Viral Hepatitis Among People with HIV

Key points

  • People with HIV who have underlying liver disease are at risk for severe disease from hepatitis A virus (HAV) infection.
  • People with HIV who become infected with hepatitis B virus (HBV) or hepatitis C virus (HCV) are at increased risk for liver-related morbidity and mortality.
  • HBV or HCV infection may affect the management of HIV infection.
  • People with HIV should be vaccinated against hepatitis A and hepatitis B and tested for hepatitis B and hepatitis C.
Two men snuggled on couch coinfected with HIV and viral hepatitis

Risks

People with HIV face additional health risks and challenges.

People with HIV and hepatitis A

People with HIV who have underlying liver disease are at risk for severe disease from HAV infection. For people with HIV, hepatitis A vaccine might not provide long-term protection.

People with HIV and hepatitis B

HBV and HIV are bloodborne viruses transmitted primarily through sexual contact and sharing injection drug equipment. Because of these shared modes of transmission, a high proportion of adults at risk for HIV infection are also at risk for HBV infection. People with HIV who become infected with hepatitis B virus are at increased risk for liver-related disease and death1234

HBV infection may also affect the management of HIV infection.

People with HIV and hepatitis C

HCV is a bloodborne pathogen transmitted through direct contact with the blood of a person who is infected with HCV. In 2009, approximately 21% of adults with HIV who were tested for past or present HCV infection tested positive, although coinfection prevalence varies substantially according to risk group (for example, men who have sex with men [MSM], high-risk heterosexuals, and people who use injection drug equipment)567.

HCV infection may also affect the management of HIV infection

Among people who use injection drug equipment and have HIV, HCV coinfection is common (estimated 62%–80%).78 Although transmission via using or sharing injection drug equipment remains the most common mode of acquisition in the United States8, sexual transmission can happen among MSM with HIV, especially among those who have unprotected anal intercourse, use sex toys, or use non-injection drugs9. HCV is one of the primary causes of chronic liver disease in the US, and HCV-related liver injury progresses more rapidly among people coinfected with HIV.1011121314People with HIV who become infected with hepatitis C are at increased risk for liver-related disease. HCV infection may also affect the management of HIV infection.9

Preventing hepatitis A

Beginning in 2020, CDC and the Advisory Committee on Immunization Practices (ACIP) began recommending that all people with HIV who are 1 year of age or older:

  • Be vaccinated against hepatitis A.
  • Receive post-vaccination serologic testing (PVST) 1 month or more after completing the hepatitis A vaccine series.

Clinicians should conduct PVST 1–2 months after completion of the hepatitis A vaccine series. The clinician should explain to the patient that, regardless of PVST results, the vaccine might not provide long-term protection and they might need to receive immune globulin (IG) after a high-risk exposure (for example, sexual or household contact).

Keep Reading: Hepatitis A Vaccine Administration

Preventing hepatitis B

Screening and testing for hepatitis B

CDC recommends screening all adults 18 and older for hepatitis B at least once in their lifetime. The screening tests include:

  • Hepatitis B surface antigen (HBsAg).
  • Antibody to hepatitis B surface antigen (anti-HBs).
  • Antibody to hepatitis B core antigen (anti-HBc).

CDC recommends hepatitis B testing for all people, regardless of age, who are susceptible to hepatitis B and have risk for exposure. This includes people with a history of sexually transmitted infections or multiple sex partners, people with HIV infection, and those who share injection drug use equipment. Some might be reluctant to disclose stigmatizing risks, therefore anyone who requests HBV testing should receive it regardless of disclosure of risk. Anyone with ongoing risk who is susceptible to hepatitis B should have periodic testing as long as risk persists.

Any person with hepatitis B should be tested for HIV.

Keep Reading: Clinical Testing and Diagnosis for Hepatitis B

Vaccinating against hepatitis B

Hepatitis B testing is not a requirement for vaccination, and in settings where testing is not feasible, vaccination should continue without testing. Serologic testing should not be a barrier to vaccination of susceptible persons, especially in populations where it is difficult to access screening or testing services.

Hepatitis B vaccination is the most effective means of preventing hepatitis B transmission for all people, including those at risk for infection. ACIP recommends:

  • Hepatitis B vaccination for all infants starting at birth.
  • Hepatitis B vaccination among all adults aged 19–59.
  • Hepatitis B vaccination among adults aged 60 and older with risk factors for hepatitis B like, HIV infection.
  • Post-vaccination serologic testing (PVST) for those with HIV 1–2 months after completion of the hepatitis B vaccine series.

