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 hepatitis A (HAV), hepatitis B (HBV) and hepatitis C (HCV) virus. These are different viruses with different treatment.

This section mainly deals with HBV and HCV.

HBV is acquired sexually including through saliva.

HCV is acquired by blood contact through infected needles. 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 of the symptoms of acute (early) or active liver infection are similar for any viral infection to the liver. 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

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 HIV positive people have already been exposed to HBV. Most people have cleared HBV without treatment.

HIV seems to makes HBV a more serious illness. Some common HIV drugs also work against HBV and complicate the of managment of HIV/HBV coinfection.

Diagnosis

Blood tests can screen for either previous exposure to viral hepatitis 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+).
  • 2-10% of people exposed to HBV become chronic carriers and remain infectious, shown by a testing positive for HBV surface antigen (HBsAg+).

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

Treatment

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 HIV positive people in a 3 drug ARV combination because of the risk of 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.
  • 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.

Prophylaxis

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

There is research into new drugs to treat hepatitis B is ongoing. Some of these drugs will be available in the next 5-10 years.

HCV

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.

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 HIV positive people clear HCV in the first months after infection, without needing HCV treatment.

However, new oral direct acting antivrials (DAAs) to treat HCV are highly effective irrespective of HIV status. But if HCV is cleared, you are not immune and can catch it again.

Diagnosis

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 immunological tests are either negative or unclear.

If you are diagnosed with HCV, then you need to have an HCV genotype test to find out which type of HCV you have (genotype 1, 2, 3, 4, 5 or 6).

Treatment

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

Treatment is dependant on HCV genotype and on local guidelines. DAAs are highly effective with a short course of treatment and have few side effects. However, these drugs are also very expensive in most countries.

Older and more difficult treatment with PEG interferon plus ribavirin is still often used or recommended.

Prophylaxis

Effective vaccinations are available for hepatitis A and hepatitis B. There is no vaccination against hepatitis C.

Research

Extensive research into new HCV drugs that work in other ways and which have less side effects than interferon, including oral drugs. Some of these will be available in the next 5-10 years.

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.
  • Earlier access to experimental HCV drugs for people coinfected with HIV.

Further reading

The 2015 i-Base/TAG pipeline report includes a chapter on antiretrovirals that includes a review of new drugs for hepatitis C including a review of boceprevir and telaprevir.

Last updated: 1 January 2016.