What are Opportunistic Infections (OIs)?
AIDS (acquired immune deficiency syndrome) is a condition caused by a virus called HIV. This virus attacks the immune system, the body's "security force" that fights off infections. When the immune system breaks down, one looses this protection and can develop many serious, often deadly infections and cancers. These are called "opportunistic infections" (OIs) because they take advantage of the body's weakened defenses. You have heard it said that someone "died of AIDS." This is not entirely accurate, since it is the opportunistic infections that cause death. AIDS is the condition that lets them take hold. AIDS includes the words "immune deficiency".

There are specific criteria for determining when a person living with HIV progresses to AIDS. One thing that is considered is the T-cell counts: if a person falls below 200 T4 cells, then they have officially progressed to AIDS.

Many OIs can be prevented and/or treated. In fact, a lot of the AIDS research you hear about has been done to find treatments or cures for specific OIs, and not just looking for drugs to stop HIV.

Below are lessons about some of the major OIs & cancers that can occur during late-stage HIV disease, along with possible Interventions.

Hepatitis & HIV

There's little doubting the tremendous impact anti-HIV drug therapy has had on the lives, and futures, of HIV-positive people. It is abundantly clear that people are living longer with HIV infection - thanks to the availability and widespread use of these treatments.

Unfortunately, the life-extending benefits of anti-HIV drug treatment have opened up a new set of problems for many HIV-positive people. Thousands of HIV-positive people are also infected - or at risk of being infected - with one of several hepatitis viruses. Some of the hepatitis viruses can cause chronic infection, meaning that they remain active for many years and can lead to serious liver damage over time. And because many HIV-positive people are now at a much lower risk of dying from AIDS-related opportunistic infections, they must now face the challenge of having to manage these other viral diseases that pose a threat to their health and lives.

Viral hepatitis, which can cause long-term liver problems, liver failure, and liver cancer, is considered to be a leading cause of death among HIV-positive people. In turn, numerous HIV-positive people must fight two infections at once. Here are lessons to help people better understand three hepatitis viruses that are a potential threat to their health: hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV). Each of the following lessons discuss the ways these hepatitis viruses are transmitted, cause disease, and are treated, particularly in people living with HIV:

Hepatitis A

What is hepatitis A and how is it transmitted?
Hepatitis A is caused by the hepatitis A virus (HAV). HAV is spread from one person to another when the feces (shit) of someone with the virus get into another person's mouth. There are a number of ways that this can happen:

• Eating food - particularly food that is raw or not thoroughly cooked (shellfish, for example) - that has been handled or prepared by someone who has hepatitis A.
• Drinking water or ice that is contaminated with feces.
• Engaging in oral-anal sex ("rimming") with someone who has hepatitis A.
• Rarely, HAV can also be spread through blood-to-blood exposure (sharing intravenous drug injection equipment, for example).

Hepatitis A is an acute form of hepatitis, meaning that it does not cause long-term (chronic) infection. If you have had hepatitis A once, you cannot be infected with the virus again. However, you can still be infected with other hepatitis viruses ( hepatitis B virus and hepatitis C virus , for example).

People with HIV are not at greater risk of becoming infected with HAV than anyone else. However, some studies suggest that people with HIV are more likely to experience prolonged symptoms of hepatitis A, meaning that it might take longer for someone who is HIV-positive to recover fully from hepatitis A.

Another important issue to consider is that many people with HIV are taking anti-HIV medications that can be toxic to the liver. Some of these medications can make symptoms of hepatitis A worse. In turn, it might be necessary to stop all anti-HIV medications until the hepatitis A has run its course or until liver enzyme levels have returned to normal. If you are HIV-positive, are taking anti-HIV medications, and develop hepatitis A, do not stop your anti-HIV medications without first discussing it with your doctor.

What are symptoms of Hepatitis A?

Not everyone who is infected with HAV will experience noticeable symptoms. For example, many babies and young children infected with HAV do not experience any symptoms of infection. Symptoms are much more likely to occur in older children, adolescents, and adults.