The Department of Health and Human Services Panel on Antiretroviral Guidelines for Adults and Adolescents has specific recommendations on hepatitis B vaccination in people with HIV, including revaccination recommendations for hepatitis B vaccine non-responders. See the National Institutes of Health (NIH)'s HBV Infection Prevention and Treatment Guidelines for details.

Keep Reading: Hepatitis B Vaccine Information for Health Care Providers

Treatment for HBV/HIV infection

Clinicians should provide HIV antiviral medication with activity against HBV for people with HIV who test positive for HBV.

Preventing hepatitis C

Screening and testing for hepatitis C

CDC recommends:

  • One-time hepatitis C testing of all adults 18 and older.
  • Pregnant people be tested during each pregnancy.
  • Periodic testing for people with risk factors, like those who have HIV or share injection drug use equipment.

Treatment for hepatitis C

The American Association for the Study of Liver Diseases (AASLD) and the Infectious Diseases Society of America (IDSA) recommend that people who are coinfected with HIV and HCV receive timely treatment with direct-acting antiviral (DAA) medications.

Keep Reading: Clinical Care of Hepatitis C

Resources

These resources from CDC and the NIH provide further guidance and information on viral hepatitis and HIV.

Scientific guidelines and recommendations

Helpful websites

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Content Source:
Division of Viral Hepatitis
  1. Gatanaga H, Yasuoka A, Kikuchi Y, et al. Influence of prior HIV-1 infection on the development of chronic hepatitis B infection. Eur J Clin Microbiol Infect Dis. 2000 Mar;19(3):237–9.
  2. Thio CL, Seaberg EC, Skolasky R, et al. Multicenter AIDS Cohort Study. HIV-1, hepatitis B virus, and risk of liver-related mortality in the Multicenter Cohort Study (MACS). Lancet. 2002 Dec;360(9349):1921–6.
  3. Bonacini M, Louie S, Bzowej N, et al. Survival in patients with HIV infection and viral hepatitis B or C: a cohort study. AIDS. 2004 Oct 21;18(15):2039–45.
  4. Weber R, Sabin CA, Friis-Møller N, et al. Liver-related deaths in persons infected with the human immunodeficiency virus: the D:A:D study. Arch Intern Med. 2006 Aug 14–28;166(15):1632–41.
  5. Garg S, Brooks J, Luo Q, Skarbinski J. Prevalence of and Factors Associated with Hepatitis C Virus (HCV) Testing and Infection Among HIV-infected Adults Receiving Medical Care in the United States. Infectious Disease Society of America (IDSA). Philadelphia, PA, 2014.
  6. Yehia BR, Herati RS, Fleishman JA, Gallant JE, Agwu AL, Berry SA, et al. Hepatitis C virus testing in adults living with HIV: a need for improved screening efforts. PLoS ONE 2014;9(7):e102766.
  7. Spradling PR, Richardson JT, Buchacz K. Trends in hepatitis C virus infection among patients in the HIV Outpatient Study, 1996–2007. J Acquir Immune Defic Syndr 2010;53:388–396.
  8. Centers for Disease Control and Prevention. Viral Hepatitis Surveillance — United States, 2021. Atlanta: US Department of Health and Human Services, Centers for Disease Control and Prevention; 2021.
  9. Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. HIV Clinical Guidelines: Adult and Adolescent Opportunistic Infections - What's New in the Guidelines. Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. Updated September 25, 2023.
  10. Telfer P, Sabin C, Devereux H, et al. The progression of HCV-associated liver disease in a cohort of haemophilic patients. Br J Haematol. 1994;87(3):555–561.
  11. Soto B, Sanchez-Quijano A, Rodrigo L, et al. Human immunodeficiency virus infection modifies the natural history of chronic parenterally acquired hepatitis C with an unusually rapid progression to cirrhosis. J Hepatol. 1997;26(1):1–5.
  12. Benhamou Y, Bochet M, Di Martino V, et al. Liver fibrosis progression in human immunodeficiency virus and hepatitis C virus coinfected patients. The Multivirc Group. Hepatology. 1999;30(4):1054–1058.
  13. Graham CS, Baden LR, Yu E, et al. Influence of human immunodeficiency virus infection on the course of hepatitis C virus infection: a meta-analysis. Clin Infect Dis. 2001;33(4):562–569.
  14. American Association for the Study of Liver Diseases/Infectious Diseases Society of America. HCV Guidance: Recommendations for Testing, Managing, and Treating Hepatitis C. Accessed July 6, 2018.