Coinfection with HIV and Viral Hepatitis

An estimated 1.2 million persons are living with HIV in the United States. Of people living with HIV in the United States, about 25 percent are coinfected with hepatitis C virus (HCV), and about 10 percent are coinfected with hepatitis B virus (HBV). People living with HIV infection are disproportionately affected by viral hepatitis, and those who are coinfected are at increased risk for serious, life-threatening complications. HIV coinfection more than triples the risk for liver disease, liver failure, and liver-related death from HCV. Because viral hepatitis infection is often serious in people living with HIV and may lead to liver damage more quickly, CDC recommends all persons at risk for HIV be vaccinated against hepatitis B and be tested for HBV and HCV infection. December 1st has been designated World AIDS Day, creating an opportunity not only for raising awareness about HIV infection, but educating health professionals and the general public worldwide about the overwhelming burden of HIV and viral hepatitis coinfection, and the importance of testing, care, and treatment.

Transmission

Hepatitis B virus, hepatitis C virus, and HIV are bloodborne viruses that can spread when blood from a person infected with the virus enters the body of someone who is not infected. These viruses are spread through sexual contact, exposures to blood in health care settings, and behaviors associated with injection drug use. Because of these shared modes of transmission, persons living with or at risk for HIV are also at substantial risk for HBV and HCV infection.

Hepatitis B: An estimated 1.2 million persons in the United States are living with hepatitis B.  When compared with HIV, the hepatitis B virus is 50–100 times more infectious than HIV and is most commonly spread through sexual contact.

Hepatitis C: An estimated 3.2 million persons in the United States are living with hepatitis C. The hepatitis C virus is approximately 10 times more infectious than HIV and lives longer outside of the body. A large number of persons, including those living with HIV, were infected many years ago before the virus was discovered in 1989. This population of baby boomer (i.e., persons born during 1945-1965) are now at immediate risk for life threatening liver damage and cancer caused by HCV. Gay, bisexual, and other men who have sex with men living with HIV are at particular risk for sexual transmission of HCV, and persons who inject drugs (PWID) who share needles, syringes, or any other drug-injection equipment represent a growing number of new infections. As a result of the expanding epidemic of injection opioid use in primarily non-urban America, PWID living in these areas are increasingly at risk for HIV-HCV coinfection, as evidenced by the recent outbreak of HIV in Scott County, Indiana.  As of November 6th, a total of 181 persons were found to be infected with HIV in Scott County, more than 90% of whom were already infected with HCV.  High rates of HCV in a community can serve as an early warning signal of increased drug use and transmission of other blood borne viruses, including HIV.

Preventing Disease Transmission

The best way to prevent hepatitis B infection is to get vaccinated. To prevent coinfection for those who are not already infected with hepatitis B, the Advisory Committee on Immunization Practices recommends universal hepatitis B vaccination of persons who have or are at risk for HIV infection; including:

  • Men who have sex with men
  • People who inject drugs
  • Sex partners of infected people
  • Persons with multiple sex partners
  • Anyone with a sexually transmitted infection
  • Health care and public safety workers exposed to blood on the job
  • All persons 18 years of age or younger
  • All persons seeking protection from hepatitis B

Preventing the Progression of Disease:  Testing, Care, and Treatment for Persons with Viral Hepatitis and HIV Infection

Because viral hepatitis infection is more likely to lead to liver damage in persons living with HIV than persons infected with viral hepatitis alone, CDC recommends that all persons living with HIV infection be tested for hepatitis B and hepatitis C.  CDC also recommends hepatitis B and hepatitis C testing for anyone who has injected drugs.

CDC and USPSTF recommend hepatitis C testing for certain individuals, including those who:

  • Were born from 1945–1965
  • Ever injected drugs, including those who injected once or a few times many years ago
  • Have certain medical conditions, including persons:
    • who received clotting factor concentrates produced before 1987
    • who were ever on long-term hemodialysis
    • with persistently abnormal alanine aminotransferase levels (ALT)
    • who have HIV infection
  • Were prior recipients of transfusions or organ transplants, including persons who:
    • were notified that they received blood from a donor who later tested positive for HCV infection
    • received a transfusion of blood, blood components, or an organ transplant before July 1992

CDC and USPSTF recommend hepatitis B testing for:

  • Persons born in geographic regions with hepatitis B surface antigen (HBsAg) prevalence of ≥2%
  • US born persons not vaccinated as infants whose parents were born in geographic regions with HBsAg prevalence of ≥8%
  • Injection-drug users
  • Men who have sex with men
  • Persons with elevated ALT/aspartate aminotransferase (AST) of unknown cause
  • Persons with selected medical conditions who require immunosuppressive therapy
  • Pregnant women
  • Infants born to HBsAg-positive mothers
  • Household contacts and sex partners of HBV-infected persons
  • Persons who are the source of blood or body fluid exposures that might warrant postexposure prophylaxis (e.g., needlestick injury to a health care worker)
  • Persons living with HIV

HBV and HCV testing linked to care and treatment reduces the risk of liver cancer and early mortality. New safe and effective treatments for hepatitis C can cure 85%–100% of persons living with the virus. Although treatment of HBV or HCV is effective for persons living with HIV, coinfection can complicate the treatment and management of HIV infection. Therefore, persons living with HIV coinfected with HBV or HCV should seek care from providers with expertise in the management of both HIV and viral hepatitis infections. HIV and viral hepatitis testing followed by lifesaving care and treatment ensures the best possible health outcomes and prevents deaths among persons living with these infections.