Symptoms of hepatitis A (and acute hepatitis in general) can include:

• Yellowing of the skin and whites of the eyes (jaundice)
• Feeling tired and rundown (fatigue)
• Pain in the upper-right abdomen
• Loss of appetite
• Weight loss
• Fever
• Nausea
• Diarrhea
• Vomiting
• Dark urine and/or pale stool
• Joint pain

HAV infection can also cause enzymes produced by the liver to increase above normal levels in the bloodstream. The most important liver enzymes are alanine aminotransferase (ALT) and aspartate aminotransferase (AST). Elevated enzyme levels indicate that the liver is not functioning properly and that there may be a risk of permanent liver damage. With hepatitis A, liver enzyme levels can be temporarily elevated, but this rarely leads to long-term liver problems. Both of these enzymes are measured as part of a standard Chem-Screen (CS) Test, which people on anti-HIV treatments usually have done on a regular basis, along with their other blood tests.

It can take the immune system up to eight weeks to clear HAV from the body. If symptoms occur, they usually do so within two to four weeks after being infected. The symptoms of hepatitis A can last anywhere from a week to more than a month. Approximately 15% of people with hepatitis A experience symptoms that last between six to nine months.

How is hepatitis A diagnosed?
Hepatitis A can be diagnosed using blood tests. Your healthcare provider can order these tests if you have symptoms of hepatitis A or if you want to know if you were infected with HAV in the past.

The blood test looks for two different types of antibodies to the virus. First it looks for IgM antibodies, which are produced by the immune system five to ten days before symptoms appear and usually disappear within six months. It also looks for IgG antibodies, which replace IgM antibodies and protect against future HAV infection.

• If the blood test shows that you are negative for both IgM and IgG antibodies, you probably have never been infected with the virus and should consider getting the HAV vaccine.
• If you are positive for IgM antibodies and negative for IgG antibodies, HAV infection most likely took place within the past six months and is either in the process of being cleared by the immune system or getting worse.
• If you are negative for IgM antibodies and positive for IgG antibodies, either you were infected with HAV some time in the past or you have been vaccinated against hepatitis A; in either case, you are now immune to the virus.

How is hepatitis A treated?
The usual treatment for hepatitis A is bed rest. It is also important to drink plenty of fluids, particularly if you are experiencing diarrhea or vomiting. Over-the-counter pain relievers can help manage some of the symptoms of hepatitis A, although it's best to consult with your healthcare provider before using any medications.

If you think that you may have recently been exposed to HAV - for example, if somebody in your household has been diagnosed with hepatitis A - you can talk to your doctor about receiving an injection of immune globulin (also called gamma globulin). Immune globulin contains high levels of antibodies to HAV, which can help prevent the disease if you have been exposed to the virus. Immune globulin needs to be given within two to six weeks after possible exposure to HAV. People who receive immune globulin to prevent active hepatitis A should also receive the hepatitis A vaccine.

How can hepatitis A be prevented?
The best way to prevent hepatitis A is to be vaccinated. Two HAV vaccines are available. Both of these vaccines require two injections, usually administered six months apart. If side effects from the hepatitis A vaccine occur, they are usually mild and may include soreness at the injection site and mild flu-like symptoms. A combination vaccine for HAV and hepatitis B virus is also available.

The HAV vaccine is very effective. More than 99% of people who are vaccinated develop immunity against the virus and will never get HAV even if they are exposed to it. There is some concern that people with HIV with suppressed immune systems are less likely to benefit from the vaccine, so it is best to get the vaccine when T-cell counts are within healthy ranges

If you do not think you were ever infected with hepatitis A, talk to your healthcare provider about the vaccine. Because people with HIV often experience worse symptoms of HAV infection and the liver plays such an important role in breaking down anti-HIV medications, the hepatitis A vaccine is strongly recommended for people with HIV. Getting vaccinated is especially important for people who are also infected with hepatitis B or hepatitis C .

Even if you haven't been vaccinated against hepatitis A, there are things you can do to prevent HAV infection:

• Avoid water that could be contaminated with fecal matter.
• Avoid undercooked or raw shellfish.
• Always wash your hands with soap and water after using the bathroom, changing a diaper, and before preparing and eating food.
• Use a latex barrier - such as a dental dam - for oral-anal sex ("rimming").

Hepatitis B

What is hepatitis B and how is it transmitted?
Hepatitis B is caused by the hepatitis B virus (HBV). HBV is a noncytopathic virus. This means that the virus, itself, does not cause direct damage to liver cells. Instead, it is the immune system's aggressive response to the virus that usually leads to inflammation and damage to the liver.

