Hepatitis A causes less severe disturbances in liver function in people with HIV but illness lasts longer

Acute hepatitis A is less severe in people with HIV but takes longer to resolve, investigators from Taiwan report in the online edition of Clinical Infectious Diseases. Antiretroviral therapy achieving HIV suppression was associated with a hepatitis A disease course which more closely resembled that observed in HIV-negative individuals.

Peaks in key markers of liver inflammation were lower in HIV-positive people but the infection took longer than 14 days to resolve in 39% of individuals with HIV compared to 21% of HIV-negative people.

“The mechanism for the different disease course of AHA [acute hepatitis A] between HIV-positive and HIV-negative patients remains speculative,” comment the authors. “The liver injury caused by HAV [hepatitis A virus] infection may not be completely associative with HAV itself but, instead, with the host immune response.”

Recently, there have been outbreaks of hepatitis A among men who have sex with men (MSM) and the homeless in cities around the world. Between mid-2015 and late 2017, there was an unprecedented outbreak of the infection in Taiwan. Nearly 1500 infections were documented. Surveillance showed that 70% of cases involved MSM and that more than half of people had HIV infection.

Little is known about the impact of HIV infection on the presentation and disease course of acute hepatitis A. Investigators in Taiwan designed a retrospective study comparing the clinical characteristics and outcomes of hepatitis A between HIV-positive and HIV-negative people.

The study population consisted of 297 people (22% of all cases seen during the outbreak) who received care at 14 hospitals. Data were collected on age, gender, sexual orientation, HIV status and hepatitis A risk factors. All the participants had tests to monitor liver function and also underwent hepatic imaging. In people with HIV, viral load and CD4 cell count were checked. In terms of outcomes, a prolonged course of hepatitis A infection was defined as an elevation in ALT at least five times the upper limit of normal for longer than 14 days after diagnosis of acute hepatitis A.

The participants had a mean age of 31 years and 83% were aged between 21 and 40 years. Most – 94% –  were male and 81% were MSM. Information on HIV infection status was available for 265 people, the majority (63%) being HIV positive.

Common symptoms at the presentation of acute hepatitis A included fatigue and malaise, loss of appetite, jaundice, fever and vomiting. These symptoms did not differ between HIV-positive and HIV-negative people.

People with HIV were more likely than HIV-negative individuals to have an enlarged liver (14% vs 2%, p = 0.005) and an enlarged spleen (34% vs 15%, p = 0.003).

Two-thirds of people were hospitalised and there was one fatality. There was a higher frequency of hospitalisation among HIV-negative than HIV-positive people (83% vs 70%).

Median peak ALT, AST and total bilirubin levels were 1512 iu/l, 866 iu/l and 8.0 mg/dl, respectively. Higher peak ALT and AST were observed in more HIV-negative than HIV-positive people.

However, individuals with HIV were more likely than HIV-negative people to have a prolonged course of hepatitis A (39% vs 21%, p = 0.009). This finding was unchanged when people with hepatitis C infection were excluded.

Data on viral load were available for 140 of the people with HIV, with 94 having viral suppression on antiretroviral therapy (below 1000 copies/ml). Individuals with viral suppression had a significantly higher peak ALT level (1420 vs 978 iu/l, p = 0.006) and were less likely to have a prolonged period of hepatitis A disease (greater than 14 days) (31% vs 49%, p = 0.047) compared to people with higher HIV viral load. There was no evidence that CD4 cell count affected the presentation or course of hepatitis A infection.

“HIV-positive patients with AHA presented with lower levels of aminotransferases but a prolonged course of hepatitis than HIV-negative patients,” conclude the authors. “Use of combination antiretroviral therapy with better HIV viral suppression was beneficial in shortening the disease course of AHA than those with poorer viral suppression.”