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Co-infection with HIV
Increasingly in Canada, people who have hepatitis C are also living with the human immunodeficiency virus (HIV). This is partly because both viruses can be transmitted by blood-to-blood contact. Sharing materials contaminated with blood (including equipment for injection drug use, piercing, tattooing or medical procedures) puts a person at risk for both viruses. Having HIV can also make a person more susceptible to getting Hep C. (For more information, see What is Risky?)
Approximately 13,000 people in Canada are co-infected with HCV and HIV. Although these numbers are based on estimates and predictions, it does mean that about 20% of people living with HIV are also living with Hep C, and about 5.2% of people living with Hep C are also living with HIV. Currently, liver disease related to Hep C is the leading cause of death among people with HCV-HIV co-infection.
People living with both HIV and HCV face significantly increased challenges related to health and disease progression, treatment decisions and stigma. These challenges are not impossible to overcome but do require that people have access to knowledgeable healthcare, information and support in order to manage their dual conditions and live long and healthy lives.
For more information on HIV, visit CATIE’s website at www.catie.ca. Here is a quick overview, followed by a comparison of HIV and Hep C and information about co-infection:
What is HIV?
HIV stands for Human Immunodeficiency Virus. It is a virus that attacks a person’s immune system and causes AIDS. AIDS stands for Acquired Immune Deficiency Syndrome.
How is HIV transmitted?
HIV is carried in five body fluids: blood, semen, vaginal fluids, rectal fluids and breast milk. A person can be infected with HIV when one of these fluids gets into the body. In Canada, this usually happens in the following ways:
- through unprotected sex (usually anal or vaginal sex) with a person who has HIV
- by reusing drug use equipment already used by someone who has HIV
- mother-to-child transmission during childbirth or breastfeeding, if the mother has HIV
- from a blood transfusion in Canada before November 1985
HIV and also Hep B enter the body in many of the same ways as Hep C, so steps people take to protect themselves from Hep C will also help protect them from HIV and Hep B. (For more information, see the section on Prevention and Harm Reduction.)
What is CD4+?
CD4+ refers to a kind of white blood cell that is part of the immune system. Like other parts of the immune system, CD4+ cells help keep people healthy. They protect the body by coordinating other parts of the immune system to attack viruses, bacteria and other invaders that may cause illness.
What does HIV do?
HIV gets into a CD4+ cell and uses it to make more viruses (called replication). This causes the CD4+ cell’s functioning to be impaired and the cell eventually dies. When there are fewer CD4+ cells, it is easier for other viral or bacterial infections to set in and make a person sick. A CD4+ cell count is an important measure of how well the immune system is functioning. A healthy immune system generally has a CD4+ count greater that 500, but this can vary from person to person.
HIV viral load is also an important measure of HIV disease. The more HIV present in the body, the more the virus attacks the immune system and the greater the chance of getting sick.
Over time, when HIV has killed many CD4+ cells, the immune system will not work as well. A person is then susceptible to illnesses that a healthy immune system could easily control. These are called AIDS-defining illnesses or opportunistic infections and include some types of pneumonia (such as PCP) and some cancers (such as Kaposi’s sarcoma). In Canada, a person is considered to have AIDS if he or she has HIV and gets sick with one or more of these diseases.
When someone has HIV, it is important to have regular checkups with a doctor to monitor HIV viral load and CD4+ count because these will guide decisions around starting or changing treatment.
HIV Treatment
There is no cure for HIV, but there are medicines that fight HIV. HIV medicines are called antiretroviral drugs (ART). HIV treatment includes taking a combination of antiretroviral drugs at the same time—usually at least three.
These medicines can reduce the HIV viral load in blood and semen to undetectable levels. Most HIV viral load tests can only detect more than 50 copies/ml and cannot measure below this threshold. Even with an “undetectable” viral load, HIV is still in the body; the risk of transmission is greatly reduced, but it can still occur. When the virus is undetectable, it is prevented from killing off CD4+ cells, and the body can replenish the CD4+ cells that have already died to a level that will protect a person from getting sick.
HIV is tricky and can mutate, which means its genetic makeup changes. This leads to drug resistance, which means that a person’s drug combination will not work to stop HIV from replicating. Drug resistance tends to happen if a person does not take his or her medicines regularly. But because there are more than 20 different anti-HIV drugs, and different combinations of these drugs, people have many treatment options and can live long and healthy lives with HIV.
Visit www.catie.ca to find out more about HIV and HIV treatment.
