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Guide to Hepatitis B for People Living With HIV

June 2009

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Section 10: Living With Chronic HBV

Probably the most important aspect of dealing with any medical condition is having the time and support to become better informed about choices that affect your health.

Many people who are diagnosed with a chronic disease take the opportunity to examine their lives in order to reduce stress and improve both their quality of life and their general health.

Some of the lifestyle changes discussed below can reduce the risk of HBV progression -- especially cutting down on or avoiding alcohol. Stopping smoking; eating better; resting properly; exercising; and other forms of stress reduction are important for everyone's health.

Alcohol and HBV

Heavy drinking is known to be harmful to the liver. Alcohol intake in amounts of more than 50 grams per day (four or five glasses of wine, beer, or mixed drinks) for men and more than 30 grams per day (two or three glasses of wine, beer, or mixed drinks) for women is clearly associated with more rapid development of liver disease. Alcohol harms the liver by increasing both inflammation and scarring. Since no one has determined what amount of alcohol is not harmful to people with liver disease, the less you drink, the better for your liver. Many doctors recommend abstinence.

Alcohol and Liver Damage

Alcohol is broken down mainly by the liver, and this process creates by-products that damage the liver more than the alcohol itself does. Prolonged inflammation from long-term alcohol use causes an overproduction of molecules called free radicals that can destroy healthy liver tissue, subsequently impairing liver function.

Alcohol can also disrupt the production of antioxidants, which defend the body against free-radical damage. The combination of overproduction of free radicals and loss of antioxidants can contribute to liver damage.

Women may be more prone than men to the damaging effects of alcohol. Drinking less -- or not at all -- can be very difficult. Some people cut down or quit on their own, while others find that support groups, counseling, and/or pharmacotherapy work best for them. A list of resources is provided on the next page.

Recreational Drugs

The liver is the organ that processes most recreational drugs. These drugs are likely to contain impurities and unspecified ingredients. If you are injecting drugs, use new, sterile equipment -- needle, cooker, filter, water, tie, and measuring syringe -- each time to protect yourself from hepatitis C and other infections.

Support Organizations

Alcohol and Drugs

Organizations that provide information and support for people who want to reduce or stop their use of alcohol and/or drugs include:

Alcoholics Anonymous:

Buprenorphine FAQs:

Buprenorphine Physician and Treatment Locator:

FAQs: A Quick Guide to Finding Effective Drug and Alcohol Treatment (from SAMHSA):

Fact Sheets on Recreational Drugs:

Referral to a Therapist : 1-888-227-7542

Moderation Management:

Narcotics Anonymous:

Opioid Treatment Program Directory:

Substance Abuse Treatment Facility Locator:

Harm Reduction Resources

Directory of Syringe-Exchange Programs and Other Resources by State

Harm Reduction Psychotherapy and Training Associates

People who are regular users of recreational drugs may not be getting enough sleep or eating well, and may be under a great deal of stress. For these reasons, recreational drug use -- especially on a daily basis -- can have a negative impact on a person's health; however, there is not enough research on whether this kind of drug use can actually cause or worsen liver damage in people with chronic hepatitis.

Street Drugs and the Liver

Since cocaine, heroin, methamphetamine, GHB (gammahydroxybutyrate), ketamine, and ecstasy are illegal, there is very little research or information on whether these drugs cause liver damage in people with chronic hepatitis. Most research on "street drugs" (illegal drugs) has been done in mice or in a test tube, not in humans. What happens inside the human body is often very different than what happens in an animal or a test tube, so it is hard to know how the results from these studies relate to what actually happens in a person's body.

The purity of street drugs varies. The other substances that are added to street drugs may be harmful to the liver, although the drug itself may not be; this makes it more difficult to know if using street drugs has an effect on chronic hepatitis.

Regular use of marijuana (one joint or more per day over several years) accelerates the progression of fibrosis in people with chronic HBV and HCV, but occasional use of marijuana has not been found to be harmful.

