Coinfection with hepatitis B virus or/and hepatitis C virus is increasingly becoming a cause of illness in people with HIV. Both these viruses affect the liver, can make you very ill and can be fatal.

Hepatitis B

Hepatitis B virus (often known as HBV) is an infection that can cause severe or even fatal damage to the liver. Long-term infection with hepatitis B can cause liver cancer, and rates of liver cancer in people with HIV are elevated because of hepatitis B and hepatitis C. Hepatitis B is quite common in some of the communities affected by HIV in the UK, as it can be contracted in the same ways as HIV, particularly through contact with blood, semen or vaginal fluid, and from mother to baby.

You should be tested soon after your diagnosis for hepatitis B, to see if you have been infected with the virus and are a carrier. A vaccine is available to protect you against hepatitis B. If you are uninfected, and a test shows that you do not have natural immunity against it, you should be vaccinated.

If you are coinfected with hepatitis B, doctors will regularly monitor your liver function using blood tests. Ultrasound examinations may also be performed, particularly if your liver shows signs of damage.

Treatments are available for hepatitis B, and three drugs have been licensed. These are alpha-interferon, adefovir (Hepsera), and the anti-HIV drug 3TC (lamivudine).  Tenfovir (Viread) and FTC (emtricitabine, Emtriva) are also effective against hepatitis B, but have not yet been formally licensed for the treatment of HIV/hepatitis B coinfection (although approval for tenofovir is being sought). Tenfovir and FTC are available in a combined pill called Truvada.

Having hepatitis B is not thought to make HIV progress faster. Anti-HIV drugs can be used safely and effectively in people with hepatitis B. However, when some people start anti-HIV treatment, they experience a short-term flare-up of hepatitis B. This is because the immune system is getting stronger and is fighting hepatitis B. Some doctors try to stop these flare-ups happening by starting treatment for HIV and hepatitis B at the same time. Some anti-HIV drugs can cause abnormal liver function, including ritonavir (Norvir), indinavir (Crixivan), nevirapine (Viracept), AZT (Retrovir) and ddI (Videx) and should be used with caution if you have hepatitis B.

British treatment guidelines recommend that if you have hepatitis B and HIV, your anti-HIV treatment should include two drugs that are effective against hepatitis B. These are 3TC, tenofovir and FTC. Some doctors think that a combination including 3TC and tenofovir is a very effective treatment for both hepatitis B and HIV.

Because of the risk of developing drug resistance, you should only take anti-HIV drugs that are effective against hepatitis B as part of an anti-HIV treatment regimen. Nor should you take adefovir unless you are taking anti-HIV treatment because of a risk of resistance.  If you are going to take treatment just for hepatitis B (and not for HIV), you should take alpha interferon.

Hepatitis C

Hepatitis C is transmitted through blood, and the sharing of injecting equipment is the most common route of hepatitis C transmission in the UK.

Many people also contracted hepatitis C before blood screening procedures and sterilisation were introduced, and 95% of people with haemophilia and HIV in the UK are also coinfected with hepatitis C.

The sexual transmission of hepatitis C is now an issue of concern. It used to be thought that this was very rare. However, there have been recent reports of increasing numbers of gay men testing positive for hepatitis C. Many of these men are HIV-positive and their only risk activity was unprotected anal sex. Sexual activity that carries a risk of contact with blood, such as fisting, seems to have a particular risk of hepatitis C transmission.

Mother-to-baby transmission of hepatitis C is thought to be uncommon, but the risk is increased if the mother is also HIV-positive. A high hepatitis C viral load also increases the risk that a mother will pass on hepatitis C to her baby, and, as with HIV, a caesarean delivery reduces the risk.

Very few people experience symptoms when they are first infected with hepatitis C. When they do occur, symptoms include jaundice, diarrhoea, and feeling sick. In the longer term, about 50% of people with hepatitis C will experience some symptoms. The most common ones are feeling generally unwell, extreme tiredness, weight loss, depression, and intolerance of fatty food and alcohol.

Although a small proportion of people infected with hepatitis C clear the infection naturally, about 85% will go on to develop chronic hepatitis C. About a third of people will develop severe liver disease within 15 to 25 years.

The severity of disease can be affected by the strain of hepatitis C you are infected with. Men, people who drink alcohol, people who are infected with hepatitis C when they are already into middle age, and people with HIV seem to experience faster hepatitis C disease progression.

Hepatitis C can cause liver fibrosis (hardening) and cirrhosis (scarring). This damages the liver to such an extent that it cannot work properly, causing jaundice, internal bleeding, and swelling of the abdomen. Chronic infection with hepatitis C can cause liver cancer. Liver cancer is especially likely to happen in people with cirrhosis, particularly if they drink heavily.

There’s also some evidence that smoking can speed up the rate of cirrhosis and increase the risk of liver cancer.

