Hepatitis
Hepatitis (sometimes shortened to hep) is an inflammation of the liver. This large organ on the right side of your body has many functions, including turning your food into energy and filtering toxins such as alcohol out of your blood.
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What happens if you have hepatitis?
Hepatitis can be acute or chronic.
Acute hepatitis is short term and begins after the first infection. It can lead to chronic hepatitis, which is long term.
Some types of hepatitis – such as hepatitis A – only cause acute infection.
Chronic hepatitis is long term and can cause lasting damage to the liver. Very serious cases can lead to liver failure or cancer.
What causes hepatitis?
Hepatitis can occur because of:
- being exposed to and picking up the virus
- excessive exposure to alcohol over many years.
The three most common viral forms that can be acquired sexually are Hepatitis A, Hepatitis B and Hepatitis C. The other forms of hepatitis – D, E, F and G – are far less common in the UK.
You can be vaccinated against hepatitis A and B. There is no vaccine for hepatitis C although there is effective treatment which cures over 95% of hepatitis C cases.
Hepatitis A is a form of hepatitis caused by a virus that infects the liver. It’s easy to pass on during sex or get from contaminated food and water. Nearly everyone makes a full recovery.
Hepatitis B is a form of hepatitis caused by a virus that infects the liver. It's easy to pass on during sex or by sharing injecting equipment. Most people who get it make a full recovery, but for a minority it can be more serious.
Hepatitis C is one of the most common types of viral hepatitis caused by a blood-borne virus that attacks the liver.
Hepatitis C is most commonly spread by sharing drug use equipment (both needles and snorting equipment). It can also be spread through sex, although this is extremely unlikely in heterosexual relationships, but the likelihood increases if one of the partners is living with HIV.
There has been a steady rise in the numbers of gay, bisexual and other men who have sex with men acquiring hepatitis C sexually, largely linked to the person acquiring hepatitis C already living with HIV.
Without treatment, the virus can cause liver disease that can be fatal.
All people diagnosed with hepatitis C will be offered 12 weeks of treatment that has few side effects and gives a cure rate of 90-95%.
There is no vaccine against hepatitis C.
Hepatitis signs and symptoms
Hepatitis A symptoms can be so mild you may not realise you have it, if you do notice symptoms they come in two phases. The first phase lasts between three to 10 days, symptoms include:
- flu-like symptoms like muscle pain and extreme tiredness
- pain in your upper right hand side.
The second phase lasts between one and three weeks, symptoms include:
- lack of appetite
- nausea
- itchy skin
- jaundice, where the whites of your eyes turn yellow, your skin may take on a yellowish colour, and your urine turns dark and your faeces (poo) turn pale.
For a few people, these symptoms can continue for 12 weeks or more.
Many people who get hepatitis B notice no symptoms, or have ones so mild that they're easily missed. But after some weeks or months the infection can cause:
- loss of appetite
- nausea or vomiting
- extreme tiredness
- fever
- pain in your upper right hand side
- jaundice, where the whites of your eyes turn yellow, your skin may take on a yellowish colour, and your urine turns dark and your faeces (poo) turn pale.
Symptoms can last for several weeks and it can take months to get back to normal.
Most people make a full recovery but up to 1 in 20 become ‘carriers’ with chronic (long-term) infection. They usually feel fine but stay infectious to others, with a small risk of going on to develop liver disease.
Around 1 in 100 people get a more serious illness which can be fatal if it's not treated.
The majority of people who get hepatitis C don't notice any symptoms when they are first infected. It can take years before you feel ill, and symptoms are often not easily identified as being linked to hepatitis C infection.
The symptoms can include:
- flu-like symptoms
- nausea
- extreme tiredness
- itchy skin
- stomach pain
- jaundice, where the whites of your eyes turn yellow, your skin may take on a yellowish colour, and your urine is dark and your faeces (poo) are pale mental confusion (often called ‘brain fog’) and depression – these are specific to the C strain of hepatitis.