You can find more detailed information about street drugs and HIV at

Some people are comfortable with their drug use, while others might find it problematic. If you want to stop using recreational drugs, there are places where you can get help. Please see the resources listed in the sidebar.

Prescription Drug Use

Some people use prescription drugs to get high. This can be risky because the drugs may interact with other medications, causing lowered or increased drug levels in a person's body. If drug levels are too low, medications may stop working, and in some cases -- such as with HIV medications and antibiotics -- resistance can develop. Drug levels that are too high can also be dangerous, since they can increase drug toxicity and side effects, or cause an overdose.

For example, midozolam interacts with alcohol; caffeine; sleeping pills; some antidepressants and anti-anxiety drugs; hormonal contraception (birth control pills); some of the drugs used to treat TB fungal infections, high blood pressure, heart problems; and even cold medications (among others).

Benzodiazipines, a family of drugs that includes midozolam, diazepam, rohypnol, and alprazolam, are addictive. Withdrawal symptoms include seizures, psychosis, and the "rebound effect," where insomnia or anxiety return and are worse than what someone experienced before they started using these drugs.

Drug Overdose

The risk of overdosing on certain prescription drugs (alprazolam, diazepam, midozolam, triazolam, fentanyl, and lidocaine) may be higher in people with cirrhosis from chronic hepatitis, since some drugs are broken down by the liver.


Smoking has a negative impact on everyone's health. Research on the impact of smoking on HBV disease progression has shown unclear results because most people in the studies also drank alcohol, making it hard to tell how much smoking mattered.

Stopping smoking is not easy. Giving up cigarettes may be a long-term goal for many people; it may not always be a person's most important short-term priority. If you feel ready to stop smoking, talk with your doctor about ways to make quitting easier.


A healthy and balanced diet is important for general good health. Liver abnormalities are more common in people who are overweight; these abnormalities may include liver steatosis and inflammation.

Liver problems are also more common among people with diabetes, and being overweight is a risk factor for developing diabetes. When overweight people lose weight, their liver condition is likely to improve.

All foods and fluids pass through the liver to be broken down. Avoiding things that are hard for the liver to break down supports liver health.

The most appropriate diet for you depends on a number of factors including age, weight, extent of liver damage, and current symptoms. With advanced liver disease, avoiding or reducing the amount of certain foods may be important. These may include:

  • Fried foods;
  • Foods with a high fat content, especially if they contain saturated or hydrogenated fats (trans fats);
  • Very high-protein diets;
  • Foods with a high iron content, and iron supplements, unless your liver specialist recommends these;
  • Processed food and "junk" food;
  • Caffeine in coffee, tea, and some carbonated drinks;
  • Salt, especially if you have advanced liver disease;
  • Foods containing additives and pesticides; and
  • Sugar, since diabetes is more common among people with chronic HBV; eat less food containing processed sugar, and switch from white bread and pasta to whole wheat bread and pasta.

If you find it hard to lose weight or want more information on a healthier diet, ask your doctor about seeing a nutritionist.

Herbal Medicine

Herbal remedies have been used for centuries to treat liver disease, but they cannot cure hepatitis B. So far, no clinical trials have demonstrated that herbal remedies are safe and effective against hepatitis B. Many people use these nonetheless: some because conventional treatment has not worked for them, others because of concerns about the side effects of HBV therapy. Keep in mind that even natural or herbal products may cause stress to the liver.

Milk thistle (silymarin) is often used to treat hepatitis B, though clinical trials have not found any benefit. Research on milk thistle and viral hepatitis is ongoing.

Licorice root (glycyrrhizin) has been used to treat HBV in Japan. There is very little information from clinical trials on its effectiveness; however, long-term use can cause side effects such as high blood pressure and fluid retention, which are especially serious for people with cirrhosis.

Many other combinations of herbs are being sold to treat HBV or benefit the liver. Unfortunately, these products are unregulated, and they differ in purity and strength. Some may actually be harmful to the liver, and others may interact with HIV drugs and other medications. It is important to discuss the use of any herbs or supplements with your doctor.


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This article was provided by Treatment Action Group.
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