Hepatitis
“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. 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 parenteral contact with infected body fluids (e.g. from blood transfusions or invasive medical procedures using contaminated equipment). Hepatitis B is also transmitted by sexual contact” (WHO, 2010c). Hepatitis B and hepatitis C are important co-infections for HIV and D is a co-infection with hepatitis B. Approximately a million deaths per year are due to hepatitis B and hepatitis C viruses. Hepatitis E should be studied in HIV co-infected people but no studies have been done to date (Kottilil et al., 2005; Kottilil, 2009). Almost no research focusing specifically on HIV and hepatitis co-infection among women in developing countries has been done.
HIV Can Reduce the Body’s 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 IDUs 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).
It is also critical that all blood is screened for hepatitis B as well as HIV. Once a person has the chronic form of hepatitis B, they can be treated but not cured. Treatment for both HIV and hepatitis B reduces the risk of transmission of both hepatitis B and HIV. Importantly, treatment for hepatitis B is less effective in those who are co-infected with HIV (Kottilil, 2009). Hepatitis B can be transmitted through sharing needles or sexual contact with a person with hepatitis B. Hepatitis B can also be transmitted through perinatal transmission, with these infants being particularly hard to treat.
Hepatitis C and HIV Co-Infection Can Limit Treatment Options
Infection with hepatitis C virus causes liver inflammation and scarring. HIV co-infection leads to worsening 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.
Hepatitis C can be averted by using condoms, by never sharing needles and by safe injection practices, including both in illicit drug use as well as injections in medical settings such as when infants are immunized. No preventive vaccine exists for hepatitis C. Globally, more than 90% of new hepatitis C infections are attributed to injection drug use, but few IDUs receive treatment (Hoover, 2009). Many people with hepatitis C, particularly IDUs, who are traditionally marginalized and underserved, are unaware that they are infected. Hepatitis C can be sexually transmitted, although transmission between heterosexual couples is rare. Hepatitis C can also be transmitted through unsterilized medical, dental, tattoo equipment and the sharing of razors (Hoover, 2009). The mother-to-infant transmission of hepatitis C is about 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).
Treatment literacy on hepatitis C and hepatitis C/HIV co-infection is needed both for those at high risk and health providers (Hoover, 2009). A 2000 to 2002 pilot study in China of needle exchange programs indicated that scaling up needle exchange programs can lower rates of hepatitis C and HIV. Participants in the intervention communities were almost three times less likely to have shared needles in the past month than those in the control communities, with significantly lower rates of infection both for HIV and hepatitis C. The results of the trials were used to develop national policy guidelines in 2002 and needle exchange programs were included in the second five-year action plan. The needle exchange program was scaled up in 2006 from 93 sites to 729 by the end of the year (Wu et al., 2007c).
PCR tests are used to detect hepatitis C but the disease is diagnosed when positive antibody test results are confirmed by HCV RNA (viral load) testing. PCR tests require high-quality laboratory facilities and trained technicians. Where PCR tests are not available, TMA tests may be used (Hoover, 2009). Liver biopsies may be used to assess liver damage but they are expensive, can be painful, and there is a risk for complications which, on rare occasions, can be life-threatening. Recent advances in technology for non-invasive testing include FibroScan, which uses sound waves to assess liver damage.
Much more research is needed regarding women, specifically, and hepatitis and HIV co-infection. For more in-depth coverage of hepatitis infections, please refer to Treatment Action Group (Swan and Raymond, 2004) at: http://www.treatmentactiongroup.org/publication.aspx?id=3306&terms=hepatitis+c+hiv.