Hepatitis and HIV by mikeholy

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									     Viral Hepatitis and HIV

based on Centers for Disease Control information




     IPPF Competencies Workshop, Mexico City,
                28 July - 1 August 2008
  Lynn Collins, Technical Advisor, HIV/AIDS, UNFPA
           What is hepatitis?
• Definition: inflammation of the liver
• Causes:
  – toxins
  – certain drugs
  – some diseases
  – heavy alcohol use
  – bacterial and viral infections
• Also the name of a family of viral infections
  that affect the liver; A,B,C,D, and E
       Hepatitis A Virus (HAV)
• Hepatitis A: an acute liver disease caused by
  the hepatitis A virus (HAV), lasting from a few
  weeks to several months. It does not lead to
  chronic infection.
• Transmission: Ingestion of fecal matter, even in
  microscopic amounts, from close person-to-
  person contact or ingestion of contaminated
  food or drinks.
• Vaccination: Hepatitis A vaccination is
  recommended for all children starting at age 1
  year, travelers to certain countries, and others at
  risk.
                              Hepatitis A
•   Signs/symptoms (usually <2 mo.)        •   Person-to-person transmission
     –   Fever                                 through the fecal-oral route
     –   Fatigue                                – ingestion of something that has
     –   Loss of appetite                         been contaminated with the feces
                                                  of an infected person
     –   Nausea
                                                – Most infections result from close
     –   Vomiting                                 personal contact with an infected
     –   Abdominal pain                           household member or sex partner.
     –   Dark urine
     –   Clay-colored bowel movements      •   Common-source outbreaks and
     –   Joint pain                            sporadic cases also can occur
     –   Jaundice                              from exposure to fecally
     –   jaundice or elevated serum            contaminated food or water.
         aminotransferase levels.
•   Confirmation:
     – a positive serologic test for IgM
       antibody to hepatitis A virus, or
     – clinical case definition
 Who is at increased risk for HAV?
• Travelers to countries with high or
  intermediate endemicity of HAV
• Men who have sex with men
• Users of injection and non-injection illegal
  drugs
• Persons with clotting factor disorders
• Persons working with nonhuman primates
  susceptible to HAV infection
                                       HAV
•   Incubation period 28 days (range: 15–50 days).
•   Survival outside the body for months, depending on the environmental
    conditions. The virus is killed by heating to 185 degrees F (85 degrees C)
    for one minute. Adequate chlorination of water kills HAV that enters the
    water supply.
•   Hepatitis A does not become chronic.
•   Reinfection not possible: IgG antibodies to HAV, which appear early in
    the course of infection, provide lifelong protection against the disease.
•   Prevention
     – by vaccination with the full, two-dose series – lasts 25 years in adults and at least
       14–20 years in children
     – The safety of hepatitis A vaccination during pregnancy has not been determined;
       however, because the vaccine is produced from inactivated HAV, the theoretical
       risk to the developing fetus is expected to be low.
     – Because hepatitis A vaccine is inactivated, no special precautions need to be
       taken when vaccinating immunocompromised persons
     – Immune globulin is available for short-term protection (approximately 3 months)
       both pre- and post-exposure. Immune globulin must be administered within 2
       weeks after exposure for maximum protection.
     – Good hygiene.
     Vaccination candidates HAV
•   All children at age 1 year (i.e., 12–23 months).
•   Children and adolescents ages 2–18 who live in states or communities where routine
    hepatitis A vaccination has been implemented because of high disease incidence..
•   Persons traveling to or working in countries that have high or intermediate rates of
    hepatitis A.
•   Men who have sex with men. Sexually active men (both adolescents and adults) who have
