Treatment training manual

5. 9 Hepatitis B and C

Type of infection

Hepatitis is a name for any infection that causes liver inflammation or damage.

Three main causes of liver infection are viral hepatitis A (HAV), hepatitis B (HBV) and hepatitis C (HCV). These are different viruses with different treatments.

This section mainly deals with HBV and HCV.

HBV is acquired sexually including through saliva.

HCV is acquired by blood contact through infected needles or during sex. Sexual transmission is generally a low risk for heterosexual sex. Sexual transmisson is a higher risk for HIV positive gay men.

HBV an HCV are considered coinfections rather than OIs.

Main symptoms

Some symptoms of acute (early) or active liver infection are similar for any viral liver infection.

These symptoms include nausea, vomiting, fatigue, diarrhoea, jaundice (yellow eyes or skin).

Not everyone will get symptoms or even know they are infected. Intolerance to fatty foods or alcohol, a swollen or tender liver or ‘liver spots’ on the skin are other symptoms of hepatitis.


HBV can be transmitted by sexual exposure including oral sex and sharing injecting drug equipment. HBV is more infectious than HIV.

Up to 90% of people living with HIV have already been exposed to HBV. Most people clear HBV without treatment.

HIV seems to make HBV a more serious illness. Some common HIV drugs also treat HBV and this can complicate treatment for HIV/HBV coinfection.


Blood tests for HBV can test for either previous exposure or active infection.

The symptoms listed above should prompt a doctor to test for HBV.

Viral load (PCR) tests for hepatitis are used similar to HIV viral load tests. These tests can confirm an infection when immune-based tests are either negative or unclear.

  • Previous exposure to HBV is shown by testing positive for HBV core antibodies (HBcAb+) or HBV surface antibodies (HBsAb+).
  • Chronic carriers: 2–10% of people exposed to HBV become chronic carriers and remain infectious. This isshown by a testing positive for HBV surface antigen (HBsAg+).

If HBV is cleared, you are usually immune to reinfection in the future.


HIV and HBV coinfection needs care from a doctor with experience of both infections.

Several drugs used to treat HIV also are active against HBV.

These drugs include 3TC, FTCtenofovir DF and TAF.

HBV monoinfection is also treated with adefovir, a drug developed for HIV, but now used just for HBV.

All these drugs have to be used very carefully in someone with both HIV and HVB infections.

  • 3TC, tenofovir and FTC should only be used in people living with HIV in a three-drug ART combination. This is to protect against HIV resistance.
  • Adefovir can be used as single treatment if ARV treatment is not needed.
  • Resistance to HIV and HBV treatment are different and occur independently.
  • Never stop active HBV drugs. There is a serious risk of HBV reactivation, and severe or fatal liver toxicity, if the drugs active against HBV are stopped in someone who has not cleared the infection.

Interferon was an early injected treatment for HBV. This is now used less often because tablets are easier to tolerate.

HBV can be successfully treated in many people. Sometimes life-long treatment is needed. Long-term HBV coinfection is a specialist area of disease management.

If HBV is cleared, you are usually immune to reinfection.


Effective vaccinations are available for hepatitis A and hepatitis B.

Response to vaccines are related to CD4 count. Depending on the vaccine and CD4 count, higher doses in HIV positive patients are sometimes recommended. (See BHIVA 2015 guidelines on vaccination).

There is no vaccination against hepatitis C.


Research into new drugs to treat hepatitis B is ongoing.

Some of these drugs will be available in the next few years. The aim for new HBV drugs is to produce a higher rate of cures.


Direct acting antivirals (DAAs) are highly effective oral drugs to treat HCV.

DAAs work just as well for people living with HIV, and annual HCV testing is now recommended. Although DAAs can have a high cure rate you can still be reinfected again in the future.

The choice of DAAs with depend on country you live in and how much HCV has damaged your liver.

However, in many countries, HCV is still diagnosed late, often after years of infection.

  • If not diagnosed and treated early, HCV can take 20-25 years in HIV negative people to progress to liver damage (scarring and liver cancer). Chronic (long-term) HCV is also associated with mental difficulties and depression.
  • If not treatment, coinfection with HIV seems to approximately double the speed of HCV progression (ie taking from 10–15 years).
  • Continued high use of alcohol is a major risk factor for faster HCV progression.
  • Up to 20% of people living with HIV can clear HCV in the first months after infection, without needing HCV treatment.


Blood tests can screen for either previous exposure to HCV or active infection.

Many people clear the virus without knowing they were infected, and produced antibodies. The symptoms listed above should prompt a doctor to test for HCV.

Viral load (PCR) tests used for hepatitis are similar to HIV viral load tests, and can confirm an infection when immune-based tests are either negative or unclear.

If you are diagnosed with HCV, then you might have an HCV genotype test to find out which type of HCV you have (genotype 1, 2, 3, 4, 5 or 6). This is not needed if you are being treated with DAAs that cover all genotypes.


HIV and hepatitis C coinfection needs to involve a doctor with experience of both infections.

DAAs are highly effective with a short course of treatment and have few side effects. However, these drugs are also expensive in most countries.

Older treatment with PEG interferon plus ribavirin or early HCV protease inhibitors should no longer be used.


There is no vaccination against hepatitis C.

Effective vaccinations are available for hepatitis A and hepatitis B.


New HCV drugs are still being developed in different settings.

Other areas of research include:

  • Risks from low levels of alcohol use.
  • Use of non-invasive test to monitor liver damage instead of needle biopsies.
  • Duration of treatment needed with different HCV genotypes.
  • How to treat the small percentage of people who do not respond to first-line DAAs.
  • Earlier access to experimental HCV drugs for people coinfected with HIV.

Further reading

EACS guidelines (2022) – Section IV hepatitis coinfection,

Recently acquired and early chronic hepatitis C in MSM: Recommendations from the European treatment network for HIV, hepatitis and global infectious diseases consensus panel. AIDS. 2020 Oct 1;34(12):1699-1711. doi: 10.1097/QAD.0000000000002622. Erratum in: AIDS. 2020 Nov 15;34(14):2161-2163.

TAG pipeline report includes a chapter on HCV and ongoing research.

Last updated: 1 January 2023.