Comparing hepatitis C and HIV
Hepatitis C and HIV are separate and distinct viruses and there are many differences between them. However, they also share some similarities. Differences and similarities are outlined in the chart below:
Comparing Hep C and HIV | ||
| Hep C | HIV |
Transmission | Through contact with infected blood. | Through contact with infected blood, semen, vaginal fluids, rectal fluids or breast milk. |
How most people get it in Canada | Using drug-use equipment already used by someone else, particularly equipment for injection drug use. | Unprotected sex. |
Testing | Antibody test looks for exposure. RNA test looks for infection. | Positive antibody test shows infection. |
Treatment duration | Six months to a year depending on the Hep C genotype. | Lifelong HIV treatment. |
Treatment regimen | Currently, peg-interferon with ribavirin. | Antiretroviral Therapy (ART)—a combination of three or more anti-HIV drugs. |
Response to treatment | HCV can be completely cleared from the body if treatment is successful. About 20% of people will spontaneously clear the virus and not need treatment. | Levels of HIV can be reduced to undetectable levels but not cleared from the body. Infection can sometimes occur with a drug-resistant strain of HIV that does not respond to treatment. |
How long virus survives outside the body | HCV can survive for at least four days outside the body. In certain conditions, such as the inside of a syringe, HCV can survive for up to eight weeks. | HIV dies within minutes in open air outside the body. In certain conditions, such as the inside of a syringe, HIV can survive from one to three weeks. |
The effect of bleach on transmission | Bleach can be effective at killing HCV on surface objects. Bleach is not effective at killing HCV in used syringes. | Bleach can be effective at killing HIV on surface objects and in used syringes. |
Possibility of re-infection | There is no immunity to HCV. Re-infection can occur even if virus was cleared before. | This is not applicable to HIV because HIV cannot be cleared from the body. |
Possibility of infection with more than one strain | People can be infected with more than one genotype, but this is rare. | People can be infected with more than one strain of HIV. |
Vaccine | No vaccine currently available for HCV. | No vaccine currently available for HIV. |
Window period (for recommended testing) | Two to four months after exposure to HCV. | Three months after exposure to HIV. |
Part of body targeted | HCV mostly replicates and multiplies in the liver, leading to liver damage. | HIV mainly targets immune cells (CD4+ cells) for replication, causing weakening of the immune system. |
Prevalence (estimates) | Canada: 250,000 infections | Canada: 65,000 infections |
Hep C | HIV | |
|---|---|---|
Transmission interactions
Having HIV increases the chances of transmitting HCV through two routes:
- from a woman to her baby during pregnancy or childbirth
- during unprotected sexual intercourse
A baby born to a woman with HIV and HCV is more likely to be born with HCV than if the baby’s mother is living with only HCV.
HCV may be transmitted sexually, especially among HIV-positive gay men, bisexual men and other men who have sex with men. Sexual transmission of HCV is rare but the risk increases with the presence of HIV, other sexually transmitted infections, menstruation or through certain sex practices, including rough sex, fisting, group sex or sex with multiple partners. Using a condom, glove or dental dam will reduce the risk of hepatitis C transmission by reducing exposure to blood. (For more information, see Sexual transmission of hepatitis C: Are HIV-positive gay and bisexual men at risk?)
Testing
Screening for Hep C is recommended for all people diagnosed with HIV, and vice versa. Repeat testing or regular surveillance at set intervals may be appropriate for individuals with ongoing exposure to other people’s blood.
Having advanced, untreated HIV can sometimes lead to false negative results in Hep C antibody tests because the immune suppression caused by HIV reduces the body’s ability to manufacture antibodies. More tests may be required to get the full understanding of the status of HCV in the body.
Co-infection complications: Impact on hepatitis C
Research shows that hepatitis-C-related liver damage (fibrosis and cirrhosis) is more common and can happen more quickly in people who are co-infected with HCV and HIV. Because of this, some healthcare providers will monitor liver damage more frequently in a co-infected individual than in someone who is mono-infected.
Co-infection complications: Impact on HIV
People with co-infection may experience lower CD4+ counts. Some studies find that people with HCV and HIV may experience smaller increases in CD4+ cells when they start HIV medications than someone who is living with only HIV. Chronically low CD4+ counts can affect the progression of HIV and people with co-infection may be at a greater risk for some opportunistic infections.
People with co-infection may also be at a greater risk for some non-AIDS-defining illnesses, including heart disease, kidney disease, diabetes, osteoporosis and neurological disorders.
Treatment interactions
Managing treatment in people who are co-infected with HCV and HIV is more complex than managing treatment in people with only one infection. This is because people who are co-infected may respond differently to medications used to treat HIV or Hep C. (For more information, see Treatment for HIV and Hepatitis C.)
Healthy living with co-infection
Actively promoting good general health is especially important for people who have both infections. (For more information, see Living with Hep C.)
Also, infection with another strain of HIV or HCV or additional viruses like Hep B can increase the progression of both infections and make treatment decisions even more difficult. Taking care to prevent more infections is part of healthy living with HIV and hepatitis C. Therefore, all of the suggestions for reducing harm and maintaining health are even more important for people who have both infections. (For more information, see Prevention and Harm Reduction.)
Revised 2011.
