The Impact of HIV-Hepatitis Co-Infection

May is Hepatitis Awareness Month, an observance intended to remind us of the high, under-recognized hepatitis-associated disease burden in this country and of the often neglected opportunities for prevention and care. An estimated 3.5-5.3 million Americans have chronic viral hepatitis, which is a leading cause of primary liver cancer. People living with HIV are disproportionately affected by viral hepatitis and the related adverse health outcomes. Of those infected with HIV, more than 25% are coinfected with Hepatitis C and an estimated 10% with Hepatitis B. While highly active antiretroviral therapy has extended the life expectancy of HIV-infected persons, liver disease–much of which is related to Hepatitis C–has become the most common non-AIDS-related cause of death of among this population.

HIV, Hepatitis B, and Hepatitis C share common modes of transmission. People living with HIV who are also living with viral hepatitis are at increased risk for serious, life threatening complications. As a result, all persons living with HIV should be tested for Hepatitis B and Hepatitis C by their doctors. Co-infection with hepatitis may also complicate the management of HIV infection.

In order to prevent co-infection with Hepatitis B, the Advisory Committee on Immunization Practices recommends universal Hepatitis B vaccination of susceptible patients with HIV/AIDS. Hepatitis A and Hepatitis B vaccines are also recommended for all men who have sex with men, users of illicit drugs, and others at increased risk of infection. There is no vaccine for Hepatitis C.

In 2010, an interagency work group of U.S. Department of Health and Human Services (HHS) experts was created to develop a comprehensive strategic action plan to respond to the viral-hepatitis-associated disease burden. The HHS Action Plan for the Prevention, Care and Treatment of Viral Hepatitis describes opportunities to improve coordination of viral hepatitis prevention activities across HHS, and the framework needed to engage other agencies and nongovernmental organizations in prevention and care. Various strategies throughout the plan outline methods of integration of HIV and viral hepatitis in education, prevention and services. The HHS Action Plan was released last week on May 12.

WHAT IS HEPATITIS:

Hepatitis literally means “inflammation of the liver,” and it is technically a symptom, not a disease, but certain viral infections are commonly called hepatitis because liver inflammation is their main effect. Hepatitis can either occur as an acute attack or a chronic problem, depending on the type of hepatitis. There are many different types of hepatitis, with hepatitis caused by a virus being the most common type. The CDC estimates that over 4.5 million Americans suffer from chronic viral hepatitis.

Symptoms of hepatitis range in severity depending on the cause of the hepatitis, the age of the patient and other factors. In general, symptoms of liver inflammation can include abdominal pain, a yellowing of the eyes and skin called jaundice, fever, fatigue, appetite suppression, discolored stools and dark urine.

Hepatitis A is a type of viral hepatitis that causes an acute episode of liver inflammation. The hepatitis A virus is spread through the feces of infected persons. The symptoms are not usually severe, and they can last from a few weeks to a few months. Symptoms of hepatitis A are more severe in adults than in children. There is a vaccination for hepatitis A, and it is usually given to children when they around 12 months old.

Hepatitis B is a type of viral hepatitis that can cause chronic liver inflammation. Hepatitis B is spread through blood and other bodily fluids. Not all cases of hepatitis B infection cause symptoms. Serious long-term liver consequences of infection can occur, but this is relatively uncommon with hepatitis B. A series of hepatitis B vaccinations are given to infants to prevent them from contracting the disease.

Hepatitis C is another type of chronic hepatitis infection. Unlike hepatitis A and B, there is no vaccine available for hepatitis C so prevention is more of a concern. Hepatitis C is transmitted through the blood. Transmission through sexual contact is possible, but not actually common. Prevention of hepatitis C transmission includes safe sex practices, avoiding sharing needles, avoiding getting piercings or tattoos in an uncertified place, and avoiding contact with bodily fluids.

Hepatitis D is an additional virus that co-infects people who already have hepatitis B. This additional infection makes the liver inflammation worse, causing more severe symptoms and increasing the risk of liver failure and liver cancer.

Hepatitis E is another hepatitis virus that causes acute liver inflammation, like hepatitis A. It is also transmitted through fecal matter. Hepatitis E is fairly rare in the United States, but is more common in some other countries.

Very rarely, a bacterial infection or a parasite infection can cause hepatitis. Viral hepatitis is much more common.

Hepatitis is sometimes a complication of an autoimmune disorder, in which the body’s own defense system backfires and attacks the liver. Some of the autoimmune diseases that may cause autoimmune hepatitis include systemic lupus erthyematosus, rheumatoid arthritis and even type 1 diabetes.

Alcohol abuse, substance abuse, medication overdose and exposure to toxins can all cause hepatitis. Chronic alcohol abuse can cause liver inflammation, cirrhosis and liver cancer over time. Certain medications, like ibuprofen or acetaminophen, can cause liver damage, especially if consumed with alcohol and used in large quantities over a long period of time. Exposure to some poisons, such as poisonous mushrooms, for example, can cause hepatitis and possibly liver failure.

Some genetic diseases may make people more prone to developing inflammation of the liver. For example, people with cystic fibrosis may have an increased risk for developing liver problems. People with a disease called hemochromatosis, in which iron is over-absorbed into the body, can get deposits of iron in their liver that can cause inflammation and interfere with liver function. A similar thing can happen with another inherited disorder called Wilson’s disease; when too much copper is absorbed into the body, copper can be deposited in the liver and cause problems, including inflammation.

Acute hepatitis may be life-threatening in severe cases and has the potential to cause liver failure. Chronic hepatitis can also be a problem, with potential complications including liver failure, liver cancer and cirrhosis, or scarring, of the liver. The next article in Pain.com’s series for Hepatitis Awareness Month will discuss treatments for the different types of hepatitis. Source: http://pain.com/

To learn more about the Viral Hepatitis Action Plan or Hepatitis Awareness Month, visit the Viral Hepatitis Web site and follow CDC’s viral hepatitis Twitter account @CDChep .

By John W. Ward, M.D., Director, Division of Viral Hepatitis, CDC

Dr. John Ward

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