Key considerations for people living with HIV

Many people living with HIV (PLWHIV) are co-infected with hepatitis B (HBV) or hepatitis C (HCV).1,2 Given the overlapping methods of transmission,3 it is not surprising that HBV and HCV infection rates are relatively high in PLWHIV.

Hepatitis B
  • Chronic HBV infection has been diagnosed in 6–14% of PLWHIV in industrialised countries.2

    • the highest rates of HBV-HIV co-infection are in areas such as sub-Saharan Africa, where both viruses are endemic.4
  • In the general population, initial infection with HBV may cause acute symptomatic disease, but many patients will be asymptomatic.5

The risk of developing chronic HBV infection after acute infection is <5% in adults, but HBV is more likely to persist in immunosuppressed individuals.4 The long-term hepatic impact of chronic HBV infection is highly variable, and sequelae can range from minimal hepatic changes to chronic hepatitis, extensive fibrosis and cirrhosis with or without hepatocellular carcinoma (HCC).3

  • In the general population, 15–40% of patients with chronic HBV infection will develop serious consequences during their lifetime4
  • Compared with people infected with HBV alone, HBV-HIV co-infected patients frequently have:4

o higher HBV DNA levels
o more severe hepatic disease

  • in HBV-HIV co-infected patients, liver enzyme levels (eg. alanine aminotransferase [ALT] levels), used as a measure of hepatic inflammation, may not be elevated despite severe disease6   

o increased rates of liver-related mortality

Hepatitis C
  •  HCV co-infection is prevalent among PLWHIV in most parts of the world2

    • in the United States and Australia, approximately one-quarter of PLWHIV are co-infected with HCV.1 In Europe, an average of 33–40% of PLWHIV also have HCV infection7,8
    • HCV co-infection rates as high as 70% have been observed in Eastern European countries such as Ukraine, and in Russia where intravenous drug use is the primary route of HIV transmission9
  • HCV co-infection rates are highest among people who have acquired HIV from injection drug use1

    • in one study from Russia, 91% of HIV-positive injecting drug users (IDUs) had HCV antibodies. Similarly high co-infection prevalence rates have been reported for HIV-positive IDUs in the USA, Australia and Asia1
  • HCV co-infection is a particular risk for PLWHIV in prisons, where illicit drug use and unsafe tattooing contribute to the spread of HCV infection1
  • HCV co-infection occurs in less than 15% of people who acquired HIV from sexual intercourse

    • however there appears to be a widespread international trend for outbreaks of HCV co-infection among HIV-positive men who have sex with men (MSM)1
  • In the general population, initial infection with HCV may cause acute symptomatic disease, but many patients will be asymptomatic5,10

    • acute HCV infection will progress to chronic infection in 50–90% of cases10
  • The probability of developing chronic HCV is higher in HIV-co-infected individuals than in non-HIV-infected individuals11,12

    • in a multicenter cross-sectional study of 547 patients with chronic parenterally-acquired HCV with or without HIV infection, HCV-HIV co-infected people were almost six times more likely to develop cirrhosis than those that were HIV-negative

      • in the first 10 years, 14.9% of HIV-positive patients developed cirrhosis, in comparison with 2.6% in the HIV-negative group12
  • The long-term hepatic impact of chronic HCV infection is highly variable, with pathological conditions ranging from minimal hepatic changes to chronic hepatitis, extensive fibrosis and cirrhosis with or without hepatocellular carcinoma (HCC) 3,9,10
Hepatitis A and D
  • Hepatitis A is predominantly spread via the faecal-oral route, and so may require particular consideration in areas of poor sanitation and/or crowded living conditions13
  • Hepatitis D is caused by an RNA virus that can only replicate in the presence of HBV.14 Therefore it is recommended that HBV-positive patients should also be screened for hepatitis D15
Hepatitis screening in PLWHIV
  • PLWHIV should be screened for HCV infection at HIV diagnosis and then every year on an ongoing basis15
  • HIV-infected patients should also be screened for hepatitis A and B virus (HAV/HBV) infection15
Hepatitis management in PLWHIV
  • Patients co-infected with HBV-HIV or HCV-HIV benefit from early antiretroviral therapy (ART) as the progression of liver fibrosis may be reduced because of the immune reconstitution and suppression of HIV RNA associated with successful ART15

    • HBV-HIV co-infected patients benefit from the anti-HIV and  anti-HBV activity of nucleoside reverse transcriptase inhibitors (NRTIs)16
    • cirrhotic patients who initiated ART showed increased overall survival compared with patients who did not receive ART15
  • Patients with cirrhosis should be managed in collaboration with experts in liver disease15

For more information on management please visit the Treatment section.


  1. Thomas DL, Leoutsakas D, Zabransky T, et al. Hepatitis C in HIV-infected individuals: cure and control, right now. J Int AIDS Soc 2011;14:22.
  2. Nikolopoulos GK, Paraskevis D, Hatzitheodorou E, et al. Impact of hepatitis B virus infection on the progression of AIDS and mortality in HIV-infected individuals: a cohort study and meta-analysis. Clin Infect Dis 2009;48:1763–1771. 
  3. Rockstroh JK, Bhagani S, Benhamou Y, et al. Guidelines for the Clinical Management and Treatment of Chronic Hepatitis B and C Co-infection in HIV-infected Adults.  HIV Med 2008;9:82–88.
  4. American Association for the Study of Liver Diseases (AASLD). Practice Guideline. Chronic Hepatitis B: Update 2009.  Accessed 1 December 2011.
  5. World Health Organization (WHO). Introduction of Hepatitis B vaccine into Childhood Immunization Services. Management Guidelines, Including Information for Health Workers and Parents. Accessed 2 December 2011.
  6. Peters MG. Diagnosis and management of hepatitis B virus and HIV coinfection. Top HIV Med 2007;15:163–166. 
  7. World Health Organization (WHO). Management of Hepatitis C and HIV coinfection. Clinical protocol for the WHO European Region. Accessed 30 November 2011.
  8. Rockstroh JK, Mocroft A, Soriano V, et al. Influence of hepatitis C virus infection on HIV-1 disease progression and response to highly active antiretroviral therapy. J Infect Dis 2005;192:992–1002. 
  9. Soriano V, Mocroft A, Rockstroh J, et al. Spontaneous viral clearance, viral load, and genotype distribution of hepatitis C virus (HCV) in HIV-infected patients with anti-HCV antibodies in Europe. J Infect Dis 2008;198:1337–1344. 
  10. 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.
  11. Thomas DL, Astemborski J, Rai RM, et al. The natural history of hepatitis C virus infection: host, viral, and environmental factors. JAMA. 2000 Jul 26;284(4):450-456. 
  12. Soto B, Sánchez-Quijano A, Rodrigo L, et al. Human immunodeficiency virus infection modifies the natural history of chronic parenterally-acquired hepatitis C with an unusually rapid progression to cirrhosis. J Hepatol 1997;26:1–5. 
  13. World Health Organization (WHO). Hepatitis A.  Accessed 1 December 2011.
  14. World Health Organization (WHO). Hepatitis Delta.  Accessed 1 December 2011.
  15. European AIDS Clinical Society (EACS). Guidelines Version 6.0.  Accessed  30 November 2011.
  16. Mendes-Corrêa M, Núñez M. Management of HIV andHepatitis Virus Coinfection. Expert Opin Pharmacother 2010;11:2497–2516.
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