Hepatitis C and diagnosis with HIV

Hepatitis C is usually transmitted through blood-to-blood contact. Needles, syringes and other equipment used to inject drugs, and equipment used to sniff drugs such as straws or banknotes, should never be shared. The sexual transmission of hepatitis C is now an issue of concern. It used to be thought that this was very rare. However, there have been recent reports of increasing numbers of gay men testing positive for hepatitis C. Many of these men are HIV positive and their only risk activity appears to be unprotected anal sex. Sexual activity that carries a risk of contact with blood, such as rougher anal sex, use of sex toys and fisting, seems to have a particular risk of hepatitis C transmission. Group sex, especially in the context of drug use, is also an important risk factor. Using condoms correctly, every time you have sex, not sharing sex toys or washing them between use, and not sharing pots of lubricant can reduce the risk. Mother-to-baby transmission of hepatitis C is thought to be uncommon, but the risk is increased if the mother is also HIV positive. A high hepatitis C viral load increases the risk that a mother will pass on hepatitis C to her baby and, as with HIV, a caesarean delivery reduces the risk. It’s best not to share razors, hair and nail clippers, nail scissors or toothbrushes if you have hepatitis C.

Very few people experience symptoms when they are first infected with hepatitis C. When they do occur, symptoms include jaundice, diarrhoea and feeling sick. In the longer term, about 50% of people with hepatitis C will experience some symptoms. The most common ones are feeling generally unwell, extreme tiredness, weight loss, depression and intolerance of fatty food and alcohol. Although a small proportion of people infected with hepatitis C clear the infection naturally, about 85% will go on to develop chronic hepatitis C. About a third of people will develop severe liver disease within 15 to 25 years. The severity of disease can be affected by the strain of hepatitis C you are infected with. Men, people who drink alcohol, people who are infected with hepatitis C when they are already into middle age, and people with HIV seem to experience faster hepatitis C disease progression. Hepatitis C can cause liver fibrosis (hardening) and cirrhosis (scarring). This damages the liver to such an extent that it cannot work properly, causing jaundice, internal bleeding and swelling of the abdomen. Chronic infection with hepatitis C can cause liver cancer (hepatocellular carcinoma, or HCC). HCC is especially likely to happen in people with cirrhosis, particularly if they drink heavily. There’s also some evidence that smoking can speed up the rate of cirrhosis and increase the risk of liver cancer. Surgery is the most effective form of treatment for liver cancer, but  other options include chemotherapy and treatment with drugs.

You should be tested soon after your diagnosis with HIV to see if you are also infected with hepatitis C. Unlike hepatitis B, there is no vaccine against hepatitis C. If you are in a group at high risk of infection with hepatitis C, it’s recommended that you have regular tests to see if you have been infected. A test is available to measure hepatitis C viral load. Unlike the HIV viral load test, this is not an indicator of when to start treatment. However, it is used to show how effective treatment any hepatitis C is being and how long it should continue. Liver function tests can give an indication of the extent to which hepatitis C has damaged your liver. Liver ultrasounds and biopsies may also be used. People co-infected with HIV and hepatitis C are more likely to develop liver damage than people who are only infected with hepatitis C. However, hepatitis C does not increase your risk of becoming ill due to HIV or responding less well to HIV treatment.

HIV treatment can be used safely and effectively if you are co-infected with HIV and hepatitis C. HIV treatment that suppresses viral load and increases your CD4 cell count can slow the rate of HCV-related liver damage. However, you may be at greater risk of experiencing the liver side-effects which some anti-HIV drugs can cause, and you and your doctor should have this in mind when selecting which anti-HIV drugs to take. It also seems to be the case that people co-infected with HIV and hepatitis C are at greater risk of developing some of the metabolic disorders which anti-HIV drugs can cause (particularly insulin resistance and diabetes). Drugs are available for the treatment of hepatitis C and you should receive your treatment and care from doctors who are expert in the treatment of both HIV and hepatitis C. This may mean that, as well as seeing an HIV doctor, you also need to see a specialist liver doctor.

If you have both HIV and hepatitis C, you should be assessed to see if you would benefit from starting hepatitis C treatment.

If you and your doctor decide that you will start hepatitis C treatment now, and your CD4 cell count is between 350 and 500, you should start hepatitis C treatment first, then start HIV treatment. If your CD4 cell count is between 350 and 500 and you don’t yet need treatment for hepatitis C, you should start HIV treatment.

If your CD4 cell count is under 350, you should start HIV treatment before starting hepatitis C treatment. A number of anti-HIV drugs have interactions with drugs used to treat hepatitis C. The choice of anti-HIV drugs you take will need to be made with these possible interactions in mind.

Before you start treatment for hepatitis C, it is important to know which strain, or genotype, of hepatitis C you have been infected with, as this can predict your response to treatment and the amount of time you will need to take treatment for. There are several hepatitis C genotypes. Type 1 is most common in the UK, and unfortunately responds least well to the currently available treatments for hepatitis C. Genotype 4 is also harder to treat. People with genotypes 2 or 3 respond better to treatment. However, there are new HCV drugs available, and more in development, which should improve the chances of a cure for people with harder-to-treat genotypes.

Factors such as your age, gender, how long you have had hepatitis C, the degree of liver damage and whether cirrhosis has developed are also important in predicting if treatment is likely to be effective. Unlike HIV treatment, treatment for hepatitis C is not lifelong. It consists of 24 or 48 weeks of treatment, and the length of treatment you receive will depend on the hepatitis C genotype you are infected with. A test after twelve weeks of treatment can predict if you are going to respond to treatment.

Drugs are available for the treatment of hepatitis C. The backbone of treatment consists is pegylated interferon and ribavirin. These are taken in combination with an anti-HCV protease inhibitor. This sort of triple combination has been found to be much more effective than dual therapy with pegylated interferon and ribavirin alone. The aim of hepatitis C treatment is to eradicate infection with hepatitis C completely.

Other aims of treatment include normalizing liver function, reducing liver inflammation and reducing further damage to the liver. If you are ill because of HIV, then the aim of hepatitis C treatment is likely to focus on improving your tolerance of anti-HIV drugs, reducing the risk of death from liver problems and improving your overall quality of life. Hepatitis C treatment can have unpleasant side-effects, including a high temperature, joint pain, weight loss, nausea and vomiting and depression. Other side-effects include disturbances in blood chemistry.