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Co-Infection of Hepatitis B and Hepatitis C

If you or someone you know has been diagnosed with Hepatitis B (HBV) or Hepatitis C (HCV), may have heard the phrase “co-infection”. It may be confusing, because your blood tests may only show that you have active HBV or HCV. So why would you and your doctor need to worry about both?

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HBV and HCV are separate viruses, but because they are transmitted the same way, it is not uncommon to have both at the same time. This is important to recognize because people who have HBV/HCV co-infections have different risks: both long-term risks if they are not treated and short-term risks during treatment.

Long-term risks of co-infection

Patients who have HBV/HCV co-infections have higher rates of cirrhosis than patients who have just HBV or just HCV.1 Cirrhosis is scar tissue that happens on your liver over a long period of time as your liver is damaged by diseases, including HBV and HCV.2 This scar tissue usually cannot be reversed and it makes your liver not work as well as it should. Cirrhosis can eventually become life-threatening and, sometimes, may require a liver transplant.

Patients with HBV/HCV co-infections are also at higher risk for hepatocellular carcinoma (HCC), the most common form of liver cancer.1 Because patients with both HBV and HCV are also more likely to have more damage to their liver, either from cirrhosis or chronic liver inflammation, they are more likely to have factors that lead to liver cancer.

Treatment for co-infection of HBV/HCV

It is important to treat HBV and HCV infections early to limit liver damage and long-term diseases like cirrhosis and HCC, but how is treating an HBV/HCV co-infection different than treating just HBV or HCV?

When a patient has a co-infection, usually only one of the viruses is dominant. This means that your immune system is only fighting one of the viruses, and the other virus is not active, even if your immune system knows that it is in your body.2 This may be because your immune system thinks that it has already fought the virus and has it under control. For most (but not all) patients with HBV/HCV co-infections, HCV is dominant, so doctors want to treat this virus first, but if the HBV is dominant, that would be the first virus treated.2

The medications used to treat HCV are called direct-acting antivirals (DAAs). These drugs now carry a “Black Box Warning” which is used by the FDA to draw attention to serious or life threatening risks.3 When DAAs are given to treat HCV patients with HBV co-infections, the HBV can potentially reactivate, even if the patient’s immune system held the HBV in-check prior to treatment.4,5 This occurs in about 30-50% of patients, and researchers are not sure why this happens; It may be due to the patient’s immune system not being as active after fighting the HCV virus for so long.3 In our 2018 Hepatitis C In America survey, approximately 50% of respondents were retested for HBV after being treated for HCV, and about 10% stated that they tested positive for HBV.

What you should know

Researchers warn that patients who are to be treated for active HCV should always be tested for HBV and if a co-infection is found, they should be treated by a liver specialist.4 Patients should receive regular blood tests throughout their HCV treatment to make sure that HBV is not being reactivated, and if it is, they should receive treatment for HBV from a liver or hepatitis specialist.

You should not be scared to seek treatment for your HBV/HCV coinfection, but you should be aware of the potential side effects that can occur. Make sure to ask your care team questions about your disease and treatments, and don’t hesitate to ask to be referred to a specialist for your disease.

  1. Konstantinou D, Deutsch M. The spectrum of HBV/HCV coinfection: epidemiology, clinical characteristics, viralinteractions and management. Ann Gastroenterol. 2015;28(2):221-228.
  2. Cirrhosis - Symptoms and causes. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/cirrhosis/symptoms-causes/syc-20351487. Published 2018. Accessed November 9, 2018.
  3. U.S. Food and Drug Administration. https://www.fda.gov/downloads/forconsumers/consumerupdates/ucm107976.pdf. Published 2018. Accessed November 9, 2018.
  4. HBV/HCV Coinfection and Possible Reactivation of HBV Following DAA Use. Gastroenterol Hepatol (N Y). 2017;13(5):292-295.
  5. Black Box Warning for Possible HBV Reactivation During DAA Therapy for Chronic HCV Infection. Gastroenterol Hepatol (N Y). 2017;13(9):536-540.

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