As part of the baseline assessment, clinicians should:
- Evaluate liver function, including aspartate aminotransferase (AST) and alanine aminotransferase (ALT)
- Ask human immunodeficiency virus (HIV)-infected patients about their hepatitis A virus (HAV) and hepatitis B virus (HBV) vaccination history
- Obtain the following serologies:
- Hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (HBsAb), and hepatitis B core antibody (HBcAb) (immunoglobulin G [IgG] or total)
- Hepatitis A IgG
- Hepatitis C IgG
Clinicians should evaluate HIV-infected substance users chronically infected with hepatitis B (or co-infected with hepatitis B and C) for liver disease. These patients should be evaluated and offered treatment when medically indicated according to current guidelines (see the National Guideline Clearinghouse [NGC] summary of the New York State Department of Health [NYSDOH] guidelines Hepatitis B Virus and Hepatitis C Virus ).
Clinicians should counsel patients about behavior modifications that decrease their risk of acquiring hepatitis infection through unprotected sexual activity and injection drug use.
For HIV-infected substance users who continue to inject drugs, clinicians should:
- Discuss avoidance of needle/syringe-sharing activity with all injection drug users, regardless of viral load, to prevent HIV and HBV and hepatitis C virus (HCV) transmission (see the Table "Viral Hepatitis Risk-Reduction Guidance for Substance Users" below).
- Issue prescriptions for new needles and syringes to patients who inject drugs.
- Discuss with patients other options for accessing new needles and syringes, including use of the Expanded Syringe Access Demonstration Program and Syringe Exchange Programs , New York State's two syringe access initiatives.
- Substance users are at high risk for infection with HAV, HBV, and HCV.
- Infection among substance users may initiate and increase the magnitude of hepatitis outbreaks.
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 antiretroviral therapy (ART) 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, including illicit drug users (see Table 1 in the original guideline document).
Clinicians should periodically readdress vaccination with individuals who initially decline either hepatitis A or hepatitis B vaccination.
Clinicians should administer the HBV vaccination series to HIV-infected patients who are negative for HBsAb, unless they are chronically infected.
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. 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 ART 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.
Clinicians should advise HIV-infected substance users with chronic hepatitis B infection that drug-sharing, sexual, and household contacts may be at risk for hepatitis B. Such contacts should be advised to undergo medical evaluations and, if susceptible, should be offered HBV vaccination.
- HBV vaccination is indicated for all HIV-infected substance users who are susceptible and may be particularly important for those co-infected with HCV.
- Advanced immune suppression is not a contraindication to HBV vaccination, and vaccination of susceptible persons should not be deferred or delayed because of advanced immune suppression or in anticipation of expected immune recovery due to the effect of ART.
Clinicians should screen all HIV-infected substance users for HCV at baseline. Patients who are seronegative for HCV infection at baseline should be screened at least annually for recent HCV infection.
HIV-infected substance users who continue to inject substances should receive counseling regarding the risk of HIV and HCV transmission from non-sterile injection practices. These patients should be referred to sources of sterile injection equipment, such as the Expanded Syringe Access Demonstration Program and Syringe Exchange Programs , New York State's two syringe access initiatives.
Clinicians should evaluate HIV-infected substance users with chronic hepatitis C infection (or with hepatitis B and C co-infection) for liver disease. These patients should be evaluated and offered treatment when medically indicated according to current guidelines.
Substance-sharing contacts should be advised to undergo medical evaluations. As part of this medical evaluation, all contacts should be offered testing for HIV and hepatitis C.
Clinicians should advise patients with HCV infection to discontinue consumption of alcohol.
HCV seems to be more easily transmitted parenterally than HIV.
Table. Viral Hepatitis Risk-Reduction Guidance for Substance Users
- Stop using illicit drugs—substance users who wish to stop using drugs should be referred to substance abuse treatment when indicated.
- If unable to stop using illicit drugs, substance users should stop injection of illicit drugs.
- If unable to stop injection of illicit drugs, substance users should use a new, sterile needle for every injection.
- Substance users should use their own needle, syringe, filtration cotton, and cooker, without sharing with others.
- If assisting others with injections, the substance user should wash hands thoroughly between injections and use all new equipment.
- Substance users should know their own HIV, hepatitis B, and hepatitis C status; should not engage in unprotected sex; and should be advised to avoid sharing injection equipment.
Effect of Substance Use and Substance Use Treatment on HCV Disease Progression and Treatment
Clinicians should be guided by patients' symptoms (e.g., opioid craving or oversedation) when considering whether a change in methadone or buprenorphine dose is indicated.
Treatment and Adherence
Adherence to the HCV treatment regimen is difficult for all patients, not just substance users or those with HIV. Identification of potential barriers and consideration of measures to promote adherence are essential.
Clinicians should obtain a TST (tuberculin skin test, commonly known as purified protein derivative [PPD]) or other U.S. Food and Drug Administration (FDA)-approved test for diagnosis of TB infection, unless the patient has previously tested positive or has had previously documented TB.
For patients with a new positive TB test, clinicians should obtain a detailed history, perform a physical examination, and obtain a chest x-ray to determine whether active TB is present.
After active TB has been excluded, clinicians should prescribe TB treatment when a TST results in induration of ≥5 mm or when another FDA-approved test indicates the presence of latent TB infection (LTBI).
HIV-infected substance users with active TB should receive expedited treatment and should be enrolled into directly observed therapy (DOT). TB and HIV therapy should be closely coordinated with the local health department.
Clinicians should evaluate HIV-infected substance users who have LTBI, and, in the absence of medical contraindications or previous completion of preventive therapy, these patients should be offered treatment for LTBI.
- Rifampin may increase the catabolism of opioids and can precipitate opioid withdrawal in opioid users or those on methadone maintenance regimens unless methadone doses are increased.
- Co-locating TB services may improve adherence and rates of treatment completion.
Sexually Transmitted Infections (STIs) in HIV-infected Substance Users
Clinicians should reinforce behavioral risk-reduction measures for STI prevention, including consistent condom use.
Primary care clinicians play an important role in reinforcing behavioral risk-reduction measures.
Screening for STIs in HIV-infected Substance Users
Clinicians should screen HIV-infected substance-using patients for syphilis by obtaining a nontreponemal test (rapid plasma reagin [RPR] test or Venereal Disease Research Laboratory [VDRL]) with verification of reactive tests by confirmatory fluorescent treponemal antibody-absorption (FTA-Abs) or T. pallidum particle agglutination (TP-PA) at baseline and at least annually. Patients with continued high-risk behavior should be screened for syphilis every 3 months.
Clinicians should screen all sexually active HIV-infected substance-using women for gonorrhea and chlamydia at baseline and at least annually at all sites of exposure, including the cervix, rectum, and pharynx. Culture or nucleic acid amplification tests (NATs) should be used to screen for gonorrhea. Immunofluorescence or DNA amplification should be used for chlamydia.
Clinicians should screen HIV-infected substance-using men who have sex with men for gonorrhea and chlamydia at baseline and at least annually. Clinicians should screen all sites of exposure, including the urethra, rectum, and pharynx.
Clinicians should counsel injection drug users (IDUs) on risk reduction for soft-tissue infections (see Tables 4 and 5 in the original guideline document).