Non-HIV-related illnesses – hepatitis

‘Hepatitis’ means inflammation of the liver.

The liver is the largest internal organ in your body. It is located at the upper right-hand side of the abdomen. Having a healthy liver is important for everybody, but it is especially important for people with HIV. The liver plays a vital part in processing medicines used to treat HIV and other conditions. Viral infections that affect the liver, such as hepatitis A, hepatitis B and hepatitis C, can make you ill and also mean that the liver is unable to process medicines properly.

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. However, it is also possible to recover from these conditions spontaneously, and for them to be treated.

Hepatitis B

Hepatitis B virus (often known as HBV) is 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.

It is possible to clear HBV without treatment, through the response of the immune system. If this does not happen (which is the case for about 10% of people), the infection can remain for many years and become ‘chronic’. People with HIV are more likely to develop chronic hepatitis B. HBV 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. However, you may not have any symptoms at all for many years. During this time, it is still possible to pass HBV on to others. Using condoms correctly, every time you have sex, can protect against hepatitis B if you have a detectable HBV viral load. HBV can also be passed on through saliva, unlike HIV.

You should be tested soon after your HIV diagnosis for hepatitis B, to see if you have been infected with the virus. If you have had a previous infection, and have recovered from it, you will then be immune to HBV.

 A vaccine is available to protect you against hepatitis B. If you don’t have the virus, and a test shows that you do not have natural immunity against it, it is recommended you are vaccinated against it.

It is now recommended that all people with HIV, who have never had HBV, should have an annual test to check their immunity levels and be offered a booster vaccine if their immunity level has dropped below protective levels since their last vaccine.

Your regular HIV monitoring involves checking the health of your liver. If you are co-infected with hepatitis B, this becomes even more important. Your healthcare team 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. These include antiviral drugs such as  adefovir (Hepsera) and interferon alpha. Some  anti-HIV drugs also work against hepatitis B. These are 3TC (lamivudine, known as Zeffix when used to treat hepatitis B and Epivir when used to treat HIV), tenofovir (Viread) and FTC (emtricitabine, Emtriva). Tenofovir and FTC are available in a combined pill called Truvada.

There is conflicting evidence about the impact of hepatitis B on the progression of HIV disease. 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.

UK treatment guidelines recommend that if you have hepatitis B and HIV, your HIV treatment should include two drugs that are also effective against hepatitis B. These are 3TC, tenofovir and FTC. A combination including 3TC/FTC 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 interferon alpha. Which drugs you are treated with will depend on your CD4 cell count and whether you already need HIV treatment. People with hepatitis B are recommended to start HIV treatment when their CD$ cell count reaches 500, or if you also need to start treatment for hepatitis B.

Hepatitis C

Hepatitis C is usually transmitted through blood-to-blood contact. Sharing injecting equipment is the most common route of hepatitis C transmission in the UK. Needles, syringes and other equipment used to inject drugs, and equipment used to sniff drugs such as straws or banknotes, should never be shared.

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 appears to be unprotected anal sex. Sexual activity that carries a risk of contact with blood, such as rougher anal sex, use of sex toys and fisting, seems to have a particular risk of hepatitis C transmission. Group sex, especially in the context of drug use, is also an important risk factor. Using condoms correctly, every time you have sex, not sharing sex toys or washing them between use, and not sharing pots of lubricant can reduce the risk.

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 increases the risk that a mother will pass on hepatitis C to her baby and, as with HIV, a caesarean delivery reduces the risk.

It’s best not to share razors, hair and nail clippers, nail scissors or toothbrushes if you have hepatitis C.

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 (hepatocellular carcinoma, or HCC). HCC 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.

Surgery is the most effective form of treatment for liver cancer, but  other options include chemotherapy and treatment with drugs.

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. If you are in a group at high risk of infection with hepatitis C, it’s recommended that you have regular tests to see if you have been infected.

A test is available to measure hepatitis C viral load. 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 any hepatitis C is being and how long it should continue.

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

People co-infected with HIV and hepatitis C are more likely to develop liver damage than people who are only infected with hepatitis C. However, hepatitis C does not increase your risk of becoming ill due to HIV 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. HIV treatment that suppresses viral load and increases your CD4 cell count can slow the rate of HCV-related liver damage. 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 co-infected 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 also need to see a specialist liver doctor.

If you have both HIV and hepatitis C, you should be assessed to see if you would benefit from starting hepatitis C treatment.

If you and your doctor decide that you will start hepatitis C treatment now, and your CD4 cell count is between 350 and 500, you should start hepatitis C treatment first, then start HIV treatment.

If your CD4 cell count is between 350 and 500 and you don’t yet need treatment for hepatitis C, you should start HIV treatment.

If your CD4 cell count is under 350, you should start HIV treatment before starting hepatitis C treatment.

A number of anti-HIV drugs have interactions with drugs used to treat hepatitis C. The choice of anti-HIV drugs you take will need to be made with these possible interactions in mind.

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. Genotype 4 is also harder to treat. People with genotypes 2 or 3 respond better to treatment. However, there are new HCV drugs available, and more in development, which should improve the chances of a cure for people with harder-to-treat genotypes.

Factors such as your age, gender, how long you have had hepatitis C, the degree of liver damage and whether cirrhosis has developed are also important in predicting if treatment is likely to be effective.

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. The backbone of treatment consists is pegylated interferon and ribavirin. These are taken in combination with an anti-HCV protease inhibitor. This sort of triple combination has been found to be much more effective than dual therapy with pegylated interferon and ribavirin alone.

The aim of hepatitis C treatment is to eradicate infection with hepatitis C completely.

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 a high temperature, joint pain, weight loss, nausea and vomiting and depression. Other side-effects include disturbances in blood chemistry.

Liver transplants

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 hepatitis B or C..

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.

Hepatitis A

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 (poo), diarrhoea, nausea (feeling sick) and vomiting (being sick). 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. Anyone who has HIV is recommended to have this vaccine unless they are naturally immune to the infection (a test before vaccination can show this).

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.