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