Non-HIV-related illnesses – hepatitis

Co-infection with hepatitis B virus or/and hepatitis C virus is increasingly becoming a cause of illness in people with HIV. Both these viruses affect the liver, can make you very ill and can be fatal.

Hepatitis A is a virus that affects the liver. It can cause a short-term illness that normally lasts between ten and 14 days. Symptoms include tiredness, a yellowing of the skin, pale stools, diarrhoea, nausea and vomiting. You can normally expect to get better without any treatment, and once you've had hepatitis A you cannot get it again.

The infection is spread by contact with infected human faeces (stools, excrement, shit). Contaminated food and water are often common sources of infection, but it can be spread during sex, particularly by rimming (oral-anal contact).

In people with HIV, the symptoms of hepatitis A might last for longer. Many anti-HIV drugs (as well as medicines used to treat other conditions) are processed using the liver. The liver inflammation that hepatitis A causes can mean that some people need to stop taking their treatment when they have hepatitis A. But this needs to be discussed with your doctor.

There is a vaccine against hepatitis A that works well in people with HIV and everybody who has HIV is recommended to have this vaccine unless they are naturally immune to the infection (a test before vaccination can show this).

Hepatitis B virus (often known as HBV) is an infection that can cause severe or even fatal damage to the liver. Long-term infection with hepatitis B can cause liver cancer, and rates of liver cancer in people with HIV are elevated because of hepatitis B and hepatitis C. Hepatitis B is quite common in some of the communities affected by HIV in the UK, as it can be contracted in the same ways as HIV, particularly through contact with blood, semen or vaginal fluid, and from mother to baby.

You should be tested soon after your diagnosis for hepatitis B, to see if you have been infected with the virus and are a carrier. A vaccine is available to protect you against hepatitis B. If you are uninfected, and a test shows that you do not have natural immunity against it, you should be vaccinated.

If you are coinfected with hepatitis B, doctors will regularly monitor your liver function using blood tests. Ultrasound examinations may also be performed, particularly if your liver shows signs of damage.

Treatments are available for hepatitis B, and three drugs have been licensed. These are alpha-interferon, adefovir (Hepsera) and the anti-HIV drug 3TC (lamivudine).  Tenfovir (Viread) and FTC (emtricitabine, Emtriva) are also effective against hepatitis B, but have not yet been formally licensed for the treatment of HIV/hepatitis B co-infection (although approval for tenofovir is being sought). Tenfovir and FTC are available in a combined pill called Truvada.

Having hepatitis B is not thought to make HIV progress faster. Anti-HIV drugs can be used safely and effectively in people with hepatitis B. However, when some people start HIV treatment, they experience a short-term flare-up of hepatitis B. This is because the immune system is getting stronger and is fighting hepatitis B. Some doctors try to stop these flare-ups happening by starting treatment for HIV and hepatitis B at the same time. Some anti-HIV drugs can cause abnormal liver function, including ritonavir (Norvir), indinavir (Crixivan), nevirapine (Viracept), AZT (Retrovir) and ddI (Videx) and should be used with caution if you have hepatitis B.

UK treatment guidelines recommend that if you have hepatitis B and HIV, your HIV treatment should include two drugs that are effective against hepatitis B. These are 3TC, tenofovir and FTC. Some doctors think that a combination including 3TC and tenofovir is a very effective treatment for both hepatitis B and HIV.

Because of the risk of developing drug resistance, you should only take anti-HIV drugs that are effective against hepatitis B as part of an HIV treatment regimen. Nor should you take adefovir unless you are taking HIV treatment because of a risk of resistance.  If you are going to take treatment just for hepatitis B (and not for HIV), you should take alpha-interferon.

Hepatitis C is transmitted through blood, and the sharing of injecting equipment is the most common route of hepatitis C transmission in the UK.

Many people also contracted hepatitis C before blood screening procedures and sterilisation were introduced, and 95% of people with haemophilia and HIV in the UK are also co-infected with hepatitis C.

The sexual transmission of hepatitis C is now an issue of concern. It used to be thought that this was very rare. However, there have been recent reports of increasing numbers of gay men testing positive for hepatitis C. Many of these men are HIV-positive and their only risk activity was unprotected anal sex. Sexual activity that carries a risk of contact with blood, such as fisting, seems to have a particular risk of hepatitis C transmission.

Mother-to-baby transmission of hepatitis C is thought to be uncommon, but the risk is increased if the mother is also HIV-positive. A high hepatitis C viral load also increases the risk that a mother will pass on hepatitis C to her baby and, as with HIV, a caesarean delivery reduces the risk.

Very few people experience symptoms when they are first infected with hepatitis C. When they do occur, symptoms include jaundice, diarrhoea and feeling sick. In the longer term, about 50% of people with hepatitis C will experience some symptoms. The most common ones are feeling generally unwell, extreme tiredness, weight loss, depression and intolerance of fatty food and alcohol.

Although a small proportion of people infected with hepatitis C clear the infection naturally, about 85% will go on to develop chronic hepatitis C. About a third of people will develop severe liver disease within 15 to 25 years.

The severity of disease can be affected by the strain of hepatitis C you are infected with. Men, people who drink alcohol, people who are infected with hepatitis C when they are already into middle age, and people with HIV seem to experience faster hepatitis C disease progression.