Liver cancer is difficult to treat, and often surgery is the only option. Small tumours can be removed, but there’s a high chance of them recurring. Chemotherapy is not effective against liver cancer.

You should be tested soon after your diagnosis with HIV to see if you are also infected with hepatitis C. Unlike hepatitis B, there is no vaccine against hepatitis C, and if you are in a group at high risk of infection with hepatitis C, it’s recommended that you should have frequent tests to see if you have been infected.

A test is also available to measure hepatitis C viral load (PCR). Unlike the HIV viral load test, this is not an indicator of when to start treatment. However, it is used to show how effective treatment for hepatitis C is and how long it should continue for.

Liver function tests can give an indication of the extent to which hepatitis C has damaged your liver. Liver ultrasounds and liver biopsies may also be used.

It seems that people coinfected with HIV and hepatitis C are more likely to develop liver disease than people who are only infected with hepatitis C. However, hepatitis C does not seem to increase your risk of becoming ill due to HIV, developing or dying of AIDS, or responding less well to anti-HIV treatment.

Anti-HIV treatment can be used safely and effectively if you are coinfected with HIV and hepatitis C. However, you may be at greater risk of experiencing the liver side-effects which some anti-HIV drugs can cause, and you and your doctor should have this in mind when selecting which anti-HIV drugs to take. It also seems to be the case that people coinfected with HIV and hepatitis C are at greater risk of developing some of the metabolic disorders which anti-HIV drugs can cause (particularly insulin resistance and diabetes).

Drugs are available for the treatment of hepatitis C and you should receive your treatment and care from doctors who are expert in the treatment of both HIV and hepatitis C. This may mean that as well as seeing an HIV doctor, you may also need to see a specialist liver doctor.

Before you start treatment for hepatitis C, it is important to know which strain, or genotype, of hepatitis C you have been infected with, as this can predict your response to treatment and the amount of time you will need to take treatment for. There are several hepatitis C genotypes. Type 1 is most common in the UK, and unfortunately responds least well to the currently available treatments for hepatitis C.

Unlike anti-HIV treatment, treatment for hepatitis C is not lifelong. It consists of 24 or 48 weeks of treatment, and the length of treatment you receive will depend on the hepatitis C genotype you are infected with. A test after twelve weeks of treatment can predict if you are going to respond to treatment.

Drugs are available for the treatment of hepatitis C. These are pegylated interferon and ribavirin. Treatment with a combination of pegylated interferon and ribavirin is the standard treatment, as it produces better results and is recommended by British HIV doctors.

If you have a CD4 cell count above 200, then the aim of hepatitis C treatment is to eradicate infection with hepatitis C completely. Although over 50% of people who are only infected with hepatitis C achieve this, the response rate is much lower in people with HIV. But some London HIV treatment centres have recently seen some very good treatment responses in people with HIV and hepatitis C. The chance of a good treatment response seems to be increased if treatment is started soon after a person is infected with hepatitis C.

Other aims of treatment include normalising liver function, reducing liver inflammation and reducing further damage to the liver. If you are ill because of HIV, then the aim of hepatitis C treatment is likely to focus on improving your tolerance of anti-HIV drugs, reducing the risk of death from liver problems and improving your overall quality of life.

Hepatitis C treatment can have unpleasant side-effects, including temperature, joint pain, weight loss, nausea and vomiting and depression. Other side-effects include disturbances in blood chemistry.

If you are taking ribavirin you should not take ddI (didanosine, Videx), or d4T (stavudine, Zerit) because of the risk of very serious side-effects, including pancreatitis and lactic acidosis. Nor should ribavirin and AZT (zidovudine, Retrovir) be taken together, because of the risk of anaemia.

The infection which is the greatest risk to your health should be treated first. If you have a good CD4 cell count and are not ill because of HIV, then you should be given the chance to start hepatitis C treatment before starting HIV drugs. However, if your CD4 cell count is below 200, or is rapidly falling, or you are ill because of HIV, then you should start HIV treatment first.

Liver transplants

An increasing number of liver transplants are being performed on people with HIV who are coinfected with hepatitis B or C.

You are most likely to be considered for a liver transplant if HIV hasn’t done too much damage to your immune system, or you have responded well to anti-HIV drugs, and have a good CD4 cell count and a low viral load.

Liver transplants seem to be just as successful in people coinfected with HIV and hepatitis B or C as in people who are just infected with either hepatitis B or C. Studies have found that HIV-positive people are just as likely as HIV-negative transplant recipients to be alive three years after receiving their new liver.

Organ transplant is a very specialist medical skill, and there’s a chance that the hospital where you receive your HIV care may not be a centre with expertise in this area. This could mean that you are referred to another hospital.

If you have a successful liver transplant, you will need to take medication to stop your body rejecting your new liver for the rest of your life. You’ll still have to take your anti-HIV medication as well.