Vaccine-Preventable Hepatitis (VPH) and high-risk patients with HIV.

Introduction

All forms of viral hepatitis cause up to 15,000 deaths annually in the United States, and it is estimated that one third of the US population will be infected with viral hepatitis at some point in their lives. (1) Nearly 90% of new cases of viral hepatitis arise from Vaccine-Preventable Hepatitis (VPH), a group of diseases that can cause acute illness characterized by flu-like symptoms and jaundice. (1,2) One form of VPH, hepatitis B virus (HBV), can cause chronic conditions, such as cirrhosis and chronic hepatitis, and can lead to liver cancer and death. (2) VPH, which includes hepatitis A virus (HAV) and HBV, results in 171,000 total infections and approximately 5100 deaths per year in the United States. (2) VPH can be contracted through sexual activity and the use of nonsterile needles (2); HBV can be transmitted through contaminated blood and bodily fluids. HBV can be 100 times more contagious than human immunodeficiency virus (HW), (3,4) making VPH a serious concern for populations who engage in high-risk behaviors. Although no treatment exists, VPH can be prevented by a series of vaccinations. VPH is the only sexually transmitted disease preventable through vaccination. (5)

VPH in HIV-Positive Patients

In persons with HIV, coinfection by VPH increases morbidity and mortality and compromises treatment programs. (6) Chronic HBV infection occurs in 10% to 15% of HiV-infected persons, (7) and coinfection with HIV increases the likelihood of acute HBV becoming chronic by 3- to 6-fold. (8) Furthermore, HBV coinfection in AIDS patients reduces survival (212 vs 439 days). (9) HBV coinfection with HIV also complicates the evaluation of hepatotoxicity, a common side effect of antiretroviral therapy, (7) and HAV in persons with HIV may require suspension of highly active antiretroviral therapy (HAART) due to elevation of liver enzyme levels. (10) In a descriptive study following HIV-positive patients, all 7 patients who developed HAV while on HAART required suspension of therapy. (10) In light of the effects of coinfection with VPH and HW, it should be noted that the Centers for Disease Control and Prevention (CDC) recommends HBV immunization for all HIV patients and HAV immunization for all susceptible HIV patients, such as men who have sex with men (MSM), intravenous drug users, and persons with chronic liver disease. (11)

VPH and HIV-Risk Populations

Patients who engage in high-risk behaviors for contracting HIV are also at high risk for VPH. (12) Although MSM are at increased risk for VPH due to sexual activity, the majority of these men fail to recognize the inherent risks associated with VPH and consequently are not immunized. (13,14) A national survey of MSM between ages 15 and 22, conducted between 1994 and 1998, found that only 9% of respondents had been immunized against HBV. (15) In one recent study of 833 MSM who received treatment at a clinic for STDs, only 15% were vaccinated for HAV and 25% for HBV. (16) Several medical and public health organizations, including the CDC, the American Academy of Family Physicians, the National Medical Association, the Gay and Lesbian Medical Association, and the American Social Health Association, recommend VPH (hepatitis A and hepatitis B) immunization for MSM.

Vaccination Can Protect Patients With or at Risk for HIV From VPH

Vaccination can provide protection against all forms of VPH in patients who have or are at increased risk for HIV. Supported by numerous national health organizations, VPH immunization can reduce morbidity, mortality, and treatment-associated complications in these patient populations.

Reimbursement for VPH immunization for patients with HIV is covered by most health plans. For these patients, over 90% of top US health plans reimburse primary care physicians and specialists for adult hepatitis vaccines without prior authorization. (17) For more information, contact the VACCRIX Reimbursement Hotline[TM] at 1-888-VACCRIX.

Figure 1. A recent multicenter, prospective cohort study classified
5293 men who had sex with men according to their HIV-1 antibody and
hepatitis 13 surface antigen status (HBsAg) to examine liver-related
mortality, which was higher in men with HIV-1 and HBsAg than in those
with only HIV-1 infection or only HBsAg (P < .001). (6)

Effect of HIV/HBV Coninfection on Mortality

Liver-related mortality rate (per 1000 persons years)

HIV-1                2
HBsAg                1
HIV-1 plus HBsAg    14

Note: Table made from bar graph.

References

(1.) Centers for Disease Control and Prevention. Disease burden from viral hepatitis A, B, and C in the United States. Available at: http://www.cdc.gov/ncidod/diseases/hepatitis/resource/ PDFs/disease_burden2002.pdf. Accessed August 5, 2004.

(2.) Centers for Disease Control and Prevention. Epidemiology and Prevention of Vaccine-Preventable Diseases. 8th ed. Atkinson W, Hamborsky J, Wolfe S, eds. Washington DC: Department of Health and Human Services; 2004:177-212.

(3.) Centers for Disease Control and Prevention. Prevention and control of infections with hepatitis viruses in correctional settings. MMWR. 2003;52(RR-01):1-33.

(4.) Centers for Disease Control and Prevention. Recommendations for preventing transmission of human immunodeficiency virus and hepatitis B virus to patients during exposure-prone invasive procedures. MMWR. 1991;40(RR-08):1-9.

(5.) Centers for Disease Control and Prevention. Sexually transmitted diseases treatment guidelines 2002. MMWR. 2002;51(RR-6):1-80.

(6.) Thio CL, Seaberg EC, Skolasky R, et al. HIV-1, hepatitis B virus, and risk of liver-related mortality in the Multicenter Cohort Study (MACS). Lancet. 2002;360:1921-1926.

(7.) Sulkowski MS, Thomas DL, Chaisson RE, Moore RD. Hepatotoxicity associated with antiretroviral therapy in adults infected with human immunodeficiency virus and the role of hepatitis C or B virus infection. JAMA. 2000;283:74-80.

(8.) Piliero PJ, Faragon JJ. Case report. Hepatitis B virus and HIV coinfection. AIDS Read. 2002;12:443-451.

(9.) Ockenga J, Tillmann HL, Trautwein C, et al. Hepatitis B and C in HW-infected patients. Prevalence and prognostic value. J Hepatol. 1997;27:18-24.

(10.) Fonquernie L, Meynard JL, Charrois A, Delamare C, Meyohas MC, Frottier J. Occurrence of acute hepatitis A in patients infected with human immunodeficiency virus. Clin Infect Dis. 2001;32:297-299.

(11.) Centers for Disease Control and Prevention. Recommended adult immunization schedule by age group and medical conditions, United States, 2003-2004. Atlanta, Georgia: The Advisory Committee on Immunization Practices; 2004.

(12.) Blatmer WA, Biggar RJ, Weiss SH, et al. Epidemiology of human T-lymphotropic virus type III and the risk of the acquired immunodeficiency syndrome. Ann Intern Med. 1985;103:665-670.

(13.) Centers for Disease Control and Prevention. Undervaccination for hepatitis B among young men who have sex with men San Francisco and Berkeley, California, 1992-1993. MMWR. 1996;45:215-217.

(14.) Centers for Disease Control and Prevention. Hepatitis A vaccination of men who have sex with men--Atlanta, Georgia, 1996-1997. MMWR. 1998;47:708-711.

(15.) Sansom S, Rudy E, Strine T, Douglas W. Hepatitis A and B vaccination in a sexually transmitted disease clinic for men who have sex with men. Sex Transm Dis. 2003;30:685-688.

(16.) Diamond C, Thiede H, Perdue T, et al. Viral hepatitis among young men who have sex with men: prevalence of infection, risk behaviors, and vaccination. Sex Transm Dis. 2003;30:425-432.

(17.) Data on file, TWR5004, GlaxoSmithKline.