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Double Trouble

Winter 1998/1999

A note from TheBody.com: Since this article was written, the HIV pandemic has changed, as has our understanding of HIV/AIDS and its treatment. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!

Unlike the more familiar hepatitis A and B viruses, the hepatitis C virus (HVC) has gone essentially unnoticed for years as a silent epidemic has developed. Hepatitis C is a killer. About 10,000 people die from hepatitis C each year and the death toll is rising. Some officials from the Centers for Disease Control (CDC) predict that in the next 10 years the death toll will triple. Approximately 4 million Americans are infected with HVC (2 percent of the population) and an additional 30,000 new cases are diagnosed each year. Unlike HIV, this disease is quiet and many people are infected for years without knowing they carry this virus. People who are HIV+ are being greatly affected by this problem too, with over 9 percent of those with HIV co-infected with HVC.

The initial surge of infection occurred in the early 1970s before adequate testing of blood and blood products was available. Once a diagnostic blood test for hepatitis B was developed, transmission to those who received multiple blood transfusions decreased dramatically. It wasn't until 1989 that researchers developed the screening test for detecting HVC that has reduced the risk of transmission via transfusions to 1 in 100,000 units transferred.

Sharing of contaminated needles among injection drug users and needle-stick injuries are other ways HVC can be spread. It is thought that tattoo and body piercing parlors that do not practice good sterilization techniques can potentially transmit the virus among clients. Having multiple sex partners is also a risk factor for HVC infection but the role of sexual transmission is not well understood. The CDC recently attributed 20 percent of all cases of hepatitis C to sexual transmission. In addition, transmission from mother to child is possible (but rare), and the risk may be increased for those who are HIV+.

Because hepatitis C has been linked to increased mortality among persons with HIV, its early detection and management are very important. Understanding the answers to the following questions will help you play an active role in your health care.

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How Would I Know If I Had Hepatitis C?

Positive hepatitis C status often goes unnoticed, as symptoms are rare. It is possible to carry infection with HCV for two or three decades before becoming symptomatic. The most common symptom is fatigue. In more advanced cases, pain in the upper right area of the abdomen and anorexia may develop. Jaundice -- the discoloration of the eyes and skin often associated with hepatitis -- almost never occurs. Abnormal liver enzymes most often prompt testing for hepatitis but it has now become common practice among good physicians to test for hepatitis A, B, and C in an initial visit.


Should I Get Tested?

Those who have risk factors such as needle sharing, blood transfusions, and multiple sex partners (no matter how long ago) should get tested. Blood can be tested for antibodies to hepatitis C using a method called the enzyme-linked immunosorbent assay (ELISA). If ELISA results are positive, usually 1 to 3 weeks after exposure, a polymerase chain reaction (PCR) test is performed to measure the amount of HVC in the blood. The PCR test measures the actual virus rather than the antibody. Similar to the HIV viral load test, the HVC viral load gauges how active the virus is in your system. During the course of illness, most people experience intermittent viremia (measurable virus in the blood) and fluctuating levels of alanine aminotransferase (ALT) in the blood. ALT is a liver enzyme that can be measured in the blood, and is the most sensitive identifier of liver inflammation. A person whose ALT has been elevated for at least 16 months has chronic hepatitis C. A liver biopsy is sometimes recommended to determine how much liver damage has occurred as a result of long-term infection with HCV.

Most doctors can perform an HVC test with a simple blood draw. You can have one added to the your lab work the next time you go in for a viral load or CD4 test.


Is There Treatment for Hepatitis C?

Until recently, conventional medicine had little to offer those infected with HVC. Interferon alpha (Intron A), an immune modulating agent given as an injection into the fat tissue three times a week, has for years been the main therapy. Initial therapy with interferon seems to lower the dangerous liver enzymes, but only on a temporary basis. Some studies show that only 15 to 20 percent of people maintain sustain results once therapy is discontinued. Combination therapy has been more successful, but there are few long-term studies of those who are co-infected with HIV.

Combination therapy may actually be able to interfere with viral replication and eradicate the virus. Ribavirin (Rebetrol), a nucleoside analogue, has been in the pipeline for more than a decade. Because this drug has activity against HIV in the test tube, in the late 1980s many people with AIDS smuggled it in from Mexico in hopes of HIV viral suppression. It ended up being a very weak antiretroviral agent for HIV. However, Ribavirin has re-emerged as a modestly potent antiviral against HVC in combination with Interferon and has recently gained FDA approval for this use.

A randomized, double blind, placebo-controlled trial of Interferon with and without ribavirin was completed in Switzerland recently. The study included 100 HIV-negative participants. They were randomly selected to receive Interferon either in combination with Ribavirin or with a placebo. The study lasted for 2 years. A long-term virological response was seen in 18 (36 percent) of those on the combination arm of Interferon and Ribavirin, while only 9 people (18 percent ) had a positive response to receiving Interferon alone. The results of this study show that these drugs are less than perfect, but a step in the right direction.

Unfortunately, both Interferon and Ribavirin have side effects, which means these drugs are not for everyone. These drugs are not recommended for those with advanced cirrhosis of the liver or those who with severe depression, because these conditions can worsen while taking these medicines. Also, some individuals have such low levels of virus in their system that treatment-related side effects may cause more problems than benefits.

