HIV and the liver

There are different ways that HIV-related liver disease can be categorized. Clinically, it can be split into: disease that relates to the immunocompromised state; disease that involves co-infection with hepatitis viruses; and drug-related adverse events. In the immunocompromised patient with a low CD4+ lymphocyte count, biliary tract disease caused by cytomegalovirus and cryptosporidia, granulomatous hepatitis with infections such as tuberculosis and leishmaniasis, and malignant hepatic infiltration including lymphoma, Kaposi's sarcoma and hepatoma have to be considered. HIV patients are more likely to develop chronic hepatitis B virus (HBV) or hepatitis C virus (HCV) infection in which the prognosis is worse and treatment less effective than in HIV-uninfected individuals. Drug-related liver dysfunction is also common in HIV infection and includes hepatocellular dysfunction with antiretrovirals such as nevirapine, hyperbilirubinaemia due to atazanavir, portal hypertension due to didanosine and hepatic steatosis due to stavudine. These conditions can be treated and combination antiretroviral therapy (cART) has made HIV-related liver disease of all types more amenable to therapy. Chronic HBV infection responds to a range of drugs including pegylated interferon, adefovir, telbivudine and the antiretrovirals tenofovir, lamivudine and emtricitabine. Acute and chronic hepatitis C will respond to pegylated interferon and ribavirin. More recently, the direct-acting antivirals for hepatitis C (boceprevir and telaprevir) have greatly increased treatment response rates in HIV co-infected patients to levels similar to those seen in HCV mono-infected patients. Liver transplantation can be also offered when appropriate.