Factsheet Hepatitis B

Greta Hughson, Published March 2016

Key points

  • The majority of people with hepatitis B do not have any symptoms.
  • It is recommended that people living with HIV are tested and vaccinated for hepatitis B.
  • Most people who have hepatitis B will clear the infection without treatment.

Hepatitis B is a virus that can cause serious damage to the liver. Hepatitis B is usually transmitted through contact with blood, semen, vaginal fluids, saliva or from mother to baby before or during birth.

In the UK, it occurs predominantly among gay and bisexual men, people who share drug-injecting equipment and healthcare workers. The virus is many times more infectious than HIV.

There is an effective vaccine against hepatitis B which is recommended for anyone in these groups. The vaccine is safe for people with HIV.

Like everyone else living with HIV, people with HIV and hepatitis B co-infection are recommended to take HIV treatment.

People with co-infection may particularly benefit from antiretroviral treatment because undetectable HIV viral load and restored immune function are linked to slower liver disease progression. BHIVA guidelines recommend that you start HIV treatment with a combination containing tenofovir and lamivudine or emtricitabine. These drugs are active against both HIV and hepatitis B.

The word hepatitis means inflammation of the liver, and it can be caused by drugs and other diseases, as well as viruses. Regardless of its cause, hepatitis or liver disease can have an impact on treatment choices for people with HIV, and it can require more health monitoring.


Most people do not notice any symptoms when they first become infected with hepatitis B, or they experience some symptoms but confuse them with symptoms of flu. However, some people have more severe symptoms, including jaundice (yellowing of the eyes and skin), loss of appetite, pain in the abdomen, malaise, nausea, vomiting, muscle and joint aches or fever.

The majority of people who are infected with hepatitis B will clear the infection without treatment. At this point, most people will develop protective immunity, which means they will still have antibodies to the virus and are protected from future infection with hepatitis B. However, in a significant minority, hepatitis B continues to reproduce in the body long after infection. Around 5% of adults may become chronic carriers of hepatitis B, meaning that they are infectious for life, although they may not experience any symptoms themselves. About a quarter of chronic hepatitis B carriers eventually develop chronic liver inflammation and are at increased risk of liver disease (cirrhosis) or cancer of the liver. People living with HIV who develop hepatitis B are at higher risk of becoming chronic carriers of hepatitis B (around one-third).

"If you have hepatitis B, or other liver problems, alcohol should be avoided."

The liver damage experienced by some people with hepatitis B is caused not by the virus itself, but by the immune system’s destruction of hepatitis B-infected cells in the liver. Because the immune responses of people with HIV are often impaired, people with HIV who have chronic hepatitis B infection may actually be less likely to experience liver damage than people with fully functioning immune systems.

Levels of hepatitis B in the body fluids of people who also have HIV may be higher than those seen in HIV-negative people because less hepatitis B is cleared from the body by the immune system, so people living with HIV who are carriers of hepatitis B may be more infectious than their HIV-negative counterparts.

Diagnosis and treatment

British HIV Association (BHIVA) guidelines recommend hepatitis B testing for people who are newly diagnosed with HIV and anyone who does not have immunity should be vaccinated against hepatitis B.

Blood tests can detect the presence of hepatitis B antibodies, which show that you have been exposed to, and have cleared the virus. If you have been exposed and have not developed this protective immunity, then fragments of the virus itself, called hepatitis B surface antigen (HBsAg), will persist in your blood for at least six months. This means that you are a chronic carrier and could pass the virus on to other people. A sub-group of carriers also test e-antigen positive and this means that their hepatitis infection is highly infectious to others.

Chronic hepatitis B infection is usually treated with alpha interferon in injections of 3-5 million units three times per week. The anti-HIV drugs 3TC (lamivudine), FTC (emtricitabine, Emtriva) and tenofovir (Viread; tenofovir and FTC are also available in the combination pills Truvada, Eviplera and Atripla) are also active against hepatitis B.

Entecavir and adefovir are anti-hepatitis B drugs, but because they also have some anti-HIV activity, they must not be taken unless a person is also taking effective HIV therapy. If you take entecavir or adefovir and have a detectable HIV viral load, you could be at risk of developing drug-resistant HIV.

The BHIVA guidelines recommend that if you have hepatitis B, you should start HIV treatment when your CD4 cell count falls below 500 cells/mm3. If you need to start treatment for hepatitis B, then you should also start HIV treatment, even if your CD4 cell count is above 500. Where possible, you should start an HIV treatment combination that includes tenofovir and FTC, because of their anti-hepatitis B action.

It's important to note that alcohol is processed by the liver and drinking alcohol can make liver damage worse. If you have hepatitis B, or other liver problems, alcohol should be avoided.

This factsheet is due for review in March 2019

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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.
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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.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.