1) What is viral hepatitis?

Hepatitis literally means inflammation of the liver. Viral hepatitis is caused by one of several distinct viral agents such as hepatitis A (HAV), hepatitis B (HBV) or hepatitis C (HCV) virus. Hepatitis can also result from non-infectious causes such as excessive alcohol use, as a side effect to certain medications or as a symptom of other illnesses. The general symptoms of hepatitis include: jaundice (a yellowing of the skin and eyes), fatigue, stomach pain, poor appetite and intermittent nausea and vomiting. In addition to HAV, HBV and HCV, scientists have also identified hepatitis D, E and G. Others may be discovered in the future. This Q&A Sheet will primarily cover HAV, HBV and HCV and will touch upon hepatitis D. Knowledge of hepatitis E and G clinical syndromes is still very limited.

2) What is known about the different types of viral hepatitis?

Since the 1960’s, scientists have been working to isolate and understand the characteristics of the different types of hepatitis. The tables summarize specific information about HAV, HBV and HCV. These reference tables will help providers understand the similarities and differences between the viruses, and can serve as a tool for educating patients and clients. It is important to understand that infection with more than one type of hepatitis is possible. Co-infection with more than one type can increase the severity of symptoms and worsen the condition of the liver. For example, hepatitis D can only infect a person already infected with HBV. Individuals co-infected with HBV and hepatitis D are at high risk of liver failure. Similarly, HAV may cause severe illness to persons infected with HCV.

3) Why is it important for HIV/AIDS service providers and other health and human services professionals to learn about viral hepatitis?

High rates of HAV, HBV and HCV are found in the same communities in which we find high rates of HIV. HIV, HBV and HCV are all bloodborne pathogens which are transmitted through similar activities. HAV is not a bloodborne pathogen but it is associated with sexual practices which involve oral-anal contact. Many people with HIV (PWHIV) have a past history of infection with HAV, HBV or HCV. Similarly, individuals with current or past infection with viral hepatitis may be at risk for HIV and would benefit from knowing their HIV status. The sharing of injection drug equipment has led to high rates of HIV, BBV and HCV among active and former substance users. It is estimated that after two years of injecting drugs, 75-85% of users will be infected with HCV, and approximately 75% or more of these individuals will become HCV carriers who are able to infect others through the established routes of transmission.

HIV/AIDS service providers should be aware that it is safe for persons with HIV to receive vaccines against hepatitis. PWHIV can also benefit from treatment of chronic hepatitis. Scientists are studying whether hepatitis can worsen HIV infection and also whether HIV infection can worsen hepatitis.

4) What can health and human services providers do to assist clients with prevention, early detection, and treatment for viral hepatitis?

A) Integrate Prevention Counseling into Encounters with Clients and Patients

A critical component of prevention counseling for HAV and HBV is referral of high risk individuals for screening and vaccination. Clients should be offered clear information and behavioral counseling about how to avoid exposure to viral hepatitis. HIV prevention efforts which promote safer sex and substance use practices will also help prevent transmission of viral hepatitis. Use of barrier protection such as a condom during every act of oral, anal and vaginal intercourse will help prevent sexual transmission of HIV, HAV and HBV. Referral of active substance users to syringe exchange programs can provide users with access to clean injection equipment, can reduce sharing of injection equipment and help link users to other health and social services. Additional tailored messages needed to prevent HAV, HBV and HCV include:

• HAV is transmitted through oral-fecal contact; therefore, clients should be counseled to avoid oral-anal contact (using a latex barrier between the mouth and anus may reduce risk) and avoid oral contact with unwashed fingers, sex toys and other objects that have been in contact with the anus or fecal matter.
• Other known or suspected routes of transmission of HBV and HCV include sharing equipment used for tattooing or body piercing, sharing razors and toothbrushes and sharing straws for intra-nasal drug use.

B) The Importance of Routine Screening and Vaccination

Routine screening and vaccination for HAV and HBV is the most effective intervention available to prevent new infections with HAV and HBV.

HAV: The Centers for Disease Control and Prevention (CDC) recommends screening and vaccination for HAV for all injecting drug users and men who have sex with men. Virtually all individuals with prior HAV infection develop antibodies to HAV and have life-long immunity. If the screening detects these antibodies, vaccination is not necessary.

HBV: One of the most important steps that can be taken to prevent transmission of HBV is screening for all current and past substance users. Drug treatment programs should develop and implement policies for routine screening of all clients for HBV. Routine screening is critical because many people with HBV are carriers who do not have active symptoms of the disease but are able to transmit the virus to others. Such persons should be counseled about how to avoid infecting others. Substance users who have never been infected with HBV should be provided an explanation of the benefits of vaccination and should be offered the vaccine. Non-monogamous adults should also be screened for HBV and offered the vaccine as appropriate. Household members and sex partners of HBV carriers should be tested and if susceptible, should be vaccinated. Since the vaccine involves three shots over the course of six months, efforts should be made to ensure that clients receive the complete series of vaccinations.

HCV: The CDC recommends that individuals with risk factors for HCV be routinely offered testing. In addition, testing should be made available to any individual interested in knowing his/her HCV infection status. Testing should be accompanied by education and medical follow-up. There is no vaccine for HCV.

C. Refer Persons Infected with HAV, HBV, or HCV for Medical Care

All individuals with hepatitis should be referred for medical evaluation. Medications for chronic HBV and HCV are recommended for some, but not all, patients. Persons with active disease should be counseled against drinking alcohol and should have regular medical evaluation and monitoring. Persons with hepatitis who remain in care can be alerted to new treatments and possible drug interactions.

Table 1. Prevention Counseling for Hepatitis A, B and C

Table 2. Hepatitis A, B and C: Quick Reference Chart