People who have not been infected with HBV can be vaccinated against the virus to prevent infection.

HBV is very similar to HIV in the ways it is transmitted: through direct blood-to-blood contact and through sexual activity. However, blood levels of HBV are much higher than for HIV or the hepatitis C virus, making this virus much easier to transmit in certain situations (e.g., from mother to child during delivery).

HBV is present in blood, semen, and vaginal fluids and is transmitted primarily through sexual activity. Another major transmission route is sharing injection drug equipment (including needles, cookers, tourniquets) and, to a lesser extent, non-injection drugs (cocaine straws and crack pipes) due to the possibility of exposure to blood. Pregnant women who have hepatitis B can also transmit the virus to their babies, most likely during birth.

The number of new hepatitis B infections in the U.S. has declined from about 260,000 a year in the 1980s to about 78,000 in 2001, with the greatest decline occurring in children and adolescents due to routine HBV vaccination.

What happens when someone is infected with HBV?
Soon after HBV enters the body, it infects cells in the liver called hepatocytes. In response to this infection, the immune system targets the virus and targets the hepatocytes already infected with the virus. This causes inflammation of the liver (hepatitis).

HBV can cause acute hepatitis, meaning short-term inflammation of the liver, until the immune system is able to clear the virus from the body, usually within six months of becoming infected with the virus. HBV can become a chronic infection. This means that the immune system is not able to get rid of the virus within six months after infection. In other words, the virus continues to reproduce in the person's liver for several months or years after infection. This can increase the risk of liver damage and liver cancer. What's more, someone with chronic HBV infection can transmit the virus to others.

Less than 10% of adults infected with HBV go on to experience chronic HBV infection. Babies infected with HBV around the time of birth go on to experience chronic HBV infection approximately 90% of the time, which is why it is important that pregnant women know whether or not they are infected with the virus before giving birth. Medication can be given to the baby after birth to help prevent hepatitis B. Young children who are infected with HBV have a 25% to 50% risk of developing chronic hepatitis B. With adults, the risk of developing chronic HBV infection depends on the health of the immune system. For example, patients with impaired immune responses who are recovering from organ transplants, undergoing chemotherapy, undergoing dialysis for kidney problems, receiving steroid therapy to suppress the immune system, or are HIV-positive are more likely to develop chronic HBV infection than patients with normal immune responses.

What are the symptoms of hepatitis B?
Not everyone who is infected with HBV will experience symptoms of acute hepatitis - between 30% and 40% of people infected with the virus do not experience any noticeable symptoms. If symptoms do occur, they usually do so within four to six weeks after being infected and can last anywhere from one or two weeks to several months.

The symptoms of acute hepatitis B can include:

• Yellowing of the skin, whites of the eyes, and under the fingernails (jaundice)
• Dark urine and/or pale stool
• Feeling tired and rundown (fatigue)
• Fever
• Abdominal pain
• Loss of appetite
• Nausea
• Diarrhea
• Joint pain

If the immune system is not able to control acute HBV infection within six months, symptoms of chronic hepatitis B are possible. Not everyone with chronic hepatitis B experiences symptoms. Some people with chronic hepatitis B experience occasional symptoms, while others experience symptoms that never seem to go away.

Symptoms of chronic hepatitis B can include those typically seen in acute hepatitis B. They tend to be mild to moderate in intensity and typically come and go. Other symptoms can occur, particularly in people who have been dealing with chronic hepatitis B for many years. Additional symptoms include rash, hives (urticaria), arthritis, and burning/tingling in the arms and legs ( polyneuropathy ).

Less than 1% of people infected with HBV may experience a quick and severe (fulminant) infection, which - very rarely - can lead to liver failure and death. Symptoms of hepatitis, whether acute or chronic, should always be brought to the attention of a healthcare provider.

What laboratory tests do I need to know about?
There are laboratory tests to diagnose HBV infection and laboratory tests to monitor people with chronic hepatitis B.

