Hepatitis is an inflammation of the liver, most often caused by a virus. The most common types of viruses are hepatitis A, hepatitis B, hepatitis C, hepatitis D and hepatitis E. "Hepatitis A and E are typically caused by ingestion of contaminated food or water and are not known to cause chronic liver disease" (WHO, 2010c). A vaccine exists for hepatitis A and a meta-analysis of eight studies from 1994 to 2004 shows that the vaccine can be effective in HIV-positive people (Shire et al., 2006 cited in Vergidis et al., 2009).

Hepatitis B, C, and D usually occur as a result of contact with infected body fluids (e.g. from blood transfusions, unprotected sexual intercourse with an infected person or from contaminated equipment used in invasive medical procedures or injecting drugs). Hepatitis B can also be passed from mother to infant at birth or during early childhood (Chou, 2009). Hepatitis B and C are important co-infections for HIV and D is only found as a co-infection with hepatitis B.

Approximately a million deaths per year are due to hepatitis B and hepatitis C viruses (WHO, 2010c). Hepatitis E should be studied in HIV co-infected people but no studies have been done to date (Kottilil et al., 2005; Kottilil, 2009). Chronic hepatitis B is recognized in about 10% of people living with HIV globally (Soriano et al., 2010). A recent survey of 2,281 people in Cameroon found high rates of hepatitis B co-infection, with 10.5% having chronic hepatitis B and 8.5% living with HIV (Brennan et al., 2012). Another survey in Zambia and South Africa also found that HIV/HBV co-infection "is relatively common" (Hamers et al., 2012b).

HIV Can Reduce the Bodys Response to Hepatitis B Vaccination

Hepatitis B can be prevented through timely vaccination, ideally within 24 hours after birth. WHO recommends that all infants should receive the first dose of hepatitis B vaccine less than 24 hours after birth, followed by two to three doses to complete the series. Since 2007, more than 88% of member states have introduced hepatitis B vaccine. However, hepatitis B birth-dose global coverage was just 27% in 2007 (Wiersma, 2009). Key countries where infants are not vaccinated are India, Nigeria, China, Indonesia, Ethiopia and Pakistan.

HIV-positive infants, children and adults can also be vaccinated for hepatitis B, but HIV-positive individuals are less likely to respond to vaccination against hepatitis B (Kottilil et al., 2005). A study from 2003 to 2005 in Thailand with 1,535 IDUs (90% male), of whom 24 were HIV-positive found that PWID with HIV were more than six times as likely to not respond to the hepatitis B vaccine, with only 14 responding to the three dose vaccine (Sunthornchart et al., 2008). However, a more recent study found that standard hepatitis B vaccinations in HIV-positive adults with CD4 cell counts above 200 and with undetectable viral load was "highly effective" (Chaiklang et al., 2012). Therefore, initiation of ART is recommended prior to vaccination in people with low CD4 cell counts and titering should be done afterward (Swan, 2012).

Importantly, treatment for hepatitis B is less effective in those who are co-infected with HIV (Kottilil, 2009). "...All HIV-infected persons should be immunized against hepatitis B, because the natural history of hepatitis B is accelerated in the setting of HIV, and co-infection poses specific considerations in selection of antiretroviral agents" (Marrazzo and Cates, 2011: S66). A study in the United States found that hepatitis B co-infection with HIV doubled mortality rates compared to those without hepatitis B co-infection but who were HIV-positive (Chun et al., 2012). Vaccination is critical as "...no reliable treatment to cure HBV infection in HIV-infected persons exists" (Peters and Marston, 2012: 167).

Hepatitis C and HIV Co-Infection Can Limit Treatment Options

Hepatitis C virus (HCV) infection is a blood-borne disease with global distribution that affects almost 3% of the world's population; more than 20% of acute HCV infections cause acute viral hepatitis symptoms severe enough to cause patients to seek medical care, but the majority are asymptomatic. "Without therapy in the acute phase, approximately 75% of all infections become persistent... Individuals with chronic HCV infection usually remain asymptomatic and undiagnosed for decades before chronic hepatitis leads to severe complications" (Cox, 2012).

Infection with hepatitis C virus causes liver inflammation and scarring. HIV co-infection accelerates progression of liver disease associated with hepatitis C. Many medications used in ARV therapy are cleared through the liver. Thus, co-infection with hepatitis C can complicate ARV therapy for people living with HIV. However, pegylated interferon plus weight-based ribarin treatment results in successful eradication of HCV in about 40% of co-infected patients and when treatment is successful, survival in these patients is substantially improved (Altice et al., 2010; Soriano et al., 2010). But treatment is expensive and most people who inject drugs in countries where HIV/Hepatitis C co-infection is more common -- Russia, China, Ukraine, Vietnam -- do not have access to treatment for co-infection (Altice et al., 2010). Those in central Europe and Asia also lack access to hepatitis C testing and treatment is largely not available either (Thomas et al., 2011b). Co-infection of HIV and hepatitis C is highest among those who acquired HIV through injecting drug use (Thomas et al., 2011b). However, new treatments are on the horizon (Chung, 2012).

The mother-to-infant transmission of hepatitis C is approximately 4-7%. Maternal co-infection with HIV increases the rate of hepatitis C transmission 4-5 fold, but the actual time and mode of transmission are not known (Roberts and Yeung, 2002). An elective C-section is only recommended for women with hepatitis C/HIV co-infection (Kottilil, 2010). A recent study of HIV/HCV co-infected pregnant women in Brazil and Argentina with access to HAART and therefore had lower viral loads reported that they were less likely to transmit hepatitis C to their infants (Cabot et al., 2012). But ARVs are not sufficient to prevent complications of hepatitis C (Thomas et al., 2011b).

"HCV transmission is likely to persist in areas with limited access to antiviral drugs, and poor needle injection and blood product hygiene. The proportion of patients who access and complete treatment remains low" (Cox, 2012). An effective vaccine is needed. Much more research is needed regarding women, specifically, and hepatitis and HIV co-infection. Treatment literacy on hepatitis C and hepatitis C/HIV co-infection is needed both for those at high risk and health providers (Hoover, 2009).

Almost no research focusing specifically on HIV and hepatitis co-infection among women in developing countries has been done. See Singhatiraj et al. (Singhatiraj et al., 2012) for a discussion of general treatment options for HIV co-infections with hepatitis B and C. In the United States, updated guidelines were released in March 2012: http://www.aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-treatment-guidelines/26/hepatitis-c--hcv--hiv-coinfection. For more in-depth coverage of hepatitis infections for people living with HIV, please refer to Treatment Action Group's Guide to Hepatitis B for People Living with HIV (Chou, 2009) and Guide to Hepatitis C for People Living with HIV (Collins and Swan, 2009).