According to the Centers for Disease Control and Prevention (CDC), 21 percent of HIV-positive people across the country have also tested positive for a past or current hepatitis C (HCV) infection, although the danger varies greatly depending on your personal risk factors. If you have both conditions, that alone places you at increased risk for liver damage compared with those who have hepatitis C only. “Coinfection with hepatitis C and HIV usually represents an intersection of risk factors for each virus,” says Kenneth E. Sherman, MD, PhD, a hepatologist who is the director of the division of digestive diseases and Gould Professor of Medicine at the University of Cincinnati College of Medicine.

Both hepatitis C and HIV are transmitted the same way, says Dr. Sherman: through unprotected sexual contact with an infected person or by sharing injection drug needles with someone who is infected. (While the risk of transmitting hepatitis C through sex is low, according to the CDC, the risk increases for people who have multiple sex partners.) Engaging in high-risk behaviors , such as using injection drugs or not using a condom during sex, can increase your risk of contracting one or both viruses. Infection can happen either from the same person or different people, at the same time or different times. “Both hepatitis C and HIV are transmitted by blood exposure through needle sharing,” says Sherman. “However, hepatitis C is more transmissible, so many patients get that first, followed later by HIV. Occasionally, both viruses are transmitted at the same time.” The risk of being infected with HIV and hepatitis C is higher among Black Americans. According to the CDC and the U.S. Department of Health and Human Services, Black Americans account for about 13 percent of the population but 42 percent of new HIV diagnoses and 25 percent of chronic hepatitis C diagnoses. Black Americans have also historically been almost twice as likely to die of hepatitis C compared with white Americans. Socioeconomic factors due to poverty — limited access to healthcare, housing, and education — increase the risk for infection, according to the CDC. Stigma, fear, and discrimination may also prevent Black Americans from seeking or having access to prevention and care services, the CDC adds.

Risks of Hepatitis C and HIV Coinfection

The CDC reports that HIV coinfection can accelerate the course of hepatitis C, including the rapid progression of chronic liver disease from hepatitis C to cirrhosis, a form of permanent liver damage. This is particularly true in people with advanced immunodeficiency (CD4 T-lymphocyte count lower than 200). In addition, coinfected individuals with cirrhosis progress more rapidly to end-stage liver disease and hepatocellular carcinoma (a type of liver cancer) than those with hepatitis C alone. Both of these liver conditions can be life threatening. In fact, according to the CDC, liver disease — much of which is caused by hepatitis B or hepatitis C — is a leading non-AIDS cause of death in people with HIV. Hepatitis C has also been associated with an increased risk for conditions such as vasculitis (inflammation of the blood vessels), kidney disease, and the skin condition porphyria cutanea tarda. “Untreated, patients with HIV and hepatitis C coinfection have a worse prognosis in terms of liver disease progression and outcomes,” Sherman says.

Treating HCV and HIV Coinfection

If you have hepatitis C, be sure to get tested for HIV. The CDC also recommends that all people over 18, including those with HIV, get screened for hepatitis C. You should continue to get tested regularly if you have risk factors for HCV, including injection drug use. If you test positive for either hepatitis C or HIV, both are treatable. In fact, people who are coinfected and receive treatment for both infections can achieve viral suppression — meaning both viruses are undetectable in the blood — according to the CDC. The key is getting diagnosed and starting treatment as soon as possible to prevent serious liver complications. In general, treatment of hepatitis C in HIV-positive people is similar to the treatments for HCV alone. Direct-acting antivirals (DAAs), the treatment of choice for hepatitis C, can still be used with HIV antiretroviral drugs. If you’re diagnosed with hepatitis C while on treatment for HIV, do not interrupt or discontinue your HIV care to manage your HCV. While there are possibly harmful interactions between the drugs used to treat the two infections, your healthcare team should work together to prescribe the safest regimen that works best for your coinfection. Be sure to work with healthcare providers who have experience treating both conditions. “There is considerable evidence that HIV suppression with antiretroviral therapies is critical and should be started and maintained without a break in those with hepatitis C–HIV coinfection,” Sherman explains. “Still, some hepatitis C treatments are not compatible with HIV treatments, making treatment decisions more complex.” To prevent further damage to the liver, the CDC recommends avoiding alcohol consumption, which speeds up the progression of liver disease, and limiting the use of medications that are potentially toxic to the liver — namely, acetaminophen. And since coinfection with multiple types of hepatitis is common, the CDC also suggests getting tested for and vaccinated against hepatitis A and B viruses. Thanks to new drug therapies, coinfection doesn’t have to be life threatening, as long as you take steps to protect your liver health and get treated. “With older treatments for hepatitis C, response rates were lower for coinfected people, but newer treatments are highly effective against hepatitis C when HIV is present,” says Sherman.