HEPATITIS B, HEPATITIS C

AND HIV

Jane Minton
Consultant in Infectious Diseases &
Tropical Medicine
Leeds Teaching Hospitals Trust
 HEPATITIS B

• HOW DO YOU GET IT?

• WHAT ARE THE SYMPTOMS?

• HOW DO YOU MAKE THE DIAGNOSIS?

• CAN IT BE TREATED?

• HOW CAN IT BE PREVENTED?

 HOW DO YOU GET
HEPATITIS B?
EXPOSURE TO BODY FLUIDS
– IVDA

– NEEDLESTICKS ETC.

– AMATEUR BODYPIERCING ETC.

– BLOOD TRANSFUSION

– SEX

– PERINATAL
WHAT ARE THE SYMPTOMS OF
ACUTE HEPATITIS B?
• FATIGUE AND MALAISE

• NAUSEA AND VOMITING

• FEVER

• RUQ PAIN AND MYALGIA

• JAUNDICE
 HOW DO YOU TEST FOR
ACUTE HEPATITIS B?
• LIVER FUNCTION TESTS

– transaminases in 1000s
– deranged blood coagulation

• SEROLOGY

– HBV Core IgM

– HBV surface antigen
– HBV e antigen
 HOW DO YOU TREAT ACUTE
HEPATITIS B ?
• SYMPTOMATIC
– ANALGESIA
– ANTIEMETICS
– ANALGESIA
• SUPPORTIVE
– HYDRATION
– NUTRITION
– COAGULATION
– (TRANSPLANTATION)
• EDUCATION
– TRANSMISSION
 WHAT ARE THE
COMPLICATIONS OF CHRONIC
HEPATITIS B?
• CHRONIC LIVER DAMAGE

• CIRRHOSIS

• CANCER

• TRANSMISSION TO OTHERS
 CAN YOU TREAT CHRONIC
HEPATITIS B?

• INTERFERON

• LAMIVUDINE

• LIVER TRANSPLANT
PREVENTION OF HEPATITIS B

• EDUCATION
– SAFE SEX, NOT SHARING NEEDLES ETC

• SCREENING
– CASE CONTACTS
– ANTENATAL
– IVUs

• VACCINES
– ACTIVE (HBV sAg)
– PASSIVE (HBIG)

• PROVISION OF CLEAN NEEDLES ETC.

 Case History: Mr HB age 42

• Unwell for 10 days: malaise, nausea,

vomiting, abdo pain, dark urine & jaundice
• Previously fit, no medication
• Recently separated, has 2 sons age 8 &10
• Girl friend for 4 months, pregnant
• Fireman
• Travel to Majorca last year
• Alcohol 10U/week, non smoker & no other
recreational drug use
 Mr HB

• Examination: deeply jaundiced, enlarged

tender liver
• Investigations:
– LFTs - acute hepatitis
– Serology - acute hepatitis B
• Treatment
– symptomatic
– follow-up
• Public health issues
– notifiable
– screening +/- investigation of contacts
– vaccination of non-immune contacts
 HEPATITIS C

• HOW DO YOU GET IT?

• WHAT ARE THE SYMPTOMS?

• HOW DO YOU MAKE THE DIAGNOSIS?

• CAN IT BE TREATED?

• HOW CAN IT BE PREVENTED?

 HOW DO YOU GET
HEPATITIS C?
• BLOOB-BORNE
– IVDA

– NEEDLESTICKS ETC.

– AMATEUR BODYPIERCING ETC.

– BLOOD TRANSFUSION

• [SEX]

• [VERTICAL]
 WHAT HAPPENS WHEN YOU
GET HEPATITIS C?

• OFTEN ASYMPTOMATIC TO START WITH

• MOST PEOPLE REMAIN INFECTED

[CHRONIC HEPATITIS C]
WHAT ARE THE SYMPTOMS OF
CHRONIC HEPATITIS C?
• NOTHING

• MALAISE AND FATIGUE

• LIVER FAILURE
– CIRRHOSIS
– ASCITES
– JAUNDICE
– BLEEDING
– ENCEPHALOPATHY
 WHAT ARE THE
COMPLICATIONS OF CHRONIC
HEPATITIS C?
• CHRONIC LIVER DAMAGE

• CIRRHOSIS

• CANCER

• TRANSMISSION TO OTHERS
 HOW DO YOU TEST FOR
CHRONIC HEPATITIS C?
• SEROLOGY [HCV ANTIBODIES]

• LIVER FUNCTION TESTS

• HCV PCR

• ULTRASOUND OF LIVER

• LIVER BIOPSY
 CAN YOU TREAT CHRONIC
HEPATITIS C?

