Risk Factors and Prevention

Infection

Hepatitis B

  • HBV is transmitted by the percutaneous route or by sexual, peri-natal or close person-to-person contact via open cuts and sores (particularly among children in endemic areas).1
  • People at risk of HBV infection include:
    • residents of or travellers to areas with elevated HBV rates, such as Asia, Africa, Pacific islands and Eastern Europe
    • household contacts or sexual partners of chronically infected individuals
    • sexually active people not in a long-term mutually monogamous relationship
    • men who have sex with men (MSM)
    • people diagnosed with a sexually transmitted disease
    • injecting drug users.2

Hepatitis C

  • New HCV infections are generally linked to intravenous or nasal drug use, and recent data have linked promiscuous male homosexual activity to increased risk of HCV infection3
    • in contrast to HBV transmission, there is a low risk of HCV transmission through peri-natal contact or heterosexual intercourse.3
  • Known risk factors for new HCV infection in PLWHIV include:4
    • on-going intravenous drug use
    • mucosally traumatic sex
    • unprotected anal intercourse
    • a recent sexually transmitted infection
  • The presence of HIV increases the rate of HCV transmission by sexual contact.5

For further information on routes of HBV and HCV transmission refer to the page on causes

Risk factors for accelerated progression of liver disease

Progression of HBV- and HCV-related liver fibrosis is increased in PLWHIV compared with the general population.3,6

In the general population:

  • Risk factors for accelerated progression of HBV- and HCV-related liver disease include:
    • alcohol consumption
    • diabetes mellitus
    • older age at time of infection/longer duration of infection
    • co-infection with other hepatitis viruses.1,3,6
  • In HBV-infected people, the phase of infection may affect the risk of liver disease progression,6 and additional risk factors for the development of cirrhosis include:
    • HBV genotype C
    • high HBV DNA levels
    • exposure to carcinogens such as aflatoxin (produced by Aspergillus fungi)
    • smoking1
  • Patients who drink alcohol should be offered psychiatric, psychological, social and medical support to stop drinking4

Prevention

  • In patients with active drug use, opioid substitution therapy should be considered with the eventual aim of cessation of injection activity
    • medical support to reduce the risk of infection or re-infection (e.g. through needle and syringe exchange programmes) may be an appropriate harm reduction strategy4
  • Adequate counselling on barrier protection, such as appropriate use of condoms, is advisable since HBV, HIV and occasionally HCV are sexually transmitted
    • information should be provided on the risk of HCV transmission due to mucosally traumatic sexual practices associated with a high likelihood of blood contact, and risk reduction should be discussed4
  • Patients without anti-HAV or anti-HBs antibodies should be offered vaccination to prevent infection, regardless of their CD4 cell count4
  • HBV vaccination should also be offered to anti-HBc-positive patients who are HBs-Ag (hepatitis B surface antigen) negative according to the following table:4

Refer to the European AIDS Clinical Society (EACS) Guidelines or this review article: Non-responsiveness to hepatitis B vaccination in HIV seropositive patients; possible causes and solutions7 for guidance on strategies in PLWHIV responding inadequately to HBV vaccination.

References

  1. American Association for the Study of Liver Diseases (AASLD). Practice Guideline. Chronic Hepatitis B: Update 2009.  Accessed 1 December 2011.
  2. Immunization Action Coalition. Hepatitis A, B and C: Learn the Differences. Accessed 1 February 2012.
  3. European Association for the Study of the Liver (EASL). Clinical Practice Guidelines: Management of Hepatitis C Virus Infection.  J Hepatol 2011;55:245–264. Accessed 1 December 2011.
  4. European AIDS Clinical Society (EACS). Guidelines Version 6.0. Accessed 30 November 2011.
  5. Terrault NA. Sexual activity as a risk factor for hepatitis C. Hepatology. 2002;36:S99–105. 
  6. European Association for the Study of the Liver (EASL). Clinical Practice Guidelines: Management of Chronic Hepatitis B. J Hepatol 2009;50:227–242. Accessed 1 December 2011.
  7. van den Berg R, van Hoogstraten I, van Agtmael M. Non-responsiveness to hepatitis B vaccination in HIV seropositive patients; possible causes and solutions. AIDS Rev 2009;11:157–164.