1. Lesson 2: Secondary Prevention of Viral Hepatitis
Core Competency 2: Primary and Secondary Prevention of HCV among PLWH
Lesson 2: Secondary Prevention of Viral Hepatitis
PLWH = People Living with HIV
July 2017

2. Lesson Objective
Identify secondary prevention interventions for people with HCV infection

3. HAV and HBV Screening
Evaluation for other conditions that affect the liver, including HAV and HBV1
HAV
IgM anti-HAV2, IgG anti-HAV
Indicates past infection or vaccine-related immunity (IgG), acute infection (IgM), susceptibility3
HBV
HBsAg, anti-HBs, anti-HBc, IgM anti-HBc
Indicates resolved infection, acute infection, chronic infection, vaccine-related immunity, susceptibility4,5
Evaluation for other liver infections
Determination of susceptibility to other liver infections
HAV (fecal to oral): generally determining between immunity (past infection) and susceptibility (no past infection or vaccine). Acute infection is short.
HBV (bloodborne, sexually transmitted): several scenarios that can indicate immunity, infection, or susceptibility.
If person is actively infected with HBV, assess for treatment need.
HAV = hepatitis A virus
HBV = hepatitis B virus
HBsAg = hepatitis B surface antigen
IgG = immunoglobulin G
IgM = immunoglobulin M
HBc =  hepatitis B core antigen
Anti-HBs = hepatitis B surface antibody
Anti-HAV = hepatitis A virus antibody

4. HAV and HBV Vaccination
Recommended for all susceptible persons with HIV/HCV co-infection1
HAV/HBV combination vaccines: 3-4 doses
HAV: 2 doses6
HBV: 2-3 doses IM
Post-vaccination testing for serologic response 1-2 months after last dose7
Vaccination against other viral hepatitides.
If susceptible to both viruses, consider a combination vaccine and choose the appropriate schedule
Because of HIV infection, serologic testing after 1-2 months to assess whether immunity was acquired.
IM = Intramuscular injection

5. Risk Reduction for HAV Vaccination
Precautions when traveling in endemic regions
Bottled or boiled water (including for brushing teeth), peel and wash fruit and vegetables, avoid undercooked meat and fish
Good hygiene
Washing hands often -- diaper changes, preparing food, eating8
Barrier methods during anilingus9
HAV – fecal to oral transmission.
Best prevention is vaccination
If not immune be aware (in particular in endemic regions) when:
Eating
Drinking
Hygiene (including tooth brushing)
Mouth to anus sexual activity

6. Risk Reduction for HBV Vaccination Partner testing and disclosure
Use of condoms
Safe use of injection equipment
Precautions with piercing and tattooing
Precautions when traveling to endemic regions10
HBV – sexual and blood borne
Best prevention is vaccination.
Serodiscordant couples should avoid sharing injection equipment or having unprotected sex
Beware of anything pointy used to break the skin.

7. Harm Reduction for Liver Disease
Alcohol abstinence
Physician or pharmacist review of all medications, including:
Prescription, over the counter, supplements, herbals, hormones11
Safe food practices
Healthy behaviors
Diet and exercise for a healthy weight
Control blood sugar, cholesterol, blood fats
Reduce stress, increase emotional support12
Potential pre-existing challenges for HIV/HCV co-infected:
Existing liver damage due to HCV
Inflammation due to HIV
Liver affects of medications
Be kind to your liver – it doesn’t complain.
Avoid behaviors that challenge the liver further:
Drinking alcohol
taking certain medications
Eating/preparing food without proper precautions and appropriate cooking
Engage in behaviors that maintain health
Eat healthy
Exercise
Appropriately manage other indicators of health
Seek emotional balance, reduce stress, engage

8. References
American Association for the Study of Liver Diseases, International Antiviral Society -- USA. HCV Guidelines. Recommendations for Testing, Managing, and Treating Hepatitis C. Available at: Updated July 6, Accessed June 15, 2017. 
Centers for Disease Control and Prevention. The ABCs of Hepatitis. Available at: Updated Accessed June 15, 2017
Mayo Clinic. Interpretive Handbook Test Available at: Accessed June 15, 2017.
Centers for Disease Control and Prevention. Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection. Available at: Published September 19, Accessed June 15, 2017.
Centers for Disease Control and Prevention. Interpretation of Hepatitis B Serologic Test Results. Available at: Accessed June 15, 2017
Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Hepatitis A ACIP Vaccine Recommendations. Available at: Updated December 22, Accessed June 15, 2017.
Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Hepatitis B ACIP Vaccine Recommendations. Available at: Updated September 14, Accessed June 15, 2017.
Mayo Clinic. Hepatitis A Prevention. Available at: Accessed June 15, 2017.
Mayo Clinic. Hepatitis A Risk Factors. Available at: Accessed June 15, 2017.
Mayo Clinic. Hepatitis B Prevention. Available at: Accessed June 15, 2017
Centers for Disease Control and Prevention. Hepatitis C FAQ for Health Professionals. Available at: Accessed June 15, 2017.
U.S. Department of Veterans Affairs. Viral Hepatitis Keeping Your Liver Healthy. Available at: Accessed June 15, 2017.
American Association for the Study of Liver Diseases, International Antiviral Society -- USA. HCV Guidelines. Recommendations for Testing, Managing, and Treating Hepatitis C. Available at: Updated July 6, Accessed June 15, 2017. 
Centers for Disease Control and Prevention. The ABCs of Hepatitis. Available at: Updated Accessed June 15, 2017
Mayo Clinic. Interpretive Handbook Test Available at: Accessed June 15, 2017.
Centers for Disease Control and Prevention. Recommendations for Identification and Public Health Management of Persons with Chronic Hepatitis B Virus Infection. Available at: Published September 19, Accessed June 15, 2017.
Centers for Disease Control and Prevention. Interpretation of Hepatitis B Serologic Test Results. Available at: Accessed June 15, 2017
Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Hepatitis A ACIP Vaccine Recommendations. Available at: Updated December 22, Accessed June 15, 2017.
Centers for Disease Control and Prevention, Advisory Committee on Immunization Practices. Hepatitis B ACIP Vaccine Recommendations. Available at: Updated September 14, Accessed June 15, 2017.
Mayo Clinic. Hepatitis A Prevention. Available at: Accessed June 15, 2017.
Mayo Clinic. Hepatitis A Risk Factors. Available at: Accessed June 15, 2017.
Mayo Clinic. Hepatitis B Prevention. Available at: Accessed June 15, 2017
Centers for Disease Control and Prevention. Hepatitis C FAQ for Health Professionals. Available at: Accessed June 15, 2017.
U.S. Department of Veterans Affairs. Viral Hepatitis Keeping Your Liver Healthy. Available at: Accessed June 15, 2017.

9. Authors and Funders
This presentation was prepared by Leigh Guarinello, MPH (MidAtlantic AETC) and John Nelson, PhD, CPNP (AETC National Coordinating Resource Center) for the AETC National Coordinating Resource Center in July 2017.
This presentation is part of a curriculum developed by the AETC Program for the project: Jurisdictional Approach to Curing Hepatitis C among HIV/HCV Co-infected People of Color (HRSA ), funded by the Secretary's Minority AIDS Initiative through the Health Resources and Services Administration HIV/AIDS Bureau.

10. Disclaimer and Permissions
Users are cautioned that because of the rapidly changing medical field, information could become out of date quickly.
You may use or present this slide set and other material in its entirely or incorporate into another presentation if you credit the author and/or source of the materials.
The complete HIV/HCV Co-infection: An AETC National Curriculum is available at: