HIV and Coinfections

HIV and Viral Hepatitis

Viral hepatitis means inflammation of the liver caused by a virus. In the United States, the most common causes of viral hepatitis are hepatitis A virus, hepatitis B virus, and hepatitis C virus. You can get some forms of viral hepatitis the same way you can get HIV—through sexual contact and sharing syringes, needles, or other equipment to inject drugs.

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People with HIV, especially those who inject drugs, often have viral hepatitis. Everyone with HIV should be tested for hepatitis B and hepatitis C.

A

Hepatitis A

Hepatitis A is a liver infection caused by the hepatitis A virus. People who get hepatitis A may feel sick for a few weeks to several months. While most people recover and do not have lasting liver damage, some people need to be hospitalized. Hepatitis A can cause death, especially for people who are older or have other health problems.

The hepatitis A virus is found in the stool of people who are infected and can survive on surfaces for several months. Hepatitis A is very contagious, and people can spread the virus before they get symptoms such as nausea, stomach pain, and yellow eyes or skin. Infection can occur when someone ingests the virus, which can happen from:

  • Close contact with someone who has hepatitis A.
  • Sexual contact with someone who has hepatitis A.
  • Touching surfaces or objects that have been contaminated with hepatitis A.
  • Eating contaminated food or drinks.
B

Hepatitis B

Hepatitis B is a liver infection caused by the hepatitis B virus. Hepatitis B can range from a mild illness lasting a few weeks to a serious, lifelong illness. Some people who get hepatitis B, especially as adults, can get rid of the virus without treatment. Others, especially those infected as infants or young children, go on to develop long-term infection.

Hepatitis B is spread through blood and other body fluids, including semen. It can be spread in these ways:

  • Sexual contact with someone who has hepatitis B.
  • Sharing syringes, needles, or other equipment to inject drugs.
  • Needlestick injuries from someone infected with hepatitis B.
  • From a woman with hepatitis B to her baby at birth (but giving the first hepatitis B vaccine within 12 hours of birth to the baby can prevent infection).
C

Hepatitis C

Most people who get hepatitis C develop a long-lasting (chronic) infection. Hepatitis C is one of the primary causes of chronic liver disease in the United States, and hepatitis C-related liver injury progresses faster in people who also have HIV. Many people who have hepatitis C do not know they are infected and do not have symptoms or feel sick. Left untreated, chronic hepatitis C can cause serious health problems, including liver damage, cirrhosis (scarring of the liver), liver cancer, and even death. It is spread through contact with blood from an infected person:

  • Most often spread through sharing syringes, needles, or other injection equipment. Many people who inject drugs (PWID) and have HIV also have hepatitis C.
  • Less commonly spread through sexual contact. Sexual transmission of hepatitis B occurs more often than hepatitis C.

Coinfection

People with HIV in the United States are at increased risk of developing chronic viral hepatitis and liver disease. This means they could have a coinfection, or two or more infections at the same time.

Both hepatitis B and HIV are viruses carried by a person’s blood and are transmitted mainly through sexual contact and injection drug use. Because people can get HIV and hepatitis B in the same ways, a high number of adults at risk for HIV infection are also at risk for hepatitis B. People who have both HIV and hepatitis B are at higher risk for developing chronic hepatitis B. People who have HIV and hepatitis B coinfection can also have serious medical problems and are at higher risk for liver-related illness and death. To prevent hepatitis B infection, all patients with HIV should get a hepatitis B vaccination.

As hepatitis C is a virus transmitted through direct contact with the blood of an infected person, coinfection with HIV and hepatitis C is common (62–80%) among PWID with HIV. Although transmission via injection drug use remains the most common way that people get hepatitis C in the United States, sexual transmission is an important mode of acquisition among gay and bisexual men. Hepatitis C is one of the primary causes of chronic liver disease in the United States, and hepatitis C-related liver injury progresses more rapidly among persons coinfected with HIV. Hepatitis C infection may also affect the management of HIV infection. Guidelines recommend that all people with HIV be screened for hepatitis C and that persons with increased risk be retested annually.

HIV and Viral Hepatitis in the US: The Numbers

About 21% of people with HIV also have hepatitis C; Around 62-80% of PWID with HIV also have hepatitis C; Having both HIV and hepatitis C more than triples the odds for liver disease, liver failure, and liver-related death; About 11% of all new hepatitis B infections and 21% of all new hepatitis A infections were among men who have sex with men in 2017; The number of acute hepatitis C cases more than tripled from 2010-2017.
Viral Hepatitis Prevention

Hepatitis A: The best way to prevent hepatitis A is to get vaccinated. CDC recommends hepatitis A vaccination for people who are at risk for HIV, including gay and bisexual men; people who use recreational drugs, whether they inject or not; and sex partners of people with hepatitis A.

Hepatitis B: The best way to prevent hepatitis B is to get vaccinated. CDC recommends hepatitis B vaccination for people who have or are at risk for HIV and who have never had hepatitis B. This includes gay and bisexual men, PWID, sex partners of people with hepatitis B, people with multiple sex partners, people seeking evaluation or treatment for a sexually transmitted disease, and health care and public safety workers exposed to blood on the job.

Hepatitis C: No vaccine exists for hepatitis C. The best way to prevent hepatitis C is to never inject drugs or stop injecting drugs if you currently do so by getting and staying in a drug treatment program. If you continue injecting drugs, always use new, sterile needles or syringes, and never reuse or share needles, syringes, water, or other drug injection equipment. Using condoms lowers but does not remove the risk of getting hepatitis C through sex.

