All HIV-positive patients should:
- be screened for hepatitis A, B and C virus infections at HIV diagnosis1
- have their HBV and HCV status reassessed before commencement of ART2
- be screened for HBV and HCV infection annually if they have on-going risk factors for infection1
- be screened for HBV and HCV infection if they have unexplained increases in hepatic transaminases and on-going risk factors for infection1
HAV-negative and HBV-negative, non-immune PLWHIV should be vaccinated against both viruses. 1,2
HBV screening in PLWHIV
Patients with HBV infection may have:3
- high levels of hepatic inﬂammation
- HBV DNA in the absence of serum hepatitis B surface antigen (HBsAg), known as occult HBV
- Therefore in addition to HBsAg testing, HIV-infected patients from countries with a high prevalence of HBV should be screened for HBV DNA, particularly if they have elevated liver enzymes.1
All HBsAg-positive patients should be screened for the hepatitis D virus (HDV).1 HDV requires the presence of a hepadnavirus, such as HBV, for replication, and therefore patients with chronic HBV infection are at risk of HDV infection4
HBV-HIV co-infected patients should be screened for HDV:2
- if they develop an unexpected rise in alanine aminotransferase (ALT) levels
- in the case of significant liver damage but low or undetectable HBV DNA levels
- HBV-HIV co-infected patients should be screened for HDV:2
HCV screening in PLWHIV
- An anti-HCV antibody test should be used for initial screening.1
- HCV RNA levels should be quantified in antibody-positive patients and HCV genotype should be determined.1 These tests provide important information on prognostic/treatment-related factors
- Patients with a negative HCV antibody test who have an unexplained increase in hepatic enzymes and ongoing risk factors for infection (intravenous drug use, unprotected anal intercourse, mucosally traumatic sex or recent sexually transmitted infection) should be offered an HCV RNA test to rule out acute hepatitis C1
Assessment of liver damage
Patients diagnosed with chronic hepatitis B or C infection should be evaluated for liver damage by assessment of fibrosis stage and hepatic synthetic function.1
Grading of fibrosis stage involves procedures such as Fibroscan , liver biopsy, and assessment of serum fibrosis markers1
- serum fibrosis markers, or combinations of markers, include hyaluronic acid, Fibrotest, Fibrometer, Hepascore, the aspartate aminotransferase (AST) to platelet ratio index (APRI), the FIB-4 index, the Forns index and other indices.1
- tests such as Fibrometer , Fibrotest and Hepascore may predict liver fibrosis more accurately than simple biochemical tests such as APRI, FIB-4 or Forns.1
Markers of hepatic function may perform well in the detection of significant fibrosis, but they do not perform as well in the detection of lesser degrees of fibrosis
- the combination of multiple markers improves accuracy for detecting fibrosis5
Serum/plasma characteristics that could indicate potential viral hepatitis-related liver damage include:1,6
markers of hepatic synthetic function such as:
- coagulation tests
- serum albumin concentrations <3.4 g/dL
- serum cholinesterase test (CHE), where pseudocholinesterase levels <8 U/mL may indicate liver damage
other markers of liver function abnormalities such as:6
- alkaline phosphatase (ALP) serum concentrations >147 IU/L
- elevated alanine aminotransferase (ALT) levels compared with age- and gender- matched averages
- serum aspartate aminotransferase (AST) concentrations >34 IU/L
- gamma-glutamyltransferase (GGT) serum concentrations >51 IU/L
- total serum bilirubin levels >1.9 mg/dL
- markers of hepatic synthetic function such as:
Screening for hepatocellular carcinoma (HCC) by ultrasound scans every 6–12 months may be advisable in non-cirrhotic, HBV-HIV co-infected patients who:1
- are African and aged over 20 years
- are Asian and aged over 40 years
- have a family history of HCC
- have high HBV DNA levels (>2,000 IU/mL)
Patients with liver disease will require frequent monitoring during treatment with hepatotoxic drugs1
- Alanine/aspartate aminotransferase (ALT/AST), alkaline phosphatase (ALP) and bilirubin should also be assessed at HIV diagnosis, prior to starting ART and every 3–6 months thereafter in patients with liver disease.1
For further information you can access Guidelines from the European AIDS Clinical Society (EACS) or refer to other guidelines via the clinical practice guidelines page of this website.
- European AIDS Clinical Society (EACS). Guidelines Version 6.0. Accessed 30 November 2011.
- BHIVA Viral Hepatitis Working Group. British HIV Association Guidelines for the Management of Coinfection with HIV-1 and Hepatitis B or C Virus 2010. Accessed 1 December 2011.
- American Association for the Study of Liver Diseases (AASLD). Practice Guideline. Chronic Gepatitis B: Update 2009. Accessed 1 December 2011.
- World Health Organization (WHO). Global Alert and Response: Hepatitis D. Accessed 2 December 2011.
- 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.
US National Library of Medicine and National Institutes of Health. Medline Plus: Liver Function Tests. Accessed 2 December 2011.