Get Regular Check-Ups and Lab Work
Going for regular check-ups and getting lab tests done is a key component of monitoring your liver health.
The doctor will perform a complete physical, including:
- Examine eyes, ears, mouth.
- Check blood pressure and weight.
- Examine the liver from the outside by pressing gently over the area above the liver. The sound that he or she hears indicates abnormality in the size or position of the liver. If liver is normal, it will be normal in size and not shrunken, enlarged or tender to the touch.
Lab work includes a series of tests that are done to monitor the health and function of the liver.
- Liver Function Tests
These tests measure the level of enzymes produced by the liver, including ALT, AST, LDH, alkaline phosphatase and total bilirubin -- the yellow or orange pigment in bile. (High levels of bilirubin can lead to jaundice.)
- Blood Platelet Count
Platelets are a part of the blood that is needed for clotting. They travel to the site of an injury where they "stick" to the injured site and help develop a clot or scab to stop the bleeding. A normal blood platelet count is 150,000-440,000. A low count may indicate more advanced disease or risks for uncontrolled bleeding (hemorrhage).
- Alpha Fetoprotein Level (AFP)
This protein stimulates an immune response. Increased AFP levels can indicate liver damage.
- Liver Biopsy
A biopsy is used to confirm the diagnosis of liver damage and determine the amount of damage. This procedure is done in the hospital under local anesthesia. A needle is inserted through the abdomen and into the liver. Then, a sample of liver tissue is removed and examined under a microscope. The primary risk associated with a biopsy is bleeding at the site where the needle was inserted. Many liver specialists recommend having a biopsy performed so that the extent of liver damage can be better understood and used to decide on when to start treatment. It is more common for a liver biopsy to be recommended for people with HCV genotype 1.
- Other diagnostic tests that may be done:
- CT scan (a tool that creates pictures of the liver using x-rays and may use a special liquid intravenously to outline the liver)
- Ultrasound (a tool that uses sound waves to create pictures)
- MRI (a tool that creates pictures similar to an x-ray, but uses magnetic rays and may use a special liquid intravenously to outline the liver)
For more information, read Project Inform's "Blood Work: A Useful Tool for Monitoring HIV."
When Do I Treat?
In general, when to start HCV therapy is based on each person's individual situation. Current guidelines recommend that people with the following conditions consider starting HCV therapy, as they can be signs of liver damage:
- Increased liver enzymes (ALT)
- A liver biopsy that shows some degree of fibrosis or moderate inflammation
There are different opinions as to when to treat people with chronic HCV infection who show no signs of liver damage. Many liver specialists recommend monitoring the health of the liver and starting treatment when there are signs of damage. For example, if you have normal or slightly above normal levels of ALT with little or no fibrosis, your doctor may recommend postponing treatment and closely monitor your liver health.
As you think about anti-HCV therapy there are several factors to consider that can help guide your decision. It is important to consider each of these points:
- Results of blood tests (elevated ALT levels, etc.)
- Liver biopsy results
- HCV viral load
- HCV genotype
- Overall health
- Readiness to start therapy
- Ability to tolerate the side effects
What to Treat First, HCV or HIV?
There is no consensus on how to best treat people who have both HIV and HCV. In general, treating HCV or HIV first will depend on the stage of liver disease and the stage of your HIV disease, for example, your CD4+ cell count and/or HIV viral load.
Many researchers believe it is wise to treat HIV first. However, if liver disease is severe, it is recommended that HCV be treated first. Improving the condition of the liver may allow a person to better tolerate anti-HIV therapies.
When treating HIV first, people benefit from being on anti-HIV therapy for at least one year before starting HCV therapy. Talk with your doctor about selecting an anti-HIV regimen that may be less burdensome on your liver.
A minimum of a 1-to-2 month gap is encouraged between starting HCV and HIV treatment. As the side effects for both HCV and HIV therapies can be difficult to manage, it's not recommended that you start treatment for both at the same time.
How Do I Know if the Treatment Is Working?
Your doctor will use two time points to determine whether you're responding to treatment or not. The end of treatment response (ETR) is 6-12 months after you start. An effective ETR is when liver functions tests are normal and there's an undetectable HCV viral load 6-12 months after starting treatment.
The sustained virologic response (SVR) is 6 months after treatment was stopped. An effective SVR is when a person's liver function tests remain normal and HCV viral load remains undetectable 6 months after stopping therapy.
Some studies also show that even if a person with HIV and HCV does not have a sustained viral response, they may have a slower progression to liver damage and liver cancer with HCV treatment.
Dealing With the Side Effects -- Therapy Can Be Hard to Tolerate
Anti-HCV therapy can be difficult to tolerate and has a number of side effects. Some people may be able to deal with and manage them while others may not. The degree of difficulty varies for each person. Side effects may only last for a few weeks or months, while others may be long-term.
Identifying strategies to cope with and manage the side effects, before you start treatment, may help your decision. In addition, it's helpful to have a strong support system so those who are close to you will be aware of and perhaps help you cope with the side effects you may experience, particularly irritability, fatigue or depression. Read Project Inform's publication, "Dealing With Drug Side Effects."
What Anti-HIV Drugs Should I Avoid?
Anti-HIV medications pass through the liver, which can result in an increase in liver enzymes (ALT). However, some are more likely to cause this than others. These can include; d4T (stavudine, Zerit), ddI (didanosine, Videx) and the protease inhibitors, especially ritonavir (Norvir). Talk with your doctor about choosing a regimen that will least likely increase ALT levels.
Pregnancy and Hepatitis -- Concerns for Pregnant and Nursing Mothers
Pregnancy will not speed HCV disease or make it worse. However, if the liver is already damaged or scarred with cirrhosis, the expectant mother could be at risk for fatty liver. (Fatty liver happens when there's not enough of the enzyme that is produced to process fatty acids. This condition can be quite serious and possibly life-threatening.)
There are no preventive therapies to reduce the rate of HCV transmission. The risk of passing HCV to the infant is dependent on two factors:
- The mother's HCV viral load: If the HCV VL is above 1 million, she's at a greater risk of transmission.
- The mother's HIV status: If a mother is also HIV-positive, she's more likely to transmit HCV to her infant.
Ribavirin causes severe birth defects, so it cannot be used by pregnant women, women who are breast-feeding or by men whose partners are pregnant. Interferon should not be used during pregnancy, as the effect on the fetus is unknown. For more information, read Project Inform's "Pregnancy and HIV."
A Note About Depression
People who have been diagnosed with depression may not be good candidates for anti-HCV therapy. However, taking anti-depressants, attending support groups or therapy may be helpful. Some doctors will recommend that a person with a history of depression be on stable and effective anti-depressant treatment for six months before starting treatment for HCV. Talk with your doctor about getting the proper mental health support. Read Project Inform's publication, Wise Words #9: "Depression and HIV."
Other Treatment Considerations
- If at all possible, work with a doctor experienced in treating people living with both HCV and HIV.
- Always take into consideration other medications that you may be on or other medical conditions you may have and how they may be affected by HCV treatment.
- Alcohol use is very toxic, can further damage your liver and is a major risk factor for rapid disease progression. Whether you take treatment for HCV or not, it's strongly recommended that you avoid using alcohol. In addition, for people who are heavy drinkers, it's recommended that alcohol is avoided 6 months before starting HCV therapy.
Vaccinations for both HAV and HBV are recommended. The vaccinations are safe and effective in people living with HIV. Read Project Inform's publication, "Hepatitis," for more information.
Back to the Project Inform WISE Words August 2003 contents page.