• INTERFERON WITH RIBAVIRIN

• LIVER TRANSPLANT
 THE PROBLEMS WITH
INTERFERON
• LOW SUCCESS RATE
• SUBCUTANEOUS INJECTION
• LONG COURSE OF TREATMENT
• LOTS OF SIDE EFFECTS
– ‘FLU-LIKE
– BONE MARROW
– DEPRESSION
• THE COST
PREVENTION OF HEPATITIS C

• EDUCATION
– NOT SHARING NEEDLES ETC, SAFE SEX

• SCREENING
– CASE CONTACTS
– IVUs

• VACCINES
– NONE

• PROVISION OF CLEAN NEEDLES ETC.

CASE HISTORY: MR HC AGE 33

• Registers with GP asking for detox.

• Complains of tiredness first thing in morning
• PMH: jaundice age 26
• 10 year history IVU, has shared equipment in
the past
• Lives with partner (also IVU) who is pregnant
• Alcohol rarely, smokes 15/day
• No foreign travel
 MR HC

• Examination normal except needle tracks

• Investigations
– HCV Ab positive [HBV past infection, HIV negative]
– LFTs: ALT 121
– HCV PCR positive
– ultrasound of liver normal
– liver biopsy: moderate hepatitis
• Treatment
– candidate for interferon plus ribavirin (NB drug use)
• Public health issues
– notifiable
– screening +/- investigation of contacts
 HIV

• HOW DO YOU GET IT?

• WHAT ARE THE SYMPTOMS?

• HOW DO YOU MAKE THE DIAGNOSIS?

• HOW DO YOU TREAT IT?

• HOW CAN IT BE PREVENTED?

 HOW DO YOU GET
HIV?
EXPOSURE TO BODY FLUIDS
– IVDA

– NEEDLESTICKS ETC.

– AMATEUR BODYPIERCING ETC.

– BLOOD TRANSFUSION

– SEX

– PERINATAL
WHAT ARE THE SYMPTOMS OF
HIV?
• NON-SPECIFIC ILLNESS
(SEROCONVERSION)

• NOTHING

• OPPORTUNISTIC INFECTIONS EG:

– ORAL THRUSH
– RECURRENT SHINGLES
– PNEUMONIA (PNEUMOCYSTIS)
– HEADACHES (MENINGITIS)
– DIARRHOEA (CRYPTOSPORIDIUM)
 WHAT DOES HIV DO?

• INFECTS AND DESTROYS KEY CELLS IN

IMMUNE SYSTEM
• ESPECIALLY CD4+ OR HELPER T CELLS
• MAY INFECT OTHER TISSUES EG NERVE
CELLS
• MAKES PATIENTS MORE SUSCEPTIBLE TO
INFECTIONS
– COMMON INFECTIONS
– OPPORTUNISTIC INFECTIONS
HOW DO YOU TEST FOR HIV?

• SEROLOGY [HIV ANTIBODIES]

• CD4 COUNT [HELPER T CELLS]

• HIV PCR [VIRAL LOAD]

 HOW DO YOU TREAT HIV?

• COMBINATION ANTIRETROVIRAL DRUGS

– AT LEAST 3
– MAJOR CLASSES
• REVERSE TRANSCRIPTASE INHIBITORS
• NON-NUCLEOTIDE RTIs
• PROTEASE INHIBITORS
• PROPHYLACTIC DRUGS EG FOR PCP
• EDUCATION
• NUTRITION
• SUPPORT
 PREVENTION OF HIV
• EDUCATION
– SAFE SEX, NOT SHARING NEEDLES ETC

• SCREENING
– CASE CONTACTS, ANTENATAL, IVUs

• PROVISION OF CLEAN NEEDLES ETC

• POST-EXPOSURE PROPHYLAXIS

• NO VACCINES
 CASE HISTORY: MS HI AGE 26

• Premature delivery at 28 weeks

• PMH: anaemia & UTIs in pregnancy
• Drugs: iron
• Student from Zimbabwe in UK for 6 months
• 1 child from previous marriage
• Current partner well
• Alcohol 2u/week, non-smoker, no recreational
drug use
• Baby HIV antibody positive
 MS HI

• Examination: oral thrush

• Investigations
• HIV antibody positive
• CD4+ count 21 (normal 500+)
• HIV viral load > 100,000 virus per ml blood
• Treatment
• 3 antiviral drugs & septrin
• Support
• Counselling/testing for partner