    sex with men should be vaccinated. Hepatitis A outbreaks among men who have sex with
    men have been reported frequently.
•   Users of illegal injection and noninjection drugs. During the past two decades, outbreaks
    of hepatitis A have been reported with increasing frequency among users of both injection
    and noninjection drugs (e.g., methamphetamine) in North America, Europe, and Australia.
•   Persons who have occupational risk for infection. Persons who work with HAV-infected
    primates or with HAV in a research laboratory setting should be vaccinated. No other
    groups have been shown to be at increased risk for HAV infection because of occupational
    exposure.
•   Persons who have chronic liver disease. Persons with chronic liver disease who have
    never had hepatitis A should be vaccinated, as they have a higher rate of fulminant
    hepatitis A (i.e., rapid onset of liver failure, often leading to death). Persons who are either
    awaiting or have received liver transplants also should be vaccinated.
•   Persons who have clotting-factor disorders. Persons who have never had hepatitis A and
    who are administered clotting-factor concentrates, especially solvent detergent-treated
    preparations, should be vaccinated.
                    Hepatitis B
• Hepatitis B: a liver disease caused by the hepatitis B
  virus (HBV). It ranges in severity from a mild illness,
  lasting a few weeks (acute), to a serious long-term
  (chronic) illness that can lead to liver disease or liver
  cancer.
• Transmission: Contact with infectious blood, semen,
  and other body fluids from having sex with an infected
  person, sharing contaminated needles to inject drugs,
  orfrom an infected mother to her newborn.
• Vaccination: Hepatitis B vaccination is recommended
  for all infants, older children and adolescents who were
  not vaccinated previously, and adults at risk for HBV
  infection
                             Hepatitis B
•   Signs/symptoms (acute: several         HBV is transmitted through activities
    weeks to 6 months)                       that involve percutaneous (i.e.,
      – Fever                                puncture through the skin) or
      – Fatigue                              mucosal contact with infectious
                                             blood or body fluids (e.g., semen,
      – Loss of appetite                     saliva), including
      – Nausea                             • Sex with an infected partner
      – Vomiting                           • Injection drug use that involves sharing
      – Abdominal pain                       needles, syringes, or drug-preparation
      – Dark urine                           equipment
      – Clay-colored bowel movements       • Birth to an infected mother
      – Joint pain                         • Contact with blood or open sores of an
      – Jaundice                             infected person
•   Persons with chronic HBV infection     • Needle sticks or sharp instrument
    might be asymptomatic, have no           exposures
    evidence of liver disease, or have a   • Sharing items such as razors or
    spectrum of disease ranging from         toothbrushes with an infected person
    chronic hepatitis to cirrhosis or
    hepatocellular carcinoma (a type of    HBV is not spread through food or
    liver cancer).                           water, sharing eating utensils,
•   Confirmation:                            breastfeeding, hugging, kissing, hand
      – a serologic testing                  holding, coughing, or sneezing.
  Who is at increased risk for HBV?
• Infants born to infected mothers
• Sex partners of infected persons
• Sexually active persons who are not in a long-term, mutually
  monogamous relationship (e.g., >1 sex partner during the previous 6
  months)
• Men who have sex with men
• Injection drug users
• Household contacts of persons with chronic HBV infection
• Healthcare and public safety workers at risk for occupational
  exposure to blood or blood-contaminated body fluids
• Hemodialysis patients
• Residents and staff of facilities for developmentally disabled persons
• Travelers to countries with intermediate or high prevalence of HBV
                                 HBV
•   Incubation period 90 days (range: 60–150 days)

•   Survival outside the body for 7 days

•   Acute infection ranges from asymptomatic or mild disease to — rarely —
    fulminant hepatitis.

•   Chronic HBV infection:
     – Approximately 25% of those who become chronically infected
       during childhood and 15% of those who become chronically
       infected after childhood die prematurely from cirrhosis or liver
       cancer, and the majority remain asymptomatic until onset of
       cirrhosis or end-stage liver disease.
     – The risk for chronic infection varies according to the age at
       infection and is greatest among young children. Approximately
       90% of infants and 25%–50% of children aged 1–5 years will remain
       chronically infected with HBV. By contrast, approximately 95% of
       adults recover completely from HBV infection and do not become
       chronically infected.
                                       HBV
•   Prevention
    – Vaccination with the full, two-dose series – lasts 23 years
    – Hepatitis B vaccine contains no live virus, so neither pregnancy nor lactation
      should be considered a contraindication to vaccination of women. On the basis of
      limited experience, there is no apparent risk of adverse effects to developing
      fetuses when hepatitis B vaccine is administered to pregnant women.
    – Larger doses or additional doses might also be necessary hemodialysis and
      immunocompromised persons and serologic testing is recommended 1–2
      months after administration of the final dose of the primary vaccine series to
      determine the need for revaccination. Also for sex partners of persons with
      chronic HBV infection, and exposed infants
    – Need for booster doses not known for PLHIV
    – After a person has been exposed to HBV, appropriate prophylaxis, given as soon
      as possible but preferably within 24 hours, can effectively prevent infection. The
      mainstay of postexposure immunoprophylaxis is hepatitis B vaccine, but in
      certain circumstances the addition of HBIG will provide increased protection.
•   Treatment
    – For acute infection, no medication is available; treatment is supportive.
    – For chronic infection, several antiviral drugs (adefovir dipivoxil, interferon alfa-2b,
      pegylated interferon alfa-2a, lamivudine, entecavir, and telbivudine) are
      available. Persons with chronic HBV infection require medical evaluation and
      regular monitoring to determine whether disease is progressing and to identify
      liver damage or hepatocellular carcinoma.
        Vaccination candidates HBV
•   All infants, beginning at birth
•   All children aged <19 years who have not been vaccinated previously
•   Susceptible sex partners of hepatitis B surface antigen (HBsAg)-
    positive persons
•   Sexually active persons who are not in a long-term, mutually
    monogamous relationship (e.g., >1 sex partner during the previous 6
    months)
•   Persons seeking evaluation or treatment for a sexually transmitted
    disease
•   Men who have sex with men
•   Injection drug users
•   Susceptible household contacts of HBsAg-positive persons
•   Healthcare and public safety workers at risk for exposure to blood or
    blood-contaminated body fluids
•   Persons with end-stage renal disease, including predialysis,
    hemodialysis, peritoneal dialysis, and home dialysis patients
•   Residents and staff of facilities for developmentally disabled persons
•   Travelers to regions with intermediate or high rates of endemic HBV
•   Persons with chronic liver disease
•   Persons with HIV infection
•   All other persons seeking protection from HBV infection —
    acknowledgment of a specific risk factor is not a requirement for
    vaccination
                Hepatitis C
• Hepatitis C: a liver disease caused by the
  hepatitis C virus (HCV). HCV infection
  sometimes results in an acute illness, but most
  often becomes a chronic condition that can lead
  to cirrhosis of the liver and liver cancer.
• Transmission: Contact with the blood of an
  infected person, primarily through sharing
  contaminated needles to inject drugs.
• Vaccination: There is no vaccine for hepatitis C.
                         Hepatitis C
                                       HCV is transmitted by:
                                       • Sharing needles, syringes, or other
•   Signs/symptoms 70%–80% of             equipment to inject drugs
    people with acute hepatitis C do   • Needlestick injuries
    not have any symptoms. For those   • Being born to a HepC + mother
    who do, they appear 6-7 weeks      Less commonly, a person can also get
    after exposure.                       hepatitis C virus infection through:
     – Fever                           • Sharing personal care items that may
     – Fatigue                            have come in contact with another
     – Loss of appetite                   person’s blood (razors or toothbrushes)
                                       • Having sexual contact with a HepC+
     – Nausea                             person
     – Vomiting                             –   the risk of transmission from sexual
                                                contact is believed to be low.
     – Abdominal pain
                                            –   Risk increases for those who have
     – Dark urine                               multiple sex partners, have a sexually
                                                transmitted disease, engage in rough sex,
     – Clay-colored bowel                       or are living with HIV. More research is
        movements                               needed to better understand how and
     – Joint pain                               when hepatitis C can be spread through
                                                sexual contact.
     – Jaundice (yellow color in the   Hepatitis C virus is not spread by sharing
        skin or eyes)                     eating utensils, breastfeeding, hugging,
                                          kissing, holding hands, coughing, or
                                          sneezing. It is also not spread through
                                          food or water.
 Who is at increased risk for HCV?
• Current injection drug users
• Past injection drug users, including those who injected only one time
  or many years ago
• Recipients of donated blood, blood products, and organs
• People who received a blood product for clotting problems made
  before 1987
• Hemodialysis patients or persons who spent many years on dialysis
  for kidney failure
• People who received body piercing or tattoos done with non-sterile
  instruments
• People with known exposures to the hepatitis C virus, such as
    – Healthcare workers injured by needlesticks
    – Recipients of blood or organs from a donor who tested positive for the
      hepatitis C virus
• People living with HIV
• Children born to mothers infected with the hepatitis C virus
                              HCV
Incubation period 4–12 weeks (range: 2–24 weeks).