Hepatitis B is first diagnosed using a blood test that looks for certain antigens (fragments of HBV) and antibodies (produced by the immune system in response to HBV). Initial blood tests to diagnose HBV infection look for one antigen - HBsAg (the hepatitis B surface antigen) and two antibodies - anti-HBs (antibodies to the HBV surface antigen) and anti-HBc (antibodies to the HBV core antigen). There are actually two types of anti-HBc antibodies produced: IgM antibodies and IgG antibodies. IgM antibodies are produced early in the course of infection. IgG antibodies are produced later in the course of infection and replace IgM antibodies.

The blood test used to check for HBV infection can be quite confusing, given that a number of different combinations of antigens and antibodies are possible and can mean different things. Here's a look at the most important test results to know:

Depending on these results, additional diagnostic tests may be necessary. Somebody who has never been infected with HBV or has been vaccinated against the virus does not require any additional testing. Someone who was recently infected with HBV and has acute hepatitis B may want to get another blood test after six months have passed to make sure that the necessary immune response has occurred. People with chronic HBV infection require additional testing to learn more about their hepatitis B.

If you have chronic hepatitis B, your healthcare provider will usually order additional tests to determine if the infection is active:

How is hepatitis B different for people with HIV?
Although healthy adults who are infected with HBV have a less than 10% chance of seeing the infection develop into chronic hepatitis B, when an HIV-positive adult is infected, this risk jumps to almost 25%. In other words, people with HIV are more likely to develop chronic hepatitis B as a result of HBV infection than HIV-negative people with strong immune systems.

A number of reports have also suggested that, as HIV disease progresses, the body's immune response to HBV gradually decreases or is sometimes lost. This can cause the virus to become active again after being inactive, which can once again increase the risk of liver damage.

It is not entirely understood what impact HIV has on the severity of chronic HBV infection. There have been a number of reports showing that people infected with both viruses have higher HBV viral loads and more cirrhosis, regardless of immune system status. There are also data from studies suggesting that people with HIV with chronic hepatitis B are more than twice as likely as their HIV-negative counterparts to experience liver failure, thus requiring consideration of a liver transplant. It is not yet known if people with HIV with chronic hepatitis B are at a higher risk of liver cancer than their HIV-negative peers, but given the strong link between HBV and liver cancer, this would seem to be likely.

As discussed in the next section, people co-infected with HIV and chronic hepatitis B needs to be careful when choosing treatments for both infections.

How is hepatitis B treated?
People with acute hepatitis B do not require treatment. Bed rest, drinking lots of fluids, and over-the-counter pain relievers (such as ibuprofen) are usually all that is needed for someone who is experiencing symptoms because of acute hepatitis B.

Treatment is only recommended for people with chronic hepatitis B. The goal of therapy is to reduce HBV viral load to undetectable levels and to return liver enzymes to normal levels, with the intent of getting rid of both HBeAg and HBsAg. If these antigens are cleared from the bloodstream, the virus is less likely to rebound once treatment is stopped.

The best time to begin anti-HBV is when the HBV viral load is above 100,000 copies/mL (or above 10,000 if the person is infected with a precore HBV mutant) and ALT levels are at least two times their normal levels. Starting therapy when the ALT levels are normal or only slightly elevated isn't likely to be as effective.

There are three treatments approved for the management of chronic hepatitis B:

How can hepatitis B be prevented?
The best way to prevent hepatitis B is to be vaccinated.

The HBV vaccine is generally effective for more than 90% of adults and children who receive all three doses. However, some research suggests that people with HIV are less likely to develop immunity to HBV through vaccination, especially if they have compromised immune systems. So it is best for people with HIV to receive the hepatitis B vaccine when T4 cell counts are within healthy ranges.

If you do not think you were ever infected with hepatitis B, talk to your healthcare provider. The vaccine is recommended for:

• People with HIV
• Men who have sex with other men
• Injection drug users
• People with chronic hepatitis C virus
• Heterosexual adults with more than one sex partner in the last six months or a history of sexually transmitted disease
• People who work in places where there is a risk of infection (such as hospitals and doctors' offices)
• Hemodialysis patients
• People who share living quarters with someone with chronic hepatitis B

Increasingly, universal vaccination against HBV is being recommended for all children.

If you have not been vaccinated against hepatitis B, there are still things you can do to prevent HBV infection. These include using a condom or another type of latex barrier while having sex. If you are an injection drug user and share equipment, cleaning your syringes with bleach will not help you avoid hepatitis B - it's always best to use new needles to prevent the risk of HBV infection. Also, don't share items that may have been contaminated with someone else's blood such as toothbrushes, razors, and needles used for body piercing, tattooing, or acupuncture.

If you have not been vaccinated against hepatitis B and fear that you were recently exposed to HBV - for example, after being poked with a used hypodermic needle or as a result of sexual contact with a person with hepatitis B - it is possible to receive a single injection of hepatitis B immune globulin (HBIG). HBIG is recommended following exposure to hepatitis B virus because it provides immediate, short-term protection against the virus. A dose of the hepatitis B vaccine is given at the same time. Two additional doses of hepatitis B vaccine are given to complete the series and ensure long-term protection.

Hepatitis C

What is it?
Hepatitis C is a disease caused by a virus that infects the liver. The virus, called hepatitis C virus (HCV), can cause lifelong infection, cirrhosis (scarring) of the liver, liver cancer, liver failure, and death. Worldwide, there are estimated to be 170-200 million people infected with HCV! Fortunately, much progress has been made in terms of treating people who have hepatitis C, including people who are infected with both HIV and HCV.

HCV is a common infection among people living with HIV. It can cause liver disease faster in people who are also infected with HIV and can make it more difficult to treat HIV correctly. It is important for people infected with HIV and HCV to work closely with their healthcare providers in order to safely and effectively treat both infections.

Who is at risk for hepatitis C? How is HCV transmitted?
Hepatitis C is common in people living with HIV, Injection drug users (IDUs), if they share needles with other people, are at the highest risk of being infected with HCV - between 50% and 90% of all IDUs who are infected with HIV are also infected with HCV. This is because both viruses can be spread easily through blood and blood products.

To cause a new infection, HCV must pass from the blood of an infected person into the blood of an uninfected (susceptible) person. In other words, HCV is most easily spread through direct blood-to-blood contact, such as:

• Sharing needles and other equipment (paraphernalia) used to inject drugs.
• Needle-stick injuries and exposure of open wounds or mucous membranes to infected blood. (Note: The risk of transmission in the healthcare setting is actually quite low - 4% to 10% risk through a needle-stick injury involving a needle previously used in someone infected with HCV.)
• Blood or blood-product transfusion.

Unlike HIV, it is generally believed that HCV cannot be transmitted through semen or other genital fluids, unless blood is present. Thus, the risk of becoming infected with HCV through unprotected sexual intercourse is low - but it is still possible. As a result, experts recommend that people infected with HCV practice safer sex using a protective barrier (e.g., condoms), especially during intercourse, to protect their partners.

Women who are infected with HCV have a less than 10% chance of passing the virus along to their babies during pregnancy or delivery, although the risk increases if the woman's HCV viral load (the amount of HCV in a measurement of blood) is high. It is unlikely that HCV can be transmitted through breastfeeding or breast milk.

You may be at risk for hepatitis C and should contact your healthcare provider for a blood test if you:

• Were notified that you received blood from a donor who later tested positive for hepatitis C.
• Have ever injected illegal drugs, even if you experimented a few times many years ago.
• Have ever been on long-term kidney dialysis.
• Have evidence of liver disease (e.g., persistently abnormal liver function tests).
• Have had multiple sexual partners, or sexual contact with an HCV+ person.
• Have an HCV+ mother.

What happens when someone is infected with HCV?
Being infected with HCV does not necessarily mean that liver disease will occur. What's more, it can take several years - decades, in many cases - for HCV to cause life-threatening liver disease.

Soon after HCV enters the body, it infects cells in the liver called hepatocytes. Only a small number of people (approximately 25%) actually experience symptoms of infection, such as fatigue, decreased appetite, nausea, or jaundice (yellowing of the skin and eyes). However, almost all people infected with HCV experience an increase in their liver enzymes - such as serum alanine aminotransferase (ALT) - which can be detected by a simple blood test. An increase in ALT means that some liver cells are becoming damaged by the HCV infection.

Approximately 15% of people who are infected with HCV are able to clear the virus from their bodies, usually within six months after becoming infected. However, the majority of people (85%) who are infected with HCV have "chronic" hepatitis C - an infection that will stay with them for life. In other words, if 100 people are infected with HCV tomorrow, 15 of them will clear the virus from their bodies within six months, whereas 85 of them will remain infected with the virus.

Of the 85 people with chronic hepatitis C, approximately 20 of them will remain healthy - their liver enzymes will stay normal, even though HCV can be detected in their livers and in their blood, and they will not go on to develop liver disease or experience symptoms of the infection. The remaining 60 to 65 people with chronic hepatitis C will go on to experience some signs and symptoms of liver disease, such as fatigue, nausea, muscle aches, and abdominal pain - usually after 13 to 15 years of being infected with HCV. Approximately 20 to 25 of these people, usually after 20 years of HCV infection, will develop cirrhosis - a scarring of the liver that results from widespread fibrosis (an extreme overgrowth of the liver's connective tissue). Here are some pictures of a healthy liver, then fibrosis, then cirrhosis:

Although cirrhosis is not life threatening, it can affect the way the liver works and increases the risk of liver cancer. Of the 20 to 25 people with HCV who develop cirrhosis, between five and 10 of them will develop liver cancer and possibly liver failure after another five years.

How is hepatitis C different for people who are also infected with HIV?
There have been a number of studies showing that HIV can have a negative effect on the way HCV acts in the body. For starters, HIV can increase the chance that someone with chronic HCV infection will experience cirrhosis of the liver. As discussed in the last question, approximately 20 to 25 of every 85 people with healthy immune systems who have chronic HCV infection will go on to develop cirrhosis of the liver within 20 years. If HIV is also present, approximately 30 to 35 of every 85 people will likely experience cirrhosis.

HIV infection can also speed up the rate by which HCV infection causes cirrhosis of the liver. In one study, people infected with both HIV and HCV were twice as likely to have cirrhosis of the liver after 13 years than people only infected with HCV (15% vs. 6%). Similar results have been seen in other studies.

It is also true that people with HIV and HCV are more likely to experience liver failure - which is often fatal, unless a transplant is performed - than people infected only with HCV. In one study, people infected with both viruses were 21-times more likely to die of liver failure than those only infected with HCV.

Another issue to consider is liver health and anti-HIV medicines. Many anti-HIV treatments, including the protease inhibitors and the non-nucleoside reverse transcriptase inhibitors , are broken down (metabolized) by the liver. This can pose two problems for people infected with both HIV and HCV. First, the liver needs to be healthy in order to process these drugs correctly. If HCV damages the liver, it might not be possible to begin or continue taking life-saving anti-HIV therapy. Second, some of the drugs used to treat HIV can cause liver damage, even in people who aren't infected with HCV. In turn, some anti-HIV drugs might worsen or speed up the liver disease being caused by hepatitis C.

People infected with both HIV and HCV need to work very closely with their healthcare providers. It is important that people infected with both viruses monitor their health carefully.

What are the symptoms of hepatitis C?
Many people with chronic hepatitis C have no symptoms of liver disease. That is, they don't necessarily feel or look sick. If symptoms are present, they are usually mild, aren't very specific and tend to come and go. These symptoms may include fatigue, pains of the upper-right portion of the gut, nausea , decreased appetite, and muscle and joint pains.

If the hepatitis C begins causing serious liver damage or cirrhosis, symptoms may become more prominent. In addition to fatigue, there may be muscle weakness, poor appetite, nausea, jaundice, weight loss, itching, dark urine, fluid retention, abdominal swelling, and ankle swelling.

How is hepatitis C diagnosed? What tests are used to monitor people with hepatitis C?
HCV Antibody Testing: Diagnosing hepatitis C begins with an antibody test, similar to the one used to diagnose HIV infection. Antibodies to HCV can be detected in the blood, usually within two or three months after the virus enters the body. If the HCV antibody test is positive, a second test - either a Western blot assay or a PCR test - is performed to confirm the result.

If a person is positive for HCV antibodies, he or she has been exposed to the virus in the past. As discussed above, however, approximately 15% of people who are initially infected with the virus are able to clear the virus from their bodies, usually within six months of exposure. The next step is to look for the actual virus in the bloodstream.

HCV Viral Load Testing: To look for HCV, a healthcare provider can request a qualitative PCR test to determine whether or not the virus is in a person's bloodstream. A healthcare provider can also order a quantitative PCR or bDNA test - very similar to those used in HIV - to check for the presence of HIV and to figure out the person's HCV viral load (the amount of HCV in a measurement of blood).

