Advanced liver disease in people with HIV

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Key points

  • Chronic hepatitis B or C can cause advanced fibrosis, cirrhosis or liver cancer.
  • In cases of advanced disease, you may need to consider a liver transplant.

Over years or decades, chronic hepatitis B or C can cause serious liver disease including advanced fibrosis, cirrhosis and liver cancer. As scar tissue or tumours replace normal cells, liver function declines and blood flow through the liver is blocked. When the liver becomes unable to carry out its crucial functions this is known as decompensated liver disease.

People with advanced liver damage may not be able to process HIV medications or other drugs properly, and they therefore may need dose adjustments or a change in their drug combination. Overall, however, people living with HIV who have serious liver disease appear to do better when taking antiretroviral treatment.

Liver damage can lead to a wide range of health problems including internal bleeding in the stomach and oesophagus, swelling of the abdomen (ascites), poor blood clotting, brain impairment (hepatic encephalopathy) and increased susceptibility to infections. Some of these are due to the build-up of toxins that the liver can no longer filter out of the blood.

Liver cancer, or hepatocellular carcinoma, is commonly diagnosed late and is difficult to treat. Small tumours can sometimes be surgically removed. Other treatments include localised or whole-body chemotherapy, radiation and burning or freezing tumours. These methods can relieve symptoms and sometimes improve survival, but they usually do not cure liver cancer.

Because these treatments work best if liver cancer is diagnosed early, people at risk should be screened regularly. Current guidelines recommend ultrasound scans every six months for anyone with hepatitis B and for people with hepatitis C who have cirrhosis.

Various medications and procedures are used to manage symptoms of advanced liver disease, but mostly these do not improve the long-term health of the liver. Successful treatment of hepatitis B or C can stop liver disease from worsening and the liver may be able to partially heal itself. But advanced liver damage is often permanent, which is why it is important to start hepatitis treatment early, before it occurs.

Liver transplants

If your liver becomes so damaged that it cannot repair itself and is likely to fail completely, you may need to consider a liver transplant.

Transplants may use a donated liver from a person who has died or a piece of liver from a living donor, since liver tissue can regenerate itself. Unfortunately, donated livers are in short supply and most people who need a transplant will have to spend time on a waiting list.

Liver allocation is based on a scoring system. Donated livers go first to people who need them most but are not yet so sick that they are unlikely to benefit. Liver disease can progress rapidly in people living with HIV, so people with signs of decompensated cirrhosis or liver cancer should be referred to a transplant centre early.

The hepatitis B vaccine and a hepatitis B virus antibody preparation (HBV immunoglobulin or HBIG) can prevent the new liver graft from becoming infected with hepatitis B.

Hepatitis B almost always infects the new liver soon after a transplant. Curing hepatitis C before the transplant will prevent this from happening, and successful treatment can sometimes improve liver function enough that a person no longer needs a transplant. But people with severe decompensated liver disease may have trouble tolerating treatment and have a lower likelihood of being cured.



An essential organ involved in digestion of food and excretion of waste products from the body.


A collection of related diseases that can start almost anywhere in the body. In all types of cancer, some of the body’s cells divide without stopping (contrary to their normal replication process), become abnormal and spread into surrounding tissues. Many cancers form solid tumours (masses of tissue), whereas blood cancers such as leukaemia do not. Cancerous tumours are malignant, which means they can spread into, or invade, nearby tissues. In some individuals, cancer cells may spread to other parts of the body (a process known as metastasis).


Severe fibrosis, or scarring of organs. The structure of the organs is altered, and their function diminished. The term cirrhosis is often used in relation to the liver. 

hepatitis C virus (HCV)

The hepatitis C virus can be spread through sharing contaminated needles, syringes and other equipment to inject drugs, sharing straws to snort drugs, needlestick injuries, and during childbirth. Sexual transmission does occur, primarily between gay men. Hepatitis C can range from a mild illness lasting a few weeks to a serious, lifelong illness. Untreated chronic hepatitis C can cause serious liver damage, cirrhosis, liver cancer, and even death. While there is no vaccine, treatments are available to clear the virus from the body, leading to its cure.

chronic infection

When somebody has had an infection for at least six months. See also ‘acute infection’.

Alternatively, direct-acting antiviral (DAA) treatment can be started after a transplant. Most transplant recipients can be cured with available regimens. However, some DAAs have not been well studied in this population and some of them can interact with immune-suppressing drugs used to prevent organ rejection.

Studies have found that people with well-controlled HIV can do as well after a liver transplant as HIV-negative people, although those with hepatitis C co-infection do somewhat less well.

After a successful liver transplant, you will need to take immune-suppressing medication for the rest of your life to stop your body from rejecting the new liver. You will still have to take HIV treatment as well, and it is important to avoid or manage interactions with antiretrovirals.

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