Hepatitis C can cause liver fibrosis (hardening) and cirrhosis (scarring). This damages the liver to such an extent that it cannot work properly, causing jaundice, internal bleeding and swelling of the abdomen. Chronic infection with hepatitis C can cause liver cancer. Liver cancer is especially likely to happen in people with cirrhosis, particularly if they drink heavily.

There’s also some evidence that smoking can speed up the rate of cirrhosis and increase the risk of liver cancer.

Liver cancer is difficult to treat, and often surgery is the only option. Small tumours can be removed, but there’s a high chance of them recurring. Chemotherapy is not effective against liver cancer.

You should be tested soon after your diagnosis with HIV to see if you are also infected with hepatitis C. Unlike hepatitis B, there is no vaccine against hepatitis C and, if you are in a group at high risk of infection with hepatitis C, it’s recommended that you should have frequent tests to see if you have been infected.

A test is also available to measure hepatitis C viral load (PCR). Unlike the HIV viral-load test, this is not an indicator of when to start treatment. However, it is used to show how effective treatment for hepatitis C is and how long it should continue for.

Liver-function tests can give an indication of the extent to which hepatitis C has damaged your liver. Liver ultrasounds and liver biopsies may also be used.

It seems that people co-infected with HIV and hepatitis C are more likely to develop liver disease than people who are only infected with hepatitis C. However, hepatitis C does not seem to increase your risk of becoming ill due to HIV, developing or dying of AIDS, or responding less well to HIV treatment.

HIV treatment can be used safely and effectively if you are co-infected with HIV and hepatitis C. However, you may be at greater risk of experiencing the liver side-effects which some anti-HIV drugs can cause, and you and your doctor should have this in mind when selecting which anti-HIV drugs to take. It also seems to be the case that people coinfected with HIV and hepatitis C are at greater risk of developing some of the metabolic disorders which anti-HIV drugs can cause (particularly insulin resistance and diabetes).

Drugs are available for the treatment of hepatitis C and you should receive your treatment and care from doctors who are expert in the treatment of both HIV and hepatitis C. This may mean that as well as seeing an HIV doctor, you may also need to see a specialist liver doctor.

Before you start treatment for hepatitis C, it is important to know which strain, or genotype, of hepatitis C you have been infected with, as this can predict your response to treatment and the amount of time you will need to take treatment for. There are several hepatitis C genotypes. Type 1 is most common in the UK, and unfortunately responds least well to the currently available treatments for hepatitis C.

Unlike HIV treatment, treatment for hepatitis C is not lifelong. It consists of 24 or 48 weeks of treatment, and the length of treatment you receive will depend on the hepatitis C genotype you are infected with. A test after twelve weeks of treatment can predict if you are going to respond to treatment.

Drugs are available for the treatment of hepatitis C. These are pegylated interferon and ribavirin. Treatment with a combination of pegylated interferon and ribavirin is the standard treatment, as it produces better results and is recommended by British HIV doctors.

The aim of hepatitis C treatment is to eradicate infection with hepatitis C completely and over 50% of people who are only infected with hepatitis C achieve this. However, the response rate is much lower in people with HIV and varies from 14 to 73% depending on the type of hepatitis C and its viral load.

Other aims of treatment include normalising liver function, reducing liver inflammation and reducing further damage to the liver. If you are ill because of HIV, then the aim of hepatitis C treatment is likely to focus on improving your tolerance of anti-HIV drugs, reducing the risk of death from liver problems and improving your overall quality of life.

Hepatitis C treatment can have unpleasant side-effects, including temperature, joint pain, weight loss, nausea and vomiting and depression. Other side-effects include disturbances in blood chemistry.

According to UK treatment guidelines published in 2008, there is increasing evidence that HIV treatment is important in slowing damage to the liver.  They recommend that all patients with HIV and hepatitis C who have a CD4 count of less than 350 should start HIV treatment - and it should be considered if the CD4 count is between 350 and 500.

However, there are some important interactions between HIV and hepatitis C treatments, so if your CD4 count is over 350, your doctor is likely to recommend that you do not start HIV treatment until your course of hepatitis C treatment is finished.

If you are taking ribavirin you should not take ddI (didanosine, Videx) or d4T (stavudine, Zerit) because of the risk of very serious side-effects, including pancreatitis and lactic acidosis. Nor should ribavirin and AZT (zidovudine, Retrovir) be taken together, because of the risk of anaemia.  The 2008 treatment guidelines also advise that there may be an interaction between abacavir and ribavirin.

The infection that is the greatest risk to your health should be treated first. If you have a good CD4 cell count and are not ill because of HIV, then you should be given the chance to start hepatitis C treatment before starting HIV treatment. However, if your CD4 cell count is low, or is rapidly falling, or you are ill because of HIV, then you should start HIV treatment first.

An increasing number of liver transplants are being performed on people with HIV who are co-infected with hepatitis B or C.

You are most likely to be considered for a liver transplant if HIV hasn’t done too much damage to your immune system, or you have responded well to anti-HIV drugs, and have a good CD4 cell count and a low viral load.

Liver transplants seem to be just as successful in people co-infected with HIV and hepatitis B or C as in people who are just infected with either hepatitis B or C. Studies have found that HIV-positive people are just as likely as HIV-negative transplant recipients to be alive three years after receiving their new liver.

Organ transplant is a very specialist medical skill, and there’s a chance that the hospital where you receive your HIV care may not be a centre with expertise in this area. This could mean that you are referred to another hospital.

If you have a successful liver transplant, you will need to take medication to stop your body rejecting your new liver for the rest of your life. You’ll still have to take your HIV medication as well.