The STI Files: Hepatitis
What is viral hepatitis?
Beyond causing hepatitis and being sexually transmitted, these three viruses don’t have a ton in common – although their names are similar, they aren’t closely related to each other and there are some important differences when it comes to transmission, prevention, and treatment. It’s understandably easy to get the hepatitis viruses mixed up (they weren’t given very imaginative names), so the rest of this article breaks things down by A, B, and C.
Before the Hepatitis A vaccine became available in 1995, there were over 22,000 cases of HAV per year in the United States. Today, there are about 1000-2000 cases of HAV reported each year in the U.S.
In countries without clean drinking water or toilets and where the HAV vaccine is not available, about 90 percent of people get infected with HAV during childhood. Kids who get HAV often don’t have symptoms and usually get better without needing special medical care.
Hepatitis A is a gastrointestinal bug – it’s spread by feces (poop), and it’s most common in places where people don’t have access to clean toilets, safe drinking water, and places to wash their hands. HAV is most common in low-income countries, in refugee camps, and among homeless folks.
Most people who get HAV don’t get it from sex: they get it from contaminated water or food. If a person with HAV does not wash their hands after pooping, they can spread HAV to others from surfaces they touch or through food, so people often pick up HAV through not washing their hands before they eat. Similarly, if drinking water gets contaminated with human poop and people don’t have a way to purify their water, HAV can spread really easily.
HAV can be sexually transmitted through any activity that might cause your mouth to come into contact with feces. This includes rimming (oral-anal sex), not changing condoms between anal and oral sex, and not washing your hands after using them to touch someone’s anus.
In wealthy countries, HAV is becoming less common among young people due to vaccination. People who get HAV are usually too old to have been vaccinated as kids (the vaccine didn’t come out until the 1990s) and they usually get it from sex, food poisoning, or living on the streets without access to clean toilets. Sometimes outbreaks of HAV are caused by raw shellfish that lived in contaminated water.
Symptoms of HAV infection include abdominal pain, loss of appetite, nausea and vomiting, diarrhea, pale colored stools, dark yellow urine, fever, fatigue, and jaundice (yellowing of the whites of the eyes). Symptoms begin within 2-4 weeks following exposure. Children aged six and under usually don’t have symptoms.
Hepatitis A is an acute (short-lived) illness, so the symptoms go away on their own after a month or so. After someone gets better from HAV, they are immune and can’t get it again.
Hepatitis A is not routinely tested for. You only need to be tested for Hepatitis A if one of the following is true:
- You aren’t sure if you’ve ever been vaccinated against HAV. A blood test called a hepatitis panel test can tell you whether you are immune to HAV (either because of previous infection or vaccination).
- You have symptoms of HAV infection. An RNA test will be able to tell if you have an active HAV infection.
If you are immune to HAV (either due to vaccination or previous infection), you do not need to get tested for HAV. If you think you might have HAV or don’t know if you’ve been vaccinated, you can get tested at a community health clinic, doctor’s office, or sexual health clinic (including Planned Parenthood).
HAV is very easily prevented by vaccination, which consists of a two-shot series. If you have not been vaccinated for HAV, you can get the vaccine from most medical providers (including travel clinics, public health clinics, and student health centers). Protection is lifelong and is almost 100 percent effective.
The HAV vaccine became available in 1995 and in higher-income countries, most people born after that point were vaccinated as children. If you aren’t sure whether you need the vaccine, you can talk to a medical provider about getting a hepatitis panel test. If you have a primary care provider, you can also ask to see your vaccination records to find out if you got the vaccine as a child.
You can also protect yourself from HAV by using barriers (like latex dental dams or non-microwaveable plastic wrap) for oral-anal sex and always washing your hands with hot, soapy water after touching someone’s anus. Even if you’ve been vaccinated against HAV, these measures can protect you from other tummy problems (like stomach viruses or parasites) that are sometimes transmitted during oral-anal sex.
Hepatitis A goes away on its own and there are no specific drugs used for treating HAV. The treatment for HAV is “supportive,” which means it focuses on keeping a person well-hydrated, nourished, and comfortable while their body clears the virus on its own. This usually means lots of fluids and rest, but if a person with HAV gets really sick, they might need to go to a hospital to get care.
Almost everyone who is infected with HAV makes a full recovery within two months. HAV tends to be more serious in older adults and in people who already have liver conditions. In the United States, less than one percent of people with Hepatitis A die from it.
People who recover from HAV are immune for the rest of their lives. HAV does not cause infertility or other long-term complications.
Globally, about 257 million people are infected with HBV.
Hepatitis B infection is a major cause of liver failure and liver cancer, which can be fatal. The World Health Organization estimates that in 2015, almost 900,000 people died from liver problems related to Hepatitis B infection.
Hepatitis B can be spread by blood and sexual fluids (vaginal fluid, rectal fluid, semen, and pre-ejaculate). Fluid from an infected person must get into your blood (either directly or through cuts or open sores) for you to get Hepatitis B. Hepatitis B can also spread from a pregnant person to a baby during pregnancy or birth.
The activities that spread Hepatitis B include vaginal sex, anal sex, and blood contact (such as sharing injection drug use supplies). In the United States, most people who get HBV were infected by injection drug use and most of these people are between 30-50 years old. In high-income countries, HBV is rare in younger people because most people under 30 have been vaccinated.
Hepatitis B is not spread by casual contact, kissing, touching surfaces like toilet seats, or breastfeeding.
When a person is first infected with HBV, they might experience an acute (short-term) illness, with symptoms similar to HAV infection (listed above). These symptoms start around 90 days after exposure and can last for up to six months. Around 95 percent of adults and teens who get HBV will get better on their own.
In the five percent of adults and teens who do not get better on their own, HBV infection becomes chronic (long-term). A person with chronic HBV infection might not have any symptoms at all, but over time, they might develop liver disease. Chronic HBV infection can cause cirrhosis (when scar tissue forms in the liver), liver failure, and liver cancer. These conditions can be fatal.
There are two main types of tests for HBV. The first one is called a panel test, which looks for antibodies to Hepatitis B. A panel test can tell the difference between someone who has been vaccinated against HBV, someone who used to be infected with HBV, and someone who currently has HBV.
If a person’s panel test suggests a current HBV infection, they will get a second type of test called a viral load. This test measures the amount of HBV in the person’s body.
If a panel test shows that someone is not immune to HBV, that person can get vaccinated. People who have been vaccinated against HBV do not need routine testing for HBV.
The following people should be tested for Hepatitis B:
- Anyone who is from a part of the world where HBV is common, including Southeast Asia, the Pacific Islands, and Sub-Saharan Africa should be tested at least once in their lifetime.
- Anyone who was born to someone from one of the above regions, or who was born to someone with Hepatitis B should be tested at least once in their lifetime.
- People who are not vaccinated against HBV who inject drugs and/or have anal or vaginal sex without condoms should be tested at least once a year.
You can get a hepatitis panel test at a community health clinic, doctor’s office, or many sexual health clinics (including Planned Parenthood).
Hepatitis B is vaccine-preventable. In the United States, routine vaccination of children began in 1991. If you were born in the United States after 1991 or attended school in the United States (where the vaccine is required), you have probably already been vaccinated. If you have a primary care provider, they might have a record of whether you got the vaccine. If you do not have a primary care provider, you can get a hepatitis panel test to find out if you need to get vaccinated.
Normally, the HBV vaccine is a series of three shots. In rare cases, a person may require additional shots to become immune or won’t become immune at all (a lab test for HBV antibodies will let you know whether the vaccine worked). The vaccine is 95 percent effective at preventing HBV.
In addition to getting vaccinated, Hepatitis B can be prevented by:
- Using condoms consistently and correctly for anal and vaginal sex.
- Not sharing injection drug use supplies, including needles, syringes, cottons, and cookers.
These types of prevention are extra important for folks who don’t respond to the HBV vaccine. Both of these types of prevention are described in greater detail in the HCV prevention section below.
There is no cure for HBV infection. However, a 6-12 month treatment with antiviral drugs will cause the infection to become “inactive.” An inactive infection means the virus is still in the body but is no longer making the person sick. People with chronic HBV can live long, healthy lives with treatment, and treatment helps prevent HBV from causing problems like liver cancer.
After antiviral treatment, an HBV infection can sometimes “reactivate” and begin to damage the liver again. If this happens, an additional course of treatment is required. This means a person with chronic HBV will need regular viral load tests to check whether their infection is active.
HBV can cause liver failure and liver cancer and both of these conditions can be fatal.
HBV does not cause infertility but it can be passed from a pregnant person to an infant during pregnancy and birth. However, antiviral drugs can prevent HBV from being passed to the infant, and a person who has chronic HBV can still breastfeed without passing HBV to the infant.
There are two other viruses that cause hepatitis – Hepatitis D and Hepatitis E. We’re only touching on them briefly here because they aren’t super common (and Hepatitis E is not usually sexually transmitted).
Hepatitis D (also called Hepatitis Delta) is a little unusual in that it can only infect someone who has Hepatitis B already (which means the Hepatitis B vaccine protects you from D as well). HDV is transmitted the same way as HBV but there is no treatment or cure, which is another really good reason to get the Hepatitis B vaccine. About 15 million people worldwide have Hepatitis D. HDV is rare in North America and Western Europe, but in the rest of the world, about five percent of folks with HBV also have HDV.
Hepatitis E is really similar to Hepatitis A – it’s transmitted through feces, it’s an acute (short-term) illness, and most folks who get Hep E get it from drinking contaminated water or from eating the meat of infected animals (wild pigs and deer can carry Hep E). About 20 million people worldwide have Hep E. There is no vaccine for Hepatitis E but you can protect yourself by avoiding unpurified drinking water and undercooked game meat.
The CDC estimates that about 3.5 million people in the United States are infected with Hepatitis C, making HCV the most common type of viral hepatitis in the U.S.
Worldwide, about 71 million people have HCV.
HCV is most often spread by blood-to-blood contact from the following activities:
- Sharing any items used for injection drug use, including needles, syringes, cookers, cotton filters, and water.
- Sharing any items used for snorting drugs, like straws, or sharing items used for smoking crack or meth, like glass pipe stems or mouthpieces.
- Getting a piercing or tattoo with needles or ink that are not brand new.
- Sharing any BDSM gear or sex toys that might have blood on them.
HCV is also spread by vaginal and anal sex. Until recently, it was believed that sexual transmission of HCV was rare, but we’re learning that HCV is sexually transmitted more often than was thought. HCV seems easier to transmit through anal sex than through vaginal sex, especially when one or both partners are HIV-positive (having HIV makes it easier to transmit and become infected with HCV). There is no evidence that HCV can be transmitted through oral sex.
The symptoms of an initial infection with HCV are the same as for HAV and HBV. These symptoms would occur between 2-12 weeks after exposure, but only about 20-30 percent of people with HCV get symptoms.
People with chronic (long-term) HCV infection might develop vague symptoms like fatigue, abdominal pain, or just feeling crappy. Not everyone with chronic HCV has symptoms, though, which is why testing is important.
Routine testing for Hepatitis C is recommended for everyone whose blood comes into contact with other people’s blood. This means if you share needles (for drug use, piercing, or tattooing) or engage in types of BDSM play that involve blood (like edgeplay, flogging, and sometimes fisting), it’s a good idea to get tested for HCV when you get tested for other STIs. Routine HCV testing is also important if you have anal sex (especially if you don’t always use condoms and especially if you are HIV-positive, since it’s easier for folks with HIV to get HCV).
If you don’t do any of the above activities now but did them in the past, getting tested for HCV is definitely still a good idea because you can be infected with HCV for many years without knowing you have it.
Getting tested for Hepatitis C involves an antibody test (similar to an HIV test) that looks for the antibodies we make in response to HCV infection. This test cannot tell the difference between a current infection with HCV and a past exposure to the virus. If someone tests positive for HCV antibodies, they need an RNA test that looks for the virus itself. This test is used to confirm whether a person is currently infected with HCV.
If tests reveal that someone has a current HCV infection, they will get an additional test called a genotype. This test provides information about the specific strain of HCV someone is infected with, which is important for determining which medication to use to cure it.
There is no vaccine for HCV. Preventing HCV involves regular testing, using condoms, and avoiding blood-to-blood contact:
- Anal and vaginal sex: Using condoms for anal and vaginal sex prevents HCV transmission. Bleeding during anal and vaginal sex increases the risk of spreading HCV, so going slow and using lots of lube also helps prevent HCV.
- Sex toys: If you use sex toys (like butt plugs or dildos) on multiple partners, cover the toys with a new condom for each partner or wash the toys between partners. If you plan on using a toy on multiple partners, try to purchase toys made of medical grade silicone, metal, or glass - these toys are easy to sterilize by soaking in 10 percent bleach for three minutes or by boiling in water. Toys made out of plastic or soft “jelly rubber” are harder to clean safely and should be covered with condoms or used on one partner only.
- Drugs that are injected: The best way to prevent HCV transmission from injection drug use is to use new, unopened supplies (needles, syringes, cottons, cookers, and water) every time you inject drugs. If you need to reuse supplies, write your name on them and don’t share them with anyone else. Check out this guide from the Harm Reduction Coalition for more tips on safer injection drug use.
- Drugs that are smoked or snorted: HCV can be transmitted by sharing straws for snorting drugs, since using drugs this way often causes nosebleeds. If you snort drugs, make sure each person has their own straw. Smoking crack and meth can also spread HCV because these drugs burn at a very high temperature and the glass pipes can cause your lips to crack, burn, and bleed. Transmission can be prevented by having your own pipe mouthpiece (paper or rubber) that you don’t share and by using lip balm to prevent cracked or bleeding lips.
- BDSM: BDSM activities are only a HCV risk if they involve breaking the skin and if toys or equipment get blood on them and are used on multiple partners. The easiest way to prevent HCV transmission is to use separate sets of toys (e.g. floggers) for each partner or to thoroughly clean toys between partners.
- Fisting: You can reduce the risk of bleeding during fisting by keeping your nails trimmed and filed, going slow, and using lots of lube. Wearing gloves reduces the risk of coming into contact with someone else’s blood.
- Body Art: If you get piercings or tattoos, make sure the artist uses fresh, unused needles and ink for each client. Licensed piercing and tattoo artists are required to use new supplies for each client and are trained in preventing HIV and HCV transmission.
Hepatitis C is completely curable with an 8-12 week course of antiviral drugs (direct-acting antivirals or DAA).
Anyone with Hepatitis C can be cured. This includes people who are homeless, people who use drugs, and people who are also infected with HIV and/or another hepatitis virus.
The specific medications a person takes, and how long they need to take them, depends on the strain of HCV someone is infected with and how much liver damage they already have. There are seven strains of HCV and it is possible to be infected with any number of them at the same time.
After being cured, it is possible to be re-infected (with the same strain or a different strain), so prevention is still really important.
Help-4-Hep – Free hotline for information, peer counseling, and treatment advice for folks with Hepatitis C.
The Harm Reduction Coalition has lots of helpful information about Hepatitis C for folks who use drugs.