HIV and the Liver

Question 1

List some common opportunistic infections of the liver

Answer 1

Mycobacterium tuberculosis (MTB)
Mycobacterium avium complex (MAC)
Histoplasmosis
AIDS cholangiopathy

Question 2

What are the consequences of HBV and HIV co-infections

Answer 2

• Higher rate of chronic HBV infection
• Increased replication HBV
• Lower rate of spontaneous loss of HBeAg and/or HBsAg
• Higher risk of seroreversion to HBeAg or HBsAg in patients with advanced immunosuppression
• More rapid progression towards cirrhosis and hepatocellular carcinoma

Question 3

How is the Diagnosis of HBV and HIV co-infection made

Answer 3

Known HIV patient tested for HBV with HBsAg

Liver function test - ALT is adequate i asymptomatic patients

Question 4

What is the treatemtn for HBV and HIV co-infection

Answer 4

Current first-line antiretroviral (ARV) drug regimen has 2 drugs that are active against HBV: Tenofovir, lamivudine and dolutegravir

Question 5

What are some consequences of HCV and HIV co-infection

Answer 5

• Shortens time to developing HCV-related liver complications such as cirrhosis and hepatocellular carcinoma
• Increases levels of HCV viraemia, thus increasing risk of further transmission
• Lowers rate of spontaneous recovery of acute hepatitis

Question 6

How is the diagnosis of HCV and HIV co-infection made

Answer 6

• HCV serology - if positive do HCV PCR
• Liver function tests – ALT alone is adequate in asymptomatic patients

Question 7

What is the treatment for HCV and HIV co-infection

Answer 7

• Initiate patients on antiretroviral therapy first
• HCV treatment with directly acting antiviral (DAA) drugs

Question 8

What is meant by Non-alcoholic fatty liver disease (NAFLD)

Answer 8

Term used for a range of liver conditions caused by accumulation of fat in the liver in people who use little or no alcohol

Question 9

What are the NAFLD conditions

Answer 9

• Steatosis (fatty liver) – benign
• Non-alcoholic steatohepatitis (NASH) – moderate fibrosis
• Cirrhosis – severe fibrosis

Question 10

How is NAFLD is HIV patients diagnosed

Answer 10

• Elevated ALT, AST, GGT
• High serum lactate
• Ultrasound or other non-invasive tests
• Liver biopsy

Question 11

How is NAFLD managed

Answer 11

Use “metabolically friendly” ARVs
* Avoid older agents e.g. stavudine, didanosine

Minimize HIV associated immune activation
* Early treatment of HIV, regardless of CD4 count

• Maintain HIV suppression with potent ART
  Test for & efficiently treat HBV & HCV infection

Lifestyle & diet changes such as exercise and reducing alcohol consumption

Question 12

Which drugs can lead to drug-induced liver injury

Answer 12

ARV drugs
- Nevirapine
- Atazanavir
- Efavirenz, abacavir, other protease inhibitors

Anti-TB drugs e.g. isoniazid, rifampicin, pyrazinamide
Other e.g. fluconazole, cotrimoxazole

Question 13

What is IMMUNE RECONSTITUTION INFLAMMATORY SYNDROME (IRIS)

Answer 13

An exaggerated inflammatory response related to the recovery of immune responses to pre-existing opportunistic pathogens, following the initiation of ART.

Question 14

What are the 2 types of IRIS

Answer 14

– Paradoxical - paradoxical worsening of treated opportunistic infections
– Unmasking - unmasking of previously subclinical, untreated infections

Question 15

What are the pathogens assocaited with IRIS

Answer 15

• Mycobacterium tuberculosis
• Mycobacterium other than tuberculosis (MOTT)
• Histoplasma species
• Hepatitis viruses - HBV and HCV
• Cytomegalovirus (CMV)