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The role for hepatitis A vaccination in HIV pre-exposure prophylaxis

Ismail, Marwa, F.a; Wong, David, K.a,b; Bogoch, Isaac, I.b,c

doi: 10.1097/QAD.0000000000001742
Correspondence
Free

aDivision of Gastroenterology, Toronto General Hospital, University Health Network

bFaculty of Medicine, University of Toronto

cDivisions of General Internal Medicine and Infectious Diseases, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada.

Correspondence to Dr Isaac I. Bogoch, MD, Divisions of General Internal Medicine and Infectious Diseases, Toronto General Hospital, 14EN- 209, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada. Fax: +1 416 340 3357; isaac.bogoch@uhn.ca

Received 11 December, 2017

Accepted 13 December, 2017

HIV pre-exposure prophylaxis (PrEP) with combined emtricitabine–tenofovir (FTC/TDF) is an effective HIV prevention modality that significantly reduces the risk for HIV acquisition [1]. Comprehensive guidelines outline how patients evaluated for PrEP should be screened and vaccinated to hepatitis B (HBV) and screened for hepatitis C (HCV); however, hepatitis A (HAV) is not mentioned in these guidelines [2]. Unfortunately, many individuals, including MSM, may be at increased risk of HAV infection.

As an illustrative case, we recently cared for an individual with acute HAV infection admitted to our hospital. This 31-year-old man receives routine PrEP care in Toronto, and was sexually active with another man (source patient), who was contacted by Toronto Public Health about a potential HAV exposure at a local restaurant [3]. The source patient was hospitalized with acute HAV prior to our patient's illness. Public health officials offered vaccination for HAV postexposure prophylaxis to the source patient's roommates but not sexual contacts. Our patient suffered from nausea, vomiting, and was jaundiced. During his hospitalization, he had significant elevation in liver enzymes [aspartate aminotransferase (AST) peaking at 5771 U/l, alanine aminotransferase 2611 U/l, international normalized ratio (INR) 1.20, and bilirubin 130 μmol/l]. Serology was consistent with immunity to HBV (via vaccination), and there was no evidence of HCV or HIV acutely or at follow-up.

HAV is transmitted via the fecal–oral route typically following exposure to contaminated food or water, or with sexual exposures. Infection in adulthood typically causes severe acute illness with significant morbidity and low mortality rates [4]. Outbreaks of HAV are sporadic but may affect many individuals [5], placing close contacts and sexual contacts of those exposed at risk for infection. MSM may be at increased risk of HAV infection and recently published Canadian HIV prevention guidelines recommend evaluation for HAV immunity and vaccination in nonimmune individuals [6]. Given the severity of HAV infection and efficacy of vaccination, we suggest that other PrEP guidelines recommend routine evaluation and vaccination for HAV as well.

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Acknowledgements

Conflicts of interest

There are no conflicts of interest.

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References

1. Volk JE, Marcus JL, Phengrasamy T, Blechinger D, Nguyen DP, Follansbee S, Hare CB. No new HIV infections with increasing use of HIV preexposure prophylaxis in a clinical practice setting. Clin Infect Dis 2015; 61:1601–1603.
2. US Public Health Service. Preexposure prophylaxis for the prevention of HIV infection in the United States – 2014 Clinical Practice Guideline. 2014.
3. Toronto Public Health. Available at: https://thebulletin.ca/hepatitis-exposure-ogradys-church/. [Accessed 4 December 2017].
4. Tong MJ, el-Farra NS. Grew MI clinical manifestations of hepatitis A: recent experience in a community teaching hospital. J Infect Dis 1995; 171 (suppl 1):S15.
5. San Diego County, Health and Human Services Agency. Available at: http://www.sandiegocounty.gov/content/sdc/hhsa/programs/phs/community_epidemiology/dc/Hepatitis_A.html. [Accessed 4 December 2017].
6. Darrell H, Tan S, Hull MW, Yoong D, Tremblay C, O’Byrne P, et al. Canadian guideline on HIV preexposure prophylaxis and nonoccupational postexposure prophylaxis. Can Med Assoc J 2017; 189:E1448–E1458.
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