The HCV viral load is a very important laboratory test. Unlike viral load testing for HIV, which can help determine how fast someone may develop AIDS, the HCV viral load test cannot determine if or when someone with hepatitis C will develop cirrhosis or liver failure. However, the HCV viral load can help determine how likely it is someone will respond to treatment. As a rule of thumb, the lower the HCV viral load, the better someone's chances that he or she will respond to anti-HCV treatment. Note: HCV viral load numbers are usually much higher than HIV viral load numbers. This can be very confusing. A low HIV viral load is considered to be less than 5,000 copies/mL; a low HCV viral load is considered to be less than 2,000,000 copies/mL.

HCV viral load testing is often used during treatment to determine how well therapy is working.

Genotypic Testing: Not all hepatitis C viruses are the same. There are 11 different "genotypes" of HCV - meaning that, while they look and act very much the same, their genetic structures differ somewhat from each other. Complicating matters further is the fact that each genotype can be divided into different subtypes. For example, HCV genotype 1 can be divided into subtypes "a" and "b."

HCV's genotype does not change the likelihood that someone with hepatitis C will develop cirrhosis or liver failure, nor does it affect the speed by which these liver problems can occur. In other words, the genotype of HCV does not affect disease progression in hepatitis C. However, HCV's genotype can predict the effectiveness of treatments - HCV genotypes 1a and 1b are the most difficult to treat, whereas HCV genotypes 2 and 3 are much more likely to respond completely to treatment, perhaps in a shorter period of time.

Knowing the genotype of your HCV can help you and your healthcare provider determine how best to approach treatment when the time comes. This might include decisions about which treatments to use and the length of your treatment.

Liver Function Tests: Because hepatitis C is a disease of the liver, you and your doctor will want to monitor the health of your liver. The easiest way to do this is to have regular blood tests that measure the levels of liver enzymes. When hepatocytes (liver cells) become damaged by HCV, these enzymes can become elevated. Some tests to know:

When should treatment for hepatitis C be started?
Figuring out if you should begin treatment for hepatitis C - and determining when you should start it - are complicated issues, especially for people infected with HIV and HCV. Because HCV treatment can cause side effects, along with the fact that there is no guarantee that treatment will be completely effective, people with hepatitis C must weigh the risks of therapy against the benefits in deciding if and when treatment should be started.

As a rule of thumb, it is recommended that treatment be started before cirrhosis occurs, but only for those who are considered to be at a "high risk" of developing cirrhosis in future.

Extreme caution regarding treatment is recommended under the following circumstances:

1. The patient has severe liver disease, such as "decompensated cirrhosis" (a liver transplant may be the best option for these patients); or
2. Normal ALT levels, even if HCV is detectable by PCR; or
3. A recent kidney, liver, heart, or other solid-organ transplant; or
4. A history of problems that might interfere with the safety or effectiveness of treatment, such as severe depression (which can be made worse by the use of interferon, a mainstay treatment for hepatitis C).

For people who are infected with HIV and HCV, there are additional factors to consider when figuring out if and when to begin HCV treatment. Unfortunately, there are no specific guidelines in terms of treating both HCV and HIV, so it is very important that people who are infected with both viruses discuss their options - very carefully - with their healthcare provider. Some issues to consider:

• People with HIV and HCV may experience cirrhosis or liver failure faster than people only infected with HCV. In turn, some experts recommend treatment, even if a liver biopsy reveals mild signs of "fibrosis," "inflammation," and "necrosis" (as opposed to moderate to severe signs in the general population of people with hepatitis C).
• HCV may increase the risk of liver damage, which can prevent certain anti-HIV medications from being broken down in the body correctly. Because of this, some experts recommend early treatment for HCV, before anti-HIV treatment is indicated (for example, while a person's T-cell count is high and HIV viral load is low).
• Anti-HIV medications may cause side effects of the liver that can worsen a person's hepatitis C. This, too, has some experts recommending treatment to lessen the chance that hepatitis C will cause (more) damage to the liver once anti-HIV medicines are started.

Above all, deciding if and when to start treatment should be individualized. Meaning that, regardless of what "official" guidelines do or don't say, it is up to you and your healthcare provider to figure out what's best for you, based on your own thoughts, concerns, and capabilities.

Additional reports and resources culled from AIDSmed.com

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