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Hepatitis B

Hepatitis B virus (HBV) is an infection that can cause severe liver damage, sometimes resulting in death.

Hepatitis B is very common around the world, particularly in Africa, the Indian sub-continent and throughout the rest of Asia. Around 7% of people with HIV in the UK are also infected with hepatitis B. This is known as co-infection. Hepatitis B is also common among people who inject drugs.

Transmission and prevention

Hepatitis B virus (HBV) and HIV can be transmitted in similar ways, but hepatitis B is more infectious. Both are spread by contact with infected body fluids such as blood, semen and vaginal fluid, or from a mother to her baby during pregnancy or delivery. Blood products in the UK are routinely screened for HBV.

In richer countries such as the UK, hepatitis B has mainly affected gay and bisexual men, and people who inject drugs (due to using contaminated needles). Using a condom reduces the chances of hepatitis B being passed on during sex. Syringes and other injecting drug equipment should never be shared.

It is also possible to acquire hepatitis B through personal care items such as razors, toothbrushes and manicure tools that may come into contact with blood. These items should not be shared. New, sterile needles should be used for piercings, tattooing and acupuncture.

There is no risk of transmission through normal social contact such as sharing crockery or cutlery, or touching someone with hepatitis B. Blood spills from someone with hepatitis B should be cleaned up following sensible infection control procedures (e.g. wearing gloves, and using an appropriate cleaning product for the surface, such as diluted bleach or detergent and warm water). Scratches, cuts and wounds should be cleaned with soap and water and covered with a waterproof dressing or plaster.

In countries where hepatitis B is most common, many people got it through mother-to-child transmission, or in early childhood through household transmission. Increasing numbers of cases are being seen in people who have come to the UK from Africa, Asia and India.

The best protection against acquiring hepatitis B is the HBV vaccine. Infection rates in many countries have fallen dramatically thanks to routine infant hepatitis B vaccination. It is important that people with HIV, hepatitis C or any other liver disease get vaccinated against hepatitis B if they are not already immune.

Stages of infection

There are four stages of hepatitis B infection:

Stage 1 – immune tolerance: During this stage HBV is able to reproduce freely in the body, but does not cause any symptoms or liver damage because the immune system is not responding to the infection. In adults, this stage is very short-lived, if it happens at all. In babies and young children, it can last for several years.

Stage 2 – immune response: During this stage the immune system attacks HBV-infected cells in the liver and starts to clear the infection from the body. In some people, this phase may last for just a few weeks. But if the immune system cannot clear the virus, it can last for years. As the immune system attacks infected cells in the liver, this leads to liver inflammation and liver damage that can worsen over time. Some people with hepatitis B develop symptoms and become unwell at this stage.

Stage 3 – viral clearance: This stage is also known as ‘seroconversion’. The body produces antibodies in response to pieces of the virus known as antigens. During this stage the immune system stops HBV from reproducing. Most adults will naturally clear hepatitis B without treatment.

Stage 4 – immunity to hepatitis B: This is when the immune system produces a full antibody response against hepatitis B and clears the body of the virus. Hepatitis B genetic material (DNA) may remain inside liver cells, however, and on rare occasions it reactivates at a later time, especially if the immune system becomes weakened.

Most adults infected with hepatitis B recover fully and develop lifelong immunity. But up to 10% of people infected with HBV as adults will become chronic carriers of the virus. This means that they can pass HBV on to others and may develop serious, long-term liver damage. Babies and young children who acquire HBV are much more likely to become chronic carriers. People living with HIV are also less likely to clear HBV than HIV-negative people.

Diagnosis and monitoring

All people living with HIV should be screened for hepatitis B. There are a number of tests to determine if you are currently infected with hepatitis B, if you have been infected and if you have managed to clear the infection – which makes you immune to future infection – or if you are immune due to vaccination.

If a test finds HBV fragments called surface antigens (or HBsAg) over a period longer than six months, then you are a chronic carrier of hepatitis B. You can potentially transmit the virus to others and it can damage your liver over time.

People who also test positive for hepatitis B 'e' antigen (or HBeAg) typically have higher rates of HBV replication and are more likely to be infectious. However, some types of hepatitis B do not produce the 'e' antigen. People with HBeAg-positive hepatitis B have higher levels of virus and do not respond as well to treatment as those with HBeAg-negative disease.

If tests show you have two types of antibodies against hepatitis B core and surface antigens (anti-HBc and anti-HBs) but no surface antigen (HBsAg) after six months of infection, this means your immune system has naturally cleared hepatitis B and you are protected against future infection. Having only one type of antibody (anti-HBs) shows that you are protected due to vaccination. If you have no surface antigen and no antibodies against hepatitis B, you can still become infected with hepatitis B virus, so need vaccination.

Another type of test measures hepatitis B viral load (also known as HBV DNA). Detectable viral load means that the virus is actively reproducing in your body.

It is recommended that you have a liver function test when you are first diagnosed with HIV, at each of your routine HIV clinic appointments and if you become ill. These liver function tests measure levels of certain chemicals which give an indication of how well your liver is working. These include two enzymes, known as ALT and AST, which can indicate liver inflammation. These tests are also used to see if antiretroviral drugs are harming the liver. Find out more about tests to monitor liver health in NAM’s booklet, CD4, viral load & other tests.

Other types of tests are also done to see how much the liver is damaged. One test, called elastography or FibroScan, uses vibration waves to determine the degree of liver fibrosis or cirrhosis. In some cases, it may be necessary to perform a liver biopsy. For this test, a tiny sample of liver tissue is removed using a hollow needle inserted into the abdomen and examined under a microscope. Liver biopsies can be uncomfortable, but complications are uncommon. FibroScan and liver biopsies may be used to determine whether a person with hepatitis B needs treatment.

People with chronic hepatitis B – especially if they have advanced fibrosis or cirrhosis – should also be screened every six months for liver cancer (hepatocellular cancer), which is usually done with ultrasound scans.

Symptoms and disease progression

The majority of adults who are infected with hepatitis B have no symptoms, and infection is often only diagnosed by routine blood tests and monitoring the health of the liver. Among people with HIV, routine liver function monitoring sometimes shows elevated liver enzymes. This can be a sign of liver inflammation due to hepatitis B. Even if you have no symptoms, you can still pass on HBV to others.

Some people, however, develop symptoms soon after hepatitis B infection (known as the acute phase). These can include the following:

  • Fatigue (unusual tiredness).
  • Fever (high temperature).
  • Nausea and vomiting.
  • Loss of appetite.
  • Pain in the upper abdomen or belly.
  • Muscle or joint aches.
  • Feeling generally unwell (malaise).
  • Yellowing of the skin and whites of the eyes (jaundice).

A minority of people may develop severe symptoms during acute hepatitis B infection, and in rare cases it can lead to death.

After the acute stage (more than six months after infection), many people with chronic hepatitis B have few or no symptoms. Others may experience ongoing symptoms including fatigue and feeling unwell.

Over years or decades, however, chronic hepatitis B infection can lead to serious liver disease including fibrosis, cirrhosis and liver cancer, as described in the section Fibrosis, cirrhosis and liver cancer.

Hepatitis B and HIV

Between 5 and 10% of people with HIV are also infected with hepatitis B virus (often called co-infection). People with HIV are less likely to naturally clear hepatitis B without treatment. People with HIV and hepatitis co-infection can have faster liver disease progression and may not respond as well to hepatitis B treatment. But having hepatitis B does not seem to make HIV disease worse.

HIV & hepatitis

Published April 2015

Last reviewed April 2015

Next review April 2018

Contact NAM to find out more about the scientific research and information used to produce this booklet.

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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.