BHIVA’s Guidelines for the routine investigation and monitoring of adult HIV-1-infected individuals 2011 recommend that everyone diagnosed with HIV is screened for hepatitis B and hepatitis C regularly.
These guidelines recommend that you are vaccinated against hepatitis B if you are not already immune (because you have had it in the past or have already been vaccinated).
If you are pregnant, you should be vaccinated for hepatitis B after you have passed the first trimester of pregnancy (that is, after 13 weeks).
Unless you are already immune to hepatitis A (because you have had it in the past or have already been vaccinated), you should be vaccinated against it after you have passed the first trimester of pregnancy. If your CD4 cell count is under 300, you may need an extra dose of the vaccination.
You can find out more about hepatitis B and hepatitis C on the NHS Choices website. For more information on co-infection with HIV and hepatitis B or hepatitis C, go to www.aidsmap.com or to the Co-infection Alliance website.
Liver function tests and other tests
If you have been diagnosed with hepatitis B or hepatitis C recently, you should:
- have a viral load test to confirm the infection.
- also be tested for other forms of hepatitis: A, B or C, and hepatitis delta.
- have a range of liver function tests to see how well your liver is working and if there is any damage to it. This may include an ultrasound scan to look at the structure of your liver.
- have a test to find out what type of hepatitis C you have (called a genotype).
All women should have their liver function tested regularly during pregnancy as a change in liver function can be an important indicator of several pregnancy-related health problems.
If you start HIV treatment during your pregnancy, you should have liver function tests (LFTs) two weeks after starting. This is to check that the HIV treatment is not affecting your liver.
Women who are pregnant should not have their liver examined using a technique called FibroScan. If necessary, the health of your liver will be monitored using ultrasound scans.
Sometimes people starting HIV treatment develop symptoms from an illness they have had in the past. This is called immune reconstitution inflammatory syndrome (IRIS) and is actually a sign that the immune system is getting stronger. LFTs will be used to monitor whether liver disease from your hepatitis infection is getting temporarily worse (with more liver inflammation).
If you stop HIV treatment after your baby is born, it’s very important that your liver function continues to be monitored carefully.
Having your baby
If you are on HIV treatment and have an undetectable viral load, you can have a vaginal delivery, unless there are other medical reasons why you should not.
If you have hepatitis B, your baby should be immunised against hepatitis B in the first 24 hours after he or she is born.
Treatment for hepatitis B
If you are on hepatitis B treatment that involves the drugs pegylated interferon or adefovir (Hepsera) when you become pregnant, and you don’t need HIV treatment for your own health, your hepatitis B treatment should be changed.
You should stop taking pegylated interferon or adefovir and switch to an HIV treatment combination that includes the drug tenofovir (Viread), in combination with FTC (emtricitabine, Emtriva) or 3TC (lamivudine, Epivir). These drugs all work against both hepatitis B and HIV.
HIV treatment when you also have hepatitis B
If you haven’t already started HIV treatment for your own health, you should start HIV treatment to prevent mother-to-baby transmission. Find out more about when this should happen in Factsheet 5: HIV treatment for pregnant women: HIV treatment.
Your HIV treatment should include the drugs tenofovir (Viread) and FTC (emtricitabine, Emtriva), unless there are reasons why these drugs are not suitable for you. This is because these drugs work against both hepatitis B and HIV.
The drug 3TC (lamivudine, Epivir) can be used instead of FTC, but FTC is the preferred option. It is available together with tenofovir in a pill called Truvada.
If you are on HIV treatment that is also active against hepatitis B, you should continue on this treatment. There is no evidence of any harm to the baby when a woman becomes pregnant while taking tenofovir, FTC or 3TC.
If you have already started HIV treatment, but your treatment regimen doesn’t already include tenofovir (Viread), this drug should be added to your combination. It may replace another drug or be taken as an additional drug.
FTC or 3TC should not be used as the only anti-hepatitis B drug in a treatment combination, because of the risk of developing resistance. If your hepatitis virus is resistant to either of these drugs, you will take tenofovir as your anti-hepatitis B drug. FTC or 3TC can still be part of your HIV treatment.
If your CD4 cell count is under 500, and you have hepatitis B, you should stay on HIV treatment after your baby is born.
If your CD4 cell count is over 500, and hepatitis B is not causing liver damage that needs treatment, your doctor may suggest that you continue HIV treatment containing tenofovir and FTC after your baby is born.
If your CD4 cell count is over 500, but you have hepatitis B virus present in your blood, or evidence of liver disease, you should stay on HIV treatment. Your treatment combination should include tenofovir and FTC.
If your hepatitis gets worse after you have stopped HIV treatment, you should start treatment again, taking a combination that works against both HIV and hepatitis B (this should include tenofovir and FTC). You can also take the hepatitis B drug adefovir.
Hepatitis C treatment
You should not be treated for hepatitis C while you are pregnant or trying to become pregnant.
Hepatitis C treatment currently includes the drug pegylated interferon, with or without another anti-hepatitis C drug, ribavirin.
You must not become pregnant while you are taking ribavirin, nor for for six months after finishing it, nor while your partner is taking ribavirin and for six months after he has finished it. The guidelines suggest using at least two forms of contraception during this period.
If you discover you are pregnant while receiving treatment for hepatitis C, contact your doctor immediately to discuss stopping your hepatitis C treatment.
HIV treatment when you also have hepatitis C
As well as protecting your baby from HIV, effective HIV treatment reduces the risk of your baby being infected with hepatitis C.
If you haven’t already started HIV treatment for your own health, you should start HIV treatment to prevent mother-to-baby transmission. Find out more about when this should happen in Factsheet 5 HIV treatment for pregnant women: HIV treatment.
If your CD4 cell count is under 500 and you have hepatitis C virus present in your blood, you should stay on HIV treatment after your baby is born.
If your CD4 cell count is over 500, and you don’t have hepatitis C virus present in your blood or evidence of liver disease, you can stop HIV treatment. Find out more about how this should be done in Factsheet 4: HIV treatment for adults: Stopping treatment.
If your CD4 cell count is over 500, but you have hepatitis C virus present in your blood, or evidence of liver disease, you should stay on HIV treatment.
If your CD4 cell count is between 350 and 500, and you don’t have hepatitis C virus present in your blood or evidence of liver disease, you can stay on HIV treatment if you would prefer to, as it can slow down damage to your liver.
BHIVA produces separate guidelines on how hepatitis B and hepatitis C should be managed in people who have HIV (other than during pregnancy). The current version is called Management of coinfection with HIV-1 and hepatitis B or C virus 2010. Updated guidelines will be published during 2013.