Of every 100 people infected with the hepatitis C virus, about
• 75–85 people will develop chronic hepatitis C virus infection; of
   those,
    – 60–70 people will go on to develop chronic liver disease
    – 5–20 people will go on to develop cirrhosis over a period of 20–
      30 years
    – 1–5 people will die from cirrhosis or liver cancer

Approximately 15%–25% of people who get hepatitis C will clear the
  virus from their bodies without treatment and will not develop chronic
  infection. Experts do not fully understand why this happens for some
  people.
Prevention
                                         HCV
•   Clients should be informed about the low but present risk for transmission with sex
    partners.
•   Sharing personal items that might have blood on them, such as toothbrushes or razors,
    can pose a risk.
•   Cuts and sores on the skin should be covered to keep from spreading infectious blood or
    secretions.
•   Donating blood, organs, tissue, or semen can spread HCV to others.
•   HCV is not spread by sneezing, hugging, holding hands, coughing, sharing eating utensils
    or drinking glasses, or through food or water.
•   Patients may benefit from a joining support group.


Treatment
     – Combination therapy with pegylated interferon and ribavirin is the treatment of choice.
       Treatment success rates are now being improved with the addition of polymerase and
       protease inhibitors to standard pegylated interferon/ribavirin combination therapy.

     –   HCV-positive persons should be advised to avoid alcohol because it can accelerate
         cirrhosis and end-stage liver disease.

     –   Viral hepatitis patients should also check with a health professional before taking any
         new prescription pills, over-the counter drugs (such as non-aspirin pain relievers), or
         supplements, as these can potentially damage the liver.
Who should be tested for HCV?
• Persons who have ever injected illegal drugs, including those who
  injected only once many years ago
• Recipients of clotting factor concentrates made before 1987
• Recipients of blood transfusions or solid organ transplants before
  July 1992
• Patients who have ever received long-term hemodialysis treatment
• Persons with known exposures to HCV, such as
    – healthcare workers after needlesticks involving HCV-positive blood
    – recipients of blood or organs from a donor who later tested HCV-
      positive
• All persons living with HIV
• Patients with signs or symptoms of liver disease (e.g., abnormal liver
  enzyme tests)
• Children born to HCV-positive mothers (to avoid detecting maternal
  antibody, these children should not be tested before age 18 months)
                       HIV and Hepatitis
Hepatitis B and HIV
• HBV) and HIV are bloodborne viruses transmitted primarily through sexual contact and
   injection drug use. Because of these shared modes of transmission, a high proportion of
   adults at risk for HIV infection are also at risk for HBV infection.
• HIV-positive persons who become infected with HBVare at increased risk for developing
   chronic HBV infection.
• Persons who are co-infected with HIV and HBV can have serious medical complications,
   including an increased risk for liver-related morbidity and mortality.
• To prevent HBV infection in people living with HIV, hepatitis B vaccination is recommended
Hepatitis C and HIV
• HCV is a bloodborne virus transmitted through direct contact with the blood of an infected
   person. Thus, coinfection with HIV and HCV is common (50%–90%) among HIV positive
   injection drug users.
• HCV infection progresses more rapidly to liver damage in people living with HIV.
• HCV infection may also impact the course and management of HIV infection.
• People living with HIV should be screened for HCV infection.
• Injection drug users (IDUs) are at risk for HBV and HCV sharing needles and drug-
   preparation equipment. HAV outbreaks are believed to occur through both percutaneous and
   fecal-oral routes. IDUs should get vaccinated against hepatitis A and hepatitis B.
Hepatitis, HIV, and MSM
• Men who have sex with men (MSM) are at elevated risk for certain sexually transmitted
   diseases (STDs), including hepatitis A, hepatitis B, HIV/AIDS, syphilis, gonorrhea, and
   chlamydia. Despite the availability of safe and effective vaccines, many MSM have not been
   adequately vaccinated against viral hepatitis.
              Hepatitis D
• Hepatitis D: a serious liver disease
  caused by the hepatitis D virus (HDV) and
  relies on HBV to replicate.
• Transmission: Contact with infectious
  blood, similar to how HBV is spread.
• Vaccination: There is no vaccine for
  hepatitis D.
                 Hepatitis E
• Hepatitis E: a serious liver disease caused by
  the hepatitis E virus (HEV) that usually results in
  an acute infection. It does not lead to a chronic
  infection.
• Transmission: Ingestion of fecal matter, even in
  microscopic amounts; outbreaks are usually
  associated with contaminated water supply in
  countries with poor sanitation.
• Vaccination: There is currently no FDA-
  approved vaccine for hepatitis E.

								
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