Department of Internal Medicine, University of Nebraska Medical Center, Research Service, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE 68105, USA.
Hepatitis C virus (HCV) persistence drives the progression of HCV infection. This progression is usually asymptomatic in HCV-infected patients. For many years, clinical manifestations of HCV persistence are restricted to fatty liver followed by slow development of fibrosis, cirrhosis and hepatocellular carcinoma  . Thus, HCV persistence is a "first hit" triggering HCV pathogenesis. There are "second hits" that stabilize the infection and cause faster progression, exacerbation of pathological features of HCV infection and poor response to anti-viral therapy. One of these "second hits" known to affect HCV pathogenesis is alcohol. Liver steatosis is common for both HCV infection and alcohol and is considered as a co-factor in development and progression of fibrosis.