Symptoms and treatment of hepatitis in HIV-infected people

The liver is the largest internal human organ. It is located in the upper right side of the abdomen and is protected by the ribs. Viral liver infections, such as hepatitis A, B, and C, are especially dangerous for people with HIV infection because the liver plays a major role in the body's processing and absorption of antiretroviral drugs and other medications.

Liver functions

In the human body, the liver performs several functions:

• filters the blood, removing toxic substances from medications, foods and body waste; 
• produces bile, which enters the intestines to help digest fat; 
• breaks down food, saturating the body with energy and accumulating vitamins and minerals. 

Thus, the liver helps the human body get rid of unnecessary waste and produces energy. The liver also plays an important role in fighting infections and toxins.

Possible liver problems in HIV-positive people

Some antiretroviral drugs used to treat HIV infection have greater negative effects on the liver than others.

The drugs that most negatively affect the liver are ritonavir (used at full dose, not as a booster) and nevirapine. Severe liver damage increases the risk of developing liver cancer, which can lead to death.

Hepatitis, which is an inflammation of the liver caused by viruses, toxic substances or a compromised immune system in the body, is relatively common in people with HIV infection. Often the causative agents are hepatitis A, B and C viruses.

If hepatitis is not treated promptly in people living with HIV, the disease can seriously reduce the effectiveness of HIV treatment.

Hepatitis A

Hepatitis A can be contracted by:

• consuming food or drinks contaminated with human excrement containing the hepatitis A virus;
• oral-anal contact (rimming). 

Hepatitis A causes a short-term or acute illness that usually lasts 10 to 14 days. There is no long-term or chronic phase. People infected with hepatitis A usually recover without any special treatment, and severe complications are rare.  

Re-infection with hepatitis A is impossible because the body develops immunity.

People living with HIV may have hepatitis A longer than people who are HIV-negative. The danger is that when the liver becomes inflamed due to hepatitis A, it can no longer process HIV and other medications properly, which can cause side effects from antiretroviral therapy .

Hepatitis B

Hepatitis B is a viral infectious disease that affects liver cells and can lead to irreversible changes and degeneration of liver tissue (fibrosis and cirrhosis).

Hepatitis B is usually transmitted:

• from mother to child during pregnancy; 
• in contact with blood; 
• through unprotected anal, oral or vaginal sex.

Hepatitis B can also be contracted through personal hygiene items such as razors, toothbrushes and manicure tools that come into contact with blood. 

Statistics show that 5 to 10% of people living with HIV also have hepatitis B virus, known as coinfection. It is almost impossible for people with HIV infection to get rid of hepatitis B without treatment.  

Also, in people with HIV infection and hepatitis B coinfection, liver disease progresses faster than in HIV-negative people. 

Hepatitis C

Hepatitis C is a blood-borne virus that is spread through:

• contaminated blood products; 
• sharing needles and syringes for injecting drugs; 
• from mother to child;
• unprotected sex.

People living with HIV infection have a more difficult time recovering from hepatitis C. They are also more likely to have liver disease that progresses more rapidly, especially if they have low CD4 counts. 

However, research shows that HIV-infected people taking antiretroviral therapy cope almost as well with hepatitis C as HIV-negative patients.

Symptoms of viral hepatitis

In the early stages of liver disease, there may be no obvious symptoms. Once liver damage occurs, typical symptoms begin to appear:

• extreme fatigue
• feeling of general ill health, 
• weight loss,
• loss of appetite, 
•  nausea and vomiting,
• fever,
• abdominal pain,
• skin itching;
• enlargement or tenderness of the liver.

Jaundice can also develop against the background of viral hepatitis. In this case, the symptoms will be as follows: yellowing of the skin and whites of the eyes, darker urine, pale stools.

Diagnosis and tests for hepatitis

Every person with HIV infection should be regularly tested for hepatitis A, B and C.

Diagnosis of viral hepatitis in HIV infection may include blood donation, as well as a medical examination to determine the condition of the liver.

If the doctor believes that the patient's liver is enlarged or may be damaged, he may order an ultrasound. This is a painless, non-invasive way to diagnose the liver.

Unfortunately, a disease such as hepatitis can occur without specific symptoms. Therefore, the only reliable way to diagnose hepatitis is a laboratory examination.

It is necessary to donate blood to determine viral hepatitis on an empty stomach. Also, during the day before visiting the laboratory, you should refrain from consuming fatty foods and alcohol.

The results of a qualitative blood test for hepatitis can be found 4 hours after blood collection. A quantitative blood test may take up to 1 business day, not counting the day of testing.

Treatment

Treatment for liver disease is prescribed depending on the cause. In the case of hepatitis A , treatment can proceed under the supervision of the attending general practitioner. The patient needs to get plenty of rest and avoid alcohol consumption.

hepatitis B treatment is to clear the body of hepatitis B viruses and antigens and to reduce inflammation and further liver damage.

Most hepatitis B drugs are nucleoside or nucleotide drugs, similar to the class of drugs used to treat HIV infection (lamivudine, tenofovir, emtricitabine), since some commonly used HIV drugs are also effective against hepatitis B. This may make it easier to treat both viruses. because it requires less medication.

Before starting treatment, the patient should have tests to check liver health, CD4 cell count, HIV viral load, and hepatitis B viral load level. 

The treatment regimen prescribed will depend on how hepatitis B and HIV affect the patient's health. People with advanced liver disease are most in need of treatment for hepatitis B. This can be determined by liver biopsy, elastography, or blood tests (APRI or FIB-4).

Currently, the standard treatment for hepatitis B is the use of the drugs adefovir and lamivudine, which are also included in the antiretroviral therapy for HIV infection.

The standard of treatment for hepatitis C throughout the world is a combination of pegylated interferon alpha - 2a or 2b and ribavirin for 24 to 48 weeks (depending on the genotype, the presence of HIV co-infection, etc.).

Hepatitis C is considered cured if the virus is not detected 12 weeks after completion of treatment. This is called a sustained virological response (SVR).

Recommended treatment regimens for hepatitis C that combine drugs from different classes have shown overall cure rates of 95% to 100% in clinical trials.

Is there a vaccine for hepatitis?

Yes. There is an effective vaccine against hepatitis A and B.

The hepatitis vaccine is completely safe for people living with HIV, although there is a risk that protective immunity against hepatitis B may not be achieved after vaccination (especially in patients with low CD4 cell counts), and those who are successfully immunized may lose their immunity over time .

A small number of people are immune to hepatitis A and B due to previous infection, so before any vaccination you need to undergo an “immunity” test, i.e. the presence of antibodies to hepatitis A and/or B viruses.

There is no vaccine against hepatitis C.

Prevention of viral hepatitis in HIV infection

Prevention of viral hepatitis for people with HIV infection is as follows:

• When traveling abroad, especially to countries with poor sanitation, remember that hepatitis A can be transmitted through unwashed food and water;
• people with HIV are recommended to be vaccinated against hepatitis A and B;
• Using condoms will help reduce the risk of contracting hepatitis C during sex;
• when using injecting drugs, use only sterile injection equipment;
• Excessive alcohol consumption as well as drug use damage the liver.