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Hepatic decompensation associated with hepatitis B e antigen clearance in chronic type B hepatitis.

To examine hepatic decompensation associated with acute exacerbation preceding hepatitis B e antigen clearance in chronic type B hepatitis, 376 patients with chronic hepatitis who were hepatitis B e antigen-positive were prospectively studied for up to 7 yr (mean 25 mo). Among the 165 patients who underwent hepatitis B e antigen clearance, 4 patients experienced hepatic decompensation and one of them eventually developed hepatic encephalopathy and died. The incidence of hepatic decompensation associated with hepatitis B e antigen clearance was 2.4%. We suggest that such an event in previously unrecognized chronic hepatitis B carriers could have been erroneously interpreted as acute or subacute hepatic failure, and that it might have been the result of a stronger enhancement of the host immune response.

Acute Disease↗

Previous or occult hepatitis B virus infection in hepatitis C virus-associated hepatocellular carcinoma without hepatic fibrosis.

We investigated the role of hepatitis B virus infection in development of hepatocellular carcinoma in hepatitis C virus-infected patients without hepatic fibrosis. Of 253 patients, 8 lacked hepatic fibrosis (group 1); group 2 included the remaining 245 patients. Clinicopathologic findings were compared between the groups. