Viral Hepatitis
Updated May 2010
A. Hepatitis A Virus (HAV)
Recommendations:
Clinicians should administer the HAV vaccine to HIV-infected patients who are negative for HAV IgG. The full series, consisting of an initial dose and a second dose 6 to 12 months later, should be given to ensure maximal antibody response.
Clinicians should administer HAV vaccination early in the course of HIV infection. If a patient’s CD4 count is <200 cells/mm3, or the patient has symptomatic HIV disease, it is preferable to defer vaccination until several months after initiation of ARV therapy in an attempt to maximize the antibody response to the vaccine. However, vaccination should not be deferred in pregnant patients or patients who are unlikely to achieve an increased CD4 count.
Clinicians should obtain a post-vaccination antibody measurement in patients who are at increased risk for hepatitis A infection (see Table 1).
| Table 1: Persons Who Are At Increased Risk For Hepatitis A Infection | |
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| * Persons with chronic liver disease are at increased risk for severe infection if they become co-infected with hepatitis A. |
Infection with HAV can be prevented by active immunization prior to exposure with either of the two currently licensed vaccines, which are considered equivalent in efficacy. HAV vaccines are highly immunogenic in immunocompetent adults (>95% seroconversion); however, the seroconversion rates and the geometric mean serum antibodies in HIV-infected individuals are lower than in non-HIV-infected populations. Response rates have generally ranged from 50% to 95%.1-5 HAV vaccine appears to have no effect on the course of HIV infection or on plasma HIV viral load. A combined hepatitis A and B vaccine is also available and can be used in persons susceptible to both hepatitis A and B. It is given in three total doses at 0, 1, and 6 months.
Administration of HAV vaccine is preferred when CD4 counts are ≥200 cells/mm3 to maximize response to the vaccine. An effective antibody response may not occur in up to 15% of patients with CD4 counts <200 cells/mm3.4 Follow-up HAV antibody testing should be obtained in patients who are at increased risk for hepatitis A infection to verify vaccine efficacy and to identify patients who might benefit from vaccine boosting. Some clinicians would obtain post-vaccination antibody measurements in all HIV-infected patients. Documentation of HAV susceptibility in the patient’s medical record facilitates targeted counseling for patients who are at increased risk for HAV (see Table 1).
Serum immune globulin can be given to individuals who are not immune to HAV within 2 weeks after an exposure to an HAV household contact, sexual partner, or common source exposure. A single intramuscular dose of 0.02 mL/kg is effective in preventing infection or attenuating HAV infection that might result from such an exposure. HAV vaccine is not currently indicated for post-exposure prophylaxis in patients with HIV, although it is prudent to administer it concurrently with serum immune globulin for the long-term prophylaxis of an at-risk individual. The Advisory Committee on Immunization Practices recommends a single dose of single-antigen hepatitis A vaccine for healthy persons aged 12 months to 40 years for post-exposure prophylaxis to HAV.6
B. Hepatitis B Virus (HBV)
Recommendations:
Clinicians should counsel patients about behavior modifications that decrease their risk of acquiring HBV infection through unprotected sexual activity and injection drug use.
As part of the baseline assessment, clinicians should ask patients about their HBV vaccination history and should obtain the following:
- HBV serologies: HBsAg, HBsAb, and HBcAb (IgG or total)
- Hepatitis A IgG and hepatitis C IgG
Clinicians should administer the HBV vaccination series to HIV-infected patients who are negative for HBsAb, unless they are chronically infected (see Adults Guidelines Hepatitis B Virus: Figure 3).
Clinicians should test for HBsAb between 4 and 12 weeks after vaccination. Nonresponders (HBsAb <10 IU/L) should be revaccinated with another three-dose hepatitis B vaccine series (see Adults Guidelines Hepatitis B Virus: Figure 3). If a patient’s CD4 count is <200 cells/mm3 or the patient has symptomatic HIV disease, revaccination may be deferred until several months after initiation of ARV therapy in an attempt to maximize the antibody response to the vaccine. However, revaccination should not be deferred in pregnant patients or patients who are unlikely to achieve an increased CD4 count.
The serologic and virologic responses to hepatitis B are shown in Table 2. Active immunization and passive immunization are two types of prophylaxis for hepatitis B. Active immunization involves the administration of the hepatitis B vaccine series prior to exposure to HBV (pre-exposure prophylaxis) or after exposure (post-exposure prophylaxis) over a 6-month period. After exposure to a known chronic HBV carrier, the hepatitis B vaccine is usually given along with passive immunization using hepatitis B immunoglobulin (HBIG).
| Table 2: Serologic and Virologic Responses To HBV | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| a Studies have found occult HBV infection in approximately 10% of HBcAb-positive and HBsAg- and HBsAb-negative HIV-infected patients.2,3 Occult infection may be associated with greater immunosuppression (<200 cells/mm3) and higher HIV DNA levels.4 b Formerly known as convalescent. |
HBsAg, HBsAb, and HBcAb IgG should be included in prevaccination screening for HIV-infected persons. This panel identifies patients with prior HBV infection as well as responders to prior hepatitis B vaccination. People who are negative for all three tests are eligible to receive the hepatitis B vaccine.
In >90% of adult immunocompetent patients, three doses of the hepatitis B vaccine are efficacious and induce protective antibody. The two commercially available vaccines are equally immunogenic. Three vaccine doses are given at 0, 1 to 2 months, and 6 months. The doses of vaccine vary by the patient’s age.
Several factors reduce the vaccine’s immunogenicity. These include age >40 years, tobacco use, and HIV infection, especially when CD4 counts are low. Ideally, the HBV vaccine series should be administered early in the course of HIV disease, before severe immune suppression has occurred. However, advanced immune suppression is not a contraindication to vaccination, and vaccination should not be deferred or delayed because of advanced immune suppression or in anticipation of expected immune recovery due to the effect of HAART.
Generally, in HIV-infected patients who do not respond to the vaccine series, a rapid loss of induced antibody occurs. These patients are, therefore, at risk for HBV infection following exposure. The clinician should test for HBsAb between 4 and 12 weeks after completion of the third vaccine dose. HBV seroconversion may be enhanced by immune reconstitution (≥200 cells/mm3) prior to revaccination. However, revaccination should not be deferred in pregnant patients or patients who are unlikely to achieve an increased CD4 count.
A combined hepatitis A and B vaccine is available and may be used in persons susceptible to both hepatitis A and B. It is given in three total doses at 0, 1, and 6 months.
For information regarding occupational or non-occupational HBV postexposure prophylaxis, refer to HIV Prophylaxis Following Occupational Exposure and HIV Prophylaxis Following Non-Occupational Exposure Including Sexual Assault. For information regarding prophylaxis for perinatal HBV transmission, refer to the Women’s Committee guidelines Management of HIV-Infected Pregnant Women Including Prevention of Perinatal HIV Transmission.
C. Hepatitis C Virus (HCV)
Recommendations:
Clinicians should:
- Counsel HIV/HCV co-infected patients to avoid practices that transmit both HIV and HCV, including high-risk sexual practices, such as unprotected sex, and needle-sharing behaviors among injection drug users. (AII)
- Counsel active injection drug users to use new sterile equipment at all times, dispose of their syringes after one use, and clean their injection sites carefully with clean alcohol swabs. These patients should be urged to undergo treatment to reduce drug use (see Working With the Active User). (AIII)
- Advise household contacts of persons chronically infected with HCV to avoid sharing items that may be contaminated with blood, such as toothbrushes and razors. (AIII)
- Encourage uninfected, long-term sexual partners of persons co-infected with HCV and HIV to continue to follow safer-sex practices to prevent transmission of HIV and HCV. (AII)
Behavioral health counseling is critical for preventing HIV and HCV transmission. Patients with previously resolved HCV infection should also be informed of the risk for re-infection. Antibody to HCV will stay positive for life, even after successful anti-HCV therapy, but does not confer any protective immunity. Re-infection would be documented by a recurrence of HCV viremia.
For a table of the elements that should be included in behavioral health counseling, refer to Table 4 of Primary Care Approach to the HIV-Infected Patient. For information regarding occupational or non-occupational post-exposure management, refer to HIV Prophylaxis Following Occupational Exposure and HIV Prophylaxis Following Non-Occupational Exposure Including Sexual Assault.
REFERENCES
1. Weissman S, Feucht C, Moore BA. Response to hepatitis A vaccine in HIV-positive patients. J Viral Hepat 2006;13:81-86. [PubMed]
2. Shire NJ, Welge JA, Sherman KE. Efficacy of inactivated hepatitis A vaccine in HIV-infected patients: A hierarchical bayesian meta-analysis. Vaccine 2006;24:272-279. [PubMed]
3. Wallace MR, Brandt CJ, Earhart KC, et al. Safety and immunogenicity of an inactivated hepatitis A vaccine among HIV-infected subjects. Clin Infect Dis 2004;39:1207-1213. [PubMed]
4. Kemper CA, Haubrich R, Frank I, et al. Safety and immunogenicity of hepatitis A vaccine in human immunodeficiency virus-infected patients: A double-blind, randomized, placebo-controlled trial. J Infect Dis 2003;187:1327-1331. [PubMed]
5. Rimland D, Guest JL. Response to hepatitis A vaccine in HIV patients in the HAART era. AIDS 2005;19:1702-1704. [PubMed]
6. Advisory Committee on Immunization Practices (ACIP) Centers for Disease Control and Prevention (CDC). Update: Prevention of hepatitis A after exposure to hepatitis A virus and in international travelers. Updated recommendations of the Advisory Committee on Immunization Practices (ACIP). MMWR Morb Mortal Wkly Rep 2007;56(41):1080-1084. Available at: www.cdc.gov/mmwr/preview/mmwrhtml/mm5641a3.htm
7. Shire NJ, Rouster SD, Rajicic N, et al. Occult hepatitis B in HIV-infected patients. J Acquir Immune Defic Syndr 2004;36:869-875. [PubMed]
8. Re VL 3rd, Frank I, Gross R, et al. Prevalence, risk factors, and outcomes for occult hepatitis B virus infection among HIV-infected patients. J Acquir Immune Defic Syndr 2007;44:315-320. [PubMed]
9. Tsui JI, French AL, Seaberg EC, et al. Prevalence and long-term effects of occult hepatitis B virus infection in HIV-infected women. Clin Infect Dis 2007;45:736-740. [PubMed]
FURTHER READING
Mast EE, Margolis HS, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: Recommendations of the Advisory Committee on Immunization Practices (ACIP) part 1: Immunization of infants, children, and adolescents. MMWR Recomm Rep 2005;54(RR-16):1-31. Available at: www.cdc.gov/MMWR/preview/mmwrhtml/rr5416a1.htm
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