomatic, PLWHIV should receive appropriate screening.5 Refer to the diagnostic tools section for more details.

Hepatitis B

  • In the general population:
    • The HBV incubation period ranges from 30–180 days, with an average of 90 days6
      • HBV may be detected 30–60 days after infection, and can persist for widely variable periods of time
    • HBV can survive outside the body for about a week, and can cause infection during this time6
    • As with asymptomatic acute HBV, patients with chronic hepatitis B may not feel unwell for decades after becoming infected1
      • development of symptoms may indicate advanced liver disease in a chronically-infected individual4
    • 15–40% of patients with chronic HBV infection will develop serious consequences during their lifetime7
  • HBV-HIV co-infected patients frequently have higher HBV DNA levels, more severe hepatic disease and increased rates of liver-related mortality than those infected with HBV alone7
    • in HBV-HIV co-infected patients, liver enzyme levels (eg. alanine aminotransferase [ALT] levels), used as a measure of hepatic inflammation, may not be elevated despite severe disease8

Hepatitis C

  • In the general population:
    • The HCV incubation period ranges from 14–180 days, with an average of 45 days3
    • Estimates suggest that acute HCV infection is asymptomatic in 50–90% of cases2
    • Chronic infection occurs in 55–85% of infected individuals3
      • most people who become chronically infected with HCV have no knowledge of their infection or of the ensuing long-term hepatic damage2
      • 70% of individuals with chronic HCV infection develop chronic liver disease3
  • Progression of liver disease is accelerated in HCV-HIV co-infected people compared with HCV infected individuals who are HIV-negative2

Hepatitis-related liver damage

Serum/plasma characteristics that could indicate potential viral hepatitis-related liver damage include:

  • serum fibrosis markers, or combinations of markers, including hyaluronic acid, Fibrotest, Fibrometer, Hepascore, the aspartate aminotransferase (AST) to platelet ratio index (APRI), the FIB-4 index, the Forns index and other indices5
    • tests such as Fibrometer, Fibrotest and Hepascore may predict liver fibrosis more accurately than simple biochemical tests such as APRI, FIB-4 or Forns5

Markers of hepatic function may perform well in the detection of significant fibrosis, but they do not perform as well in the detection of lesser degrees of fibrosis

  • the combination of multiple markers improves accuracy for detecting fibrosis2
  • markers of hepatic synthetic function that could indicate potential viral hepatitis-related liver damage include:5,9
    • coagulation tests
    • serum albumin concentrations <3.4 g/dL
    • serum cholinesterase test (CHE), where pseudocholinesterase levels <8 U/mL may indicate liver damage
  • other markers of liver function that could indicate potential viral hepatitis-related liver damage include:9
    • alkaline phosphatase (ALP) serum concentrations >147 IU/L
    • elevated alanine aminotransferase (ALT) levels compared with age- and gender- matched averages
    • serum AST concentrations >34 IU/L
    • gamma-glutamyltransferase (GGT) serum concentrations >51 IU/L
    • total serum bilirubin levels >1.9 mg/dL

For information on HBV and HCV screening, refer to the diagnostic tools page. 


  1. World Health Organization (WHO). Introduction of hepatitis B vaccine into childhood immunization services. Management Guidelines, Including Information for Health Workers and Parents. Accessed 2 December 2011.
  2. European Association for the Study of the Liver (EASL). Clinical practice guidelines: management of hepatitis C virus infection. J Hepatol 2011;55:245–264. Accessed 1 December 2011.
  3. Immunization Action Coalition. Hepatitis A, B and C: Learn the differences. Accessed 1 February 2012.
  4. World Health Organization (WHO). Hepatitis C: Factsheet 164.  Accessed 1 December 2011.
  5. European AIDS Clinical Society (EACS). Guidelines Version 6.0. Accessed 30 November 2011.
  6. World Health Organization (WHO). Hepatitis B: Factsheet 204.  Accessed 1 December 2011.
  7. American Association for the Study of Liver Diseases (AASLD). Practice Guideline. Chronic Hepatitis B: Update 2009. Accessed 1 December 2011.
  8. Peters MG. Diagnosis and management of hepatitis B virus and HIV coinfection. Top HIV Med 2007;15:163–166. 
  9. US National Library of Medicine and National Institutes of Health. Medline Plus: Liver Function Tests. Accessed 2 December 2011.