Interferon can cause intense flu-like systems (fever, chills, muscle aches, and headaches) that diminish in time for most people. Injecting the drug just before bed can help to reduce the side effects that occur during waking hours. Both Ribavirin and Interferon can affect blood counts, causing anemia (low red blood cell counts) and thrombocytopenia (low platelet counts, which can cause problems with blood clotting). It is important that blood counts be monitored closely while on these two medications. The length of therapy in HIV+ people has not been determined but it is expected to be long, perhaps even a lifetime for some.


Will My Anti-HIV Therapy Help My Hepatitis C?

Some drugs taken by those with HIV may actually perform a double duty for those who are also co-infected with HVC, but the benefit comes with some problems. Many anti-HIV medications, especially protease inhibitors (PIs), are metabolized by the liver. Although PIs put an added strain on a liver that is already stressed liver by HVC, the benefits may outweigh the potential risks.

The data in this area is very controversial. One study recently looked at 19 HIV+ people who were also co-infected with HVC. All 19 had severely compromised immune systems, with an average of 63 CD4 cells, and were being heavily treated with antivirals for HIV. Depending on the drugs used in the past, the participants were placed on a PI: 9 were placed on ritonovir, 7 on indinivir, and 3 on ritonovir and Saquinivir in addition to dual nucleoside analogue therapy. HVC viral loads and liver functions were looked at over the next 6 months. Initial measurements at 6 weeks after starting antiviral therapy revealed an abrupt increase in both liver function and HVC viral loads, which looked as if the hepatitis C had worsened. However, 6 months later, liver function tests returned to baseline levels and the results of the PCR test showed that the amount of virus in the blood had dropped to below baseline levels, proving stabilization of the disease. No anti-HVC treatment was co-administered. This is a small study and no real conclusions can be reached from the results, but it looks as if this data supports antiviral therapy that includes a PI as safe in those who are co-infected with HCV. Improved immunity may in turn at least stabilize hepatitis C.

Other reports have suggested an increased risk of drug-induced liver toxicity with antiviral therapy with a PI. Two research groups report data that supports this finding. Both recognize ritonavir as the most likely of the PIs studied to cause liver toxicity in those with HVC. Again, no one was treated at the same time with anti-HVC medications. It is obvious that more research is needed in this area.


Conclusion

Hepatitis C is a serious but often non-aggressive viral infection of the liver that has hit the HIV+ community hard. Approximately 9 percent of all people with HIV have this co-infection. Hepatitis C is especially prevalent in hemophiliacs and intravenous drug users. Many people are long-term carriers and can show no signs of disease of side effects for many years. As people with HIV live longer with improved therapies, hepatitis C will most likely become an even greater concern in the next millennium. Unfortunately, unlike hepatitis A and B, there is no vaccine available so prevention is the only protection.

If you do test positive for hepatitis C discuss with your provider if treatment would benefit you or if a "watch and wait" approach is best. Also, protect your liver form further assault. Do not drink alcohol, as it is very toxic to the liver. Carefully monitor all medications for ones that affect the liver as well. Ask your provider or pharmacist about your non-prescription medications, because something as common as Tylenol can put strain on the liver. And if you are HIV+, make sure you get a hepatitis A and B vaccination.


The ABC's

Hepatitis A

Transmission -- Contaminated food and water, and sexually by oral-fecal contact. Rimming without a barrier is probably the most likely method of transmission.

Symptoms -- Some people show flu-like symptoms such as fatigue, aches, no appetite, dark urine, abdominal pain, and jaundice (yellow eyes and skin). But some infected people have no symptoms at all.

Treatment -- Vaccination administered in two shots over a 6-month period ($30 a shot at the Seattle Gay Clinic; also available at local health departments or doctor's offices). Recover with rest and increased fluid intake.


Hepatitis B

Transmission -- Sexual contact, sharing of needles, bad blood products, and sometimes from mother to child at childbirth. There is an especially high incidence of hepatitis B in the gay community and even higher incidence in people who are HIV+.

Symptoms -- Fatigue, abdominal and joint pain, vomiting, nausea, and jaundice. Some never develop symptoms.

Treatment -- Vaccination administered in three shots over a 6-month period ($30 a shot at Seattle Gay Clinic, or most doctor's offices). Interferon is effective in 30 to 40 percent of people who contract hepatitis B.


Hepatitis C

Transmission -- Sexual contact, sharing of needles, blood transfusions prior to 1992, and mother to child.

Symptoms -- Most never experience acute symptoms such as fatigue, nausea, abdominal pain, and loss of appetite. Can cause chronic liver damage.

Treatment -- Interferon, Ribavirin or a combination of the two. There is no vaccine.


Hepatitis D

Transmission -- This rare form of hepatitis is transmitted in the same way as hepatitis B but is very aggressive.

Symptoms -- Fatigue, abdominal and joint pain, vomiting, nausea, and jaundice. Produces chronic liver damage symptoms similar to hepatitis B but more severe.

Treatment -- Interferon


Hepatitis F

Transmission -- Similar to hepatitis A

Symptoms -- Similar to hepatitis A.

Treatment -- Most recover without any form of treatment.


A note from TheBody.com: Since this article was written, the HIV pandemic has changed, as has our understanding of HIV/AIDS and its treatment. As a result, parts of this article may be outdated. Please keep this in mind, and be sure to visit other parts of our site for more recent information!



  
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This article was provided by Seattle Treatment Education Project. It is a part of the publication STEP Perspective.
 
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