Testing and Treatment

Blood tests are used to detect viral hepatitis. The tests can detect the virus even if a person has no symptoms. In the case of hepatitis B, blood tests can help determine if people have had hepatitis B and, if not, whether they would benefit from the hepatitis B vaccine. If a hepatitis C screening test is positive, a follow-up test must be done to determine if the person still has hepatitis C or if the infection has cleared up.

Treatment for viral hepatitis varies. Hepatitis A infection usually runs its course over time, although some people may need to be hospitalized. Most people who get hepatitis A recover completely and do not have any lasting liver damage.  For some people, especially those with health problems, hepatitis A can cause death.  Hepatitis B can be treated with antiviral medicines, but not everyone can or should be treated. Hepatitis B treatment is lifelong and can delay or limit the effects of liver damage. Hepatitis C treatment can cure the disease with a course of all-oral medication (pills) with few side-effects, taken over the course of a few months.

For someone with HIV, coinfection with viral hepatitis may complicate HIV treatment. Because viral hepatitis is often serious in people with HIV and may lead to liver damage more quickly, CDC recommends that all people with HIV be tested for hepatitis B and hepatitis C. CDC also recommends that everyone born from 1945 to 1965 as well as younger adults with certain risk factors, be tested at least once for hepatitis C.

HIV/hepatitis B, and HIV/hepatitis C coinfections can be treated effectively in many people, but treatment is complex. People with coinfection should look for health care providers with expertise in treating both HIV and viral hepatitis.

CDC has produced a 5-minute online Hepatitis Risk Assessment tool that allows people to answer questions privately and get tailored recommendations to discuss with their doctor. This tool can also determine which tests and vaccines are right for an individual.

HIV and Tuberculosis

lungs

All people with HIV should be tested for TB infection as soon as possible after they get an HIV diagnosis.

TB virus

Anyone who has TB disease, is being evaluated for TB disease, or is a contact of a TB patient should be tested for HIV.

Tuberculosis, or TB, is caused by the bacterium Mycobacterium tuberculosis. TB is spread through the air from one person to another. Not everyone infected with TB bacteria gets sick. Some people develop TB disease soon after infection; many others keep the infection in their bodies without getting sick (called latent TB infection). A small proportion of people with latent TB infection may develop TB disease in the future. Thus, two TB-related conditions exist: latent TB infection and active TB disease.

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  • People with latent TB infection are not sick, do not have symptoms, and cannot spread TB bacteria.
  • People with TB disease are sick, have symptoms, and can spread the bacteria to others.

People with newly diagnosed HIV should be tested for TB infection even if they have no signs or symptoms of TB disease. People with HIV who have an ongoing risk for TB exposure should be tested every year. The risk for exposure to TB is the same for everyone: being in close contact with someone with infectious TB disease. The risk of developing TB disease after infection is higher for some people, especially for people with HIV who are not on treatment for HIV.

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People with newly diagnosed HIV should be tested for TB infection even if they have no signs or symptoms of TB disease. People with HIV who have an ongoing risk for TB exposure should be tested every year. The risk for exposure to TB is the same for everyone: being in close contact with someone with infectious TB disease. The risk of developing TB disease after infection is higher for some people, especially for people with HIV who are not on treatment for HIV.

Several recommended treatment regimens are available for latent TB infection.

This chart shows HIV coinfection among people with TB disease and a documented HIV test from 1993 to 2016. There were 3,466 people with TB disease and HIV infection in 1993; 3,403 in 1994; 2,869 in 1995; 2,461 in 1996; 1,999 in 1997; 1,755 in 1998; 1,658 in 1999; 1,398 in 2000; 1,369 in 2001; 1,344 in 2002; 1,280 in 2003; 1,150 in 2004; 1,017 in 2005; 927 in 2006; 845 in 2007; 792 in 2008; 687 in 2009; 596 in 2010; 649 in 2011; 611 in 2012; 536 in 2013; 491 in 2014; 456 in 2015; 454 in 2016; 439 in 2017.

CDC. Reported Tuberculosis in the United States, 2017. Accessed December 3, 2019.

The Numbers

Unfortunately, some people with HIV do not know they have latent TB infection. Similarly, some people with TB disease do not know their HIV status.

know the facts about HIV and TB

How to Address Treatment and Prevention Challenges

  • People who do not know they have HIV or TB cannot take advantage of treatment. Anyone who has recently received an HIV or TB disease diagnosis should be tested for coinfection. Without treatment, each disease makes the other disease more severe. TB disease is considered an “AIDS-defining condition.” When a person with HIV gets TB, they are diagnosed with AIDS, the most advanced stage of HIV. Worldwide, TB is a leading cause of death among people with HIV.
  • Possible drug interactions can make it difficult to manage HIV-related TB. One concern is the interaction of rifamycins (a group of drugs often used to treat latent TB infection and TB disease) with certain medicines used to treat HIV. People who have both HIV and TB should seek care from health care providers with expertise in the management of both diseases.
  • Drug-resistant TB can develop when a TB patient is not treated with the right drugs or does not take the drugs the right way. This means that the drug can no longer kill the TB bacteria. TB that is resistant to drugs is harder to treat and can lead to death. To prevent the continued emergence of drug-resistant strains, treatment for TB disease must be improved, not only in the United States but worldwide.
  • Following a treatment plan may be hard for people who have HIV and TB. People with HIV and TB disease should start treatment for TB as soon as possible, finish the medicine, and take the drugs exactly as prescribed. Health care providers should prescribe shorter regimens when possible. Patients are more likely to finish shorter treatment regimens. The most effective way to ensure that patients complete their TB treatment is through the use of patient-centered care, which may include supervision of treatment (known as “directly observed therapy” or DOT).

What CDC Is Doing

CDC and its domestic and international partners are taking many steps to prevent the further spread of TB and to reduce TB infection in the United States and around the world. Efforts include: