Safer blood and blood products, and medical practices are also important. Condoms are an effective means of preventing sexually transmitted hepatitis B [5–7]. A 40% lower prevalence and 66% reduction in incidence of serological evidence of hepatitis B is observed

in women reporting consistent condom use for vaginal sex [5]. It seems likely, given the evidence for condom use and the prevention of many other STIs, that they will be effective for preventing hepatitis C and preventing transmission of hepatitis B and C during other forms of penetrative sex such as penile/anal and penile/oral intercourse. Although hepatitis A is thought to Epacadostat concentration be sexually transmitted in MSM, it is linked to fisting and oro-anal contact [8–10], in which case condoms are unlikely to offer protection. There is an epidemic of acute HCV infection amongst HIV-infected MSM in the UK and Western Europe [1,2] linked with mucosal traumatic sexual practices and co-transmitted with other sexually transmitted infections, particularly syphilis and lymphogranuloma venereum (LGV) [3]. In many cases this seems to be related to unprotected sex between men who are both HIV-positive. Safer sex Tanespimycin clinical trial education is therefore also important, with emphasis on the risks of catching HCV and STIs through unprotected anal sex, even if partners are HIV sero-concordant (see also section 5.1.1). Although needle exchange schemes have been introduced in many parts

of the world, the benefit seems to be greater for reducing HIV rather than HBV or HCV infection [11,12]. One study showed an incidence of new Pregnenolone HIV, HBV and HCV infection of 0, 11 and 26 cases/100 years at risk, respectively,

in IDUs involved in a needle exchange scheme [11]. This reflects the greater infectivity and prevalence of HBV and HCV, but also the fact that sharing of ‘works’ other than the needle or syringe can still lead to transmission. Counselling of IDUs on reducing risk seems to have some effect, but a greater impact on HIV than the hepatitis viruses [12]. However, the challenge in preventative work in IDUs is engaging them in such schemes. Linking vaccination to either monetary inducements or doses of methadone has been successful [13,14]. All patients should be counselled about safer sex and the use of condoms for penetrative sex (II). Hepatitis B is preventable by vaccination. However, HIV-positive patients respond less well to the vaccine, and the response rate varies with the CD4 count, with greatest response (c. 80%) at >500 cells/μL and least response (c. 25%) at counts <200 cells/μL [15]. Protective antibodies may be lost more quickly. Anti-HBs levels of >10 IU/L generally confer some protection, but levels of >100 IU/L are ideal [16,17]. The 0, 1 and 6 months and the 0, 1 and 2 months, with an additional dose at 12 months schedules have both been shown to be efficacious in HIV-infected patients [18,19].