The first six months of infection with hepatitis C is called the acute phase. Around 15- 30% of people will clear the virus naturally during this time. (This percentage is lower for people who also have HIV.)
People who don’t clear the infection will enter the chronic (or long-term) phase and can pass hepatitis C on to others.
How hepatitis is passed on
Someone with hepatitis A is most infectious two weeks before jaundice appears.
The virus lives in faeces (poo) and tiny traces of it carry the infection on the hands or on food prepared by an infected person. Water can also be contaminated, especially abroad.
The virus needs to get into the mouth to infect someone. This can happen during sex when tiny amounts of faeces get on fingers and into mouths through:
- rimming
- fingering
- anal sex without condoms
- handling used condoms and sex toys that have been in someone else’s anus.
The virus can be passed on in these body fluids:
- blood
- semen
- pre-cum
- vaginal/front hole secretions.
It's passed on through:
- oral, vaginal/frontal or anal sex when not using a condom
- rimming
- sharing sex toys without using a condom, and changing the condom if the toy is shared with a partner/s
- sharing injecting drug equipment, such as needles and syringes, which can carry infected blood
- childbirth, from a parent to their child.
It can be found in saliva but there are no proven cases of it being passed on through kissing.
Infections from bites are rare.
Avoid sharing razors, toothbrushes, nail scissors, hair clippers and tweezers because traces of blood on them can pass on hepatitis B. This includes dried blood as the virus can survive for at least a week outside of the body.
The hepatitis C virus is found in blood and is passed on when infected blood gets into another person’s bloodstream. It’s seen as unlikely (but not impossible) that it can be passed on in semen.
Most people get the virus from sharing drug use equipment such as needles, syringes, water cups, tourniquets, spoons, filters and swabs. Sharing things like straws and banknotes that are used for snorting drugs can also pass the virus on, as can sharing pipes.
In the UK, piercing and tattooing should be safe – but unsterilised equipment abroad can spread the virus.
An infected person increases the possibility of infecting others if they share anything that might have blood on it like a toothbrush or razor.
The virus can be passed on to a baby during pregnancy or childbirth.
Blood transfusions in the UK are safe as blood is screened.
You can also potentially get it from medical or dental treatment abroad in countries where hepatitis C is common and infection control is inadequate.
Protecting yourself and others against hepatitis
You can protect yourself by getting vaccinated.
It's especially important to do if you:
- have close contact with someone who has the infection
- are a gay or bisexual man or have sex with men who have sex with men (GBMSM and all their sexual partners)
- inject drugs, especially if you share equipment
- travel to parts of the world where the infection is common.
You might be able to get vaccinated for free by your GP or a sexual health clinic. The vaccine protects you for 10 years or longer.
Although not as good as being vaccinated, you can also cut the possibility of infection by:
- avoiding sex that involves contact with faeces, like fingering or rimming the anus
- using condoms for anal sex and changing condoms between partners
- washing hands after touching someone’s anus or handling used condoms and sex toys
- using a barrier like a condom cut into a square for rimming and latex or polyurethane gloves for fisting.
You can protect yourself by getting vaccinated.
This is especially important if you belong to one of the groups most affected by hepatitis B.
You're more likely to acquire hepatitis B if you:
- have close contact with someone with the infection
- are a gay or bisexual man or have sex with men who have sex with men (GBMSM and all their sexual partners)
- have multiple sexual partners
- have anal sex without using condoms
- rim (oral-anal sex) your partners
- inject drugs when you share equipment
- travel to parts of the world where the infection is common.
Transmission of the virus also happens via heterosexual sex, although to a lesser degree.
There is a vaccine which can protect you against both hepatitis A and B.
If you're in a group more affected by hepatitis B you can usually get vaccinated for free by your GP or at your sexual health clinic.
You may need a booster injection of the vaccination after five years.
If you have hepatitis B, tell people you live with or recently had sex with to urgently ask their doctor about vaccination. Avoid sex with others until your clinician tells you that you're no longer infectious.
Although not as effective as being vaccinated, you can also cut the possibility of infection by:
- using condoms for penetrative sex
- using a barrier such as a condom cut into a square for rimming, or latex or polyurethane gloves for fisting.
Never share injecting drug equipment (e.g., needles, syringes, swabs, spoons, filters) or things that may have blood on them such as toothbrushes and razors. Also avoid sharing straws or rolled up banknotes if snorting drugs with others.
Use condoms for anal sex, for vaginal/frontal sex during menstruation or sex that may cause bleeding and latex or polyurethane gloves for fisting.
During group sex, cover anything which goes from one partner to another with a new condom or new latex or polyurethane glove for each new person it enters. Clean objects with warm water and anti-bacterial soap after use and before using on a new partner.
Don’t share enema equipment or pots of lubricant.
Hepatitis C and sex
Hepatitis C is rarely passed on during vaginal/frontal sex.
There’s also no significant spread of hepatitis C among HIV negative gay, bisexual and other men who have sex with men. But the infection has spread sexually among gay, bisexual and other men who have sex with men living with HIV and is much more common among them.
Group sex, chemsex and hep C
Group sex and chemsex parties can be places where hepatitis C is easily passed on.
This is because if you’re taking drugs and having sex for longer your inhibitions are likely to be lowered and the skin lining the anus could be broken or damaged, causing bleeding.
Hep C is very infectious and is easily passed on during group sex in ways you may not consider, such as being passed from one person to another on fingers.
The virus spreads through anal sex and fisting when condoms and gloves are not used. It’s also passed on during group sex, on objects such as shared sex toys, fingers, shared enema equipment, condoms or latex or polyurethane gloves used on more than one person or in lubricant used by the group that has become contaminated with the virus.
The iBase guide Safer HCV sex for gay men is a useful reminder of what to avoid and what steps to take to protect yourself.
The Hepatitis C Trust has some useful information about transmission. They also provide an advocacy service for men who have sex with men who have been re-infected with hepatitis C after previously being successfully treated.
There is no vaccination against hepatitis C.
If you already have hepatitis C, it’s recommended to have the vaccination against hepatitis A and B to protect your liver from further damage.
Testing and treatment for hepatitis
Most cases are diagnosed by GPs rather than sexual health clinics and no special treatment is needed.
A blood test will confirm whether you have picked up the virus.
The usual treatment for hepatitis A is simply to rest. You may need some time off work while you recover from the flu-like symptoms.
You should also:
- avoid paracetamol unless you discuss its use with a doctor. If possible, use ibuprofen instead.
- avoid recreational drugs to allow your liver to get better
- avoid alcohol until your liver recovers.
Once you have had hepatitis A you’re immune and cannot get it again, but you can still get other types of hepatitis.
Most cases are diagnosed by GPs. A blood test will confirm whether you have picked up the virus.
In most cases no treatment is needed for acute hepatitis B. It may take a while for you to recover and you may want to take some time off work.
You should also:
- avoid recreational drugs to allow your liver to get better
- avoid alcohol until your liver recovers
- avoid smoking because of its negative effect on your liver
- eat a healthy balanced diet.
If your body doesn’t clear the infection and you develop chronic hepatitis B, you will need ongoing treatment to slow down the replication of the virus. However, treatment cannot cure chronic hepatitis B. A small number of carriers go on to get liver disease (and a smaller number of those get liver cancer), and may need a liver transplant.
If your body clears hepatitis B, you’re immune and cannot get it again – but you can still get other types of hepatitis.
It’s recommended that you test for hepatitis C if you:
- inject recreational drugs or steroids
- test positive for HIV (you’ll be tested on a regular basis from your initial diagnosis)
- are a gay, bisexual or other man who has sex with men and test for HIV every three months
- use chemsex drugs and/or go to sex parties
- have a sexual partner who is hepatitis C positive
- had a tattoo outside of the UK
- have sex in exchange for things like money, food or accommodation
- are from a country where hepatitis C is widespread
- are, or have been an alcoholic
- snort cocaine, or other drugs
- are an ex-prisoner.
If you are an HIV negative gay, bisexual or other man who has sex with men, there is no reason for you to be screened routinely unless any of the things listed above apply to you.
If you are a gay, bisexual or other man who has sex with men who is living with HIV, you will be offered a test for hepatitis C if you are diagnosed with another STI like syphilis or LGV, or have had anal sex (including fisting) that may have caused a bleed, or have shared sex toys with others without using condoms and changing them for each new person using the toy.
It’s important to note that it’s not just injecting equipment (syringes/needles) as other drug equipment like straws and pipes can facilitate the transmission of hepatitis C.
You can get a free at-home test kit for hepatitis C from the NHS.
Treatment
Drug treatment is available and has few side effects. In fact, 90-95% of people are cured by the medications, known as direct acting antivirals (DAAs). These are taken in tablet form once or twice a day, typically for 12 weeks.
You can find out more detailed information about treatment for hepatitis C on the Hepatitis C Trust website.
If you have hepatitis C you should also:
- avoid alcohol
- avoid smoking as it can make the liver damage worse
- avoid recreational drugs to allow your liver to get better
- eat a healthy, balanced diet.
If you’re cured of hepatitis C, you’re not immune – you can get hep C again. You can also still get other types of hepatitis, and having hepatitis C and another type is more serious.
What should I do if I have hepatitis?
Tell people you live with or have recently had sex with to ask their doctor about having an urgent vaccination.
Avoid having sex with, and preparing food for other people until you’re told you’re no longer infectious.
Take sick leave and stay away from work and limit contact with other people for 7 days after your symptoms (or jaundice if you didn’t notice symptoms) started.
Rest and drink plenty of fluids.
Wash your hands thoroughly after going to the toilet.
If you're not vaccinated and are exposed to hepatitis A, you may be given the vaccine if you get to see a clinician within 14 days of being exposed to the virus.
You may also be offered a drug called human normal immunoglobulins (HNIGs) which can protect you from infection. This can be given within two weeks after exposure and it can protect you for up to three to six months.
Cases are generally diagnosed by GPs, not sexual health clinics. If you had sex with someone recently or you share your house with others, they can be vaccinated to stop them getting the infection – they should see a doctor straight away.
Avoid sex with others until a clinician tells you that you’re no longer infectious or until your partners have been vaccinated.
A blood test will confirm whether you have the virus.
If you're a carrier, let any sexual partners know, so they can decide if they want to get vaccinated and take other precautions to lessen the likelihood they will acquire hep B.
If you're not vaccinated against hepatitis B and are exposed to the virus, there’s a treatment which may stop you being infected. Hepatitis B immunoglobulin (HBIG) is an injection of antibodies. It's best to get it within 12 hours, and at a maximum of 48 hours of exposure – you'll also be vaccinated at the same time.
A doctor or sexual health clinician can test you to see if you have hepatitis C. If you do, effective treatment with few side effects is available and you can discuss how to avoid infecting your sexual partners or people you live with.
It can take three to six months before the blood test for hepatitis C will be able to detect signs of infection in your blood. For people with HIV who may be immunocompromised, the antibody may not be detectable and it may be necessary to request an RNA test, which will detect the virus.
If you have hepatitis C it’s recommended that you tell your sexual partner/s and explain that you’re infectious. They can then decide what precautions they want to take to lessen the likelihood they will acquire hep C.
HIV and hepatitis
If you are living with HIV you will not experience a more severe case of hepatitis A than someone who is HIV negative.
You may have higher viral load levels of hepatitis A and be able to pass on hepatitis A for a longer period of time, so may have to take protective measures for longer. Your doctor will be able to discuss this with you, as each case will be different.
It is very unlikely that you’d have to stop taking your HIV treatment and it would only be the case if you were experiencing a severe case of hepatitis A.
Any possible interruption of your HIV treatment would be discussed with your HIV doctor and if necessary another clinician experienced in the treatment of hepatitis and HIV.
If you are living with HIV your body will have a slower response rate to the vaccine for hepatitis B, so it’s very likely that you will be monitored and be given boosters as your antibodies to the hepatitis B virus disappear faster than in HIV negative people.
You will not be asked to interrupt or stop your HIV medications.
If you are living with HIV and acquire hepatitis C you will be offered the same treatment as HIV negative people, as it is as effective for all people with hepatitis C regardless of HIV status.
If you have not already had hepatitis A and B vaccines your clinician will recommend that you do as they will lessen the impact of hepatitis C on your health.
Pregnancy and hepatitis
Having hepatitis A while pregnant can increase the likelihood of experiencing a miscarriage or a premature birth so please discuss testing for hepatitis A with your clinicians or midwife if you believe you may have been exposed to the virus.
If you are pregnant you will be tested at 12 weeks for hepatitis B (and other blood borne viruses), and if you are found to be positive for hepatitis B you can be treated to stop the infection being passed to the baby, which has a 90% success rate.
If you are pregnant, you will be tested for hepatitis C (along with a couple of other blood borne viruses) at your 12-week appointment.
There is no evidence to show that hepatitis C causes problems during a pregnancy, although there is a small possibility of transmission of the virus to the baby during birth (thought to be between 2% and 8%) and currently there is no effective intervention to reduce this.
If you are also living with HIV then the possibility of passing on hepatitis C during birth is higher.
Breast/chest feeding is considered safe to do, as there is no firm evidence that it can transmit hepatitis C to the baby. If your nipples are cracked and bleeding, it’s recommended to not breast/chest feed until they are healed.
If you are hepatitis C positive, your baby will be tested for the virus at around 18 months old.
If you are pregnant or are planning a pregnancy and are hepatitis C positive, it’s important to discuss this with your clinician. Sometimes, you will be advised to have the hepatitis C treatment to clear the virus before you get pregnant.
Being hepatitis C positive should have little or no effect on you caring for your baby. You can do everything a parent wants to do for their child.
Untreated hepatitis
Hepatitis A is left to clear itself, and has no lasting impact on your health.
In most cases no treatment is needed for acute hepatitis B. It may take a while for you to recover and you may want to take some time off work.
If your body doesn’t clear the infection and you develop chronic hepatitis B, you will need ongoing treatment to slow down the replication of the virus.
Hepatitis C can be fatal when left untreated.
Untreated hepatitis C can lead to scarring of the liver known as cirrhosis.
A small number of people with cirrhosis will go on to get liver failure, the only treatment for which is a liver transplant. A small proportion of people with cirrhosis develop liver cancer.
Giving blood and organ donation
If you have hepatitis C, you cannot give blood.
Now that we have treatments that clear hepatitis C infection, organs can be donated from people who have cleared hepatitis C infection.
Regular testing
You can have STIs, including hepatitis, without knowing as you may not have or recognise any symptoms, so regular STI testing, and getting vaccinated against hepatitis A and B is both a good idea and important for your sexual wellbeing. This is true for everyone although it’s especially the case if you're starting a new relationship, if you want to stop using condoms with your partner, if you have multiple partners or don’t use condoms consistently.
You don’t need to have multiple sexual partners to get an STI.
There is no reason to be embarrassed or guilty about getting an STI, in fact we know that these feelings actually stop people from getting tested and treated, making it more likely that STIs will impact on your sexual health and are passed on to your partners.
Further support
Terrence Higgins Trust can provide emotional support if you are worried about your sexual health or have concerns about living with HIV. We can help you access services local to you across the UK, whether provided by us or by someone else.
Call THT Direct on 0808 802 1221 for support, advice and information or email info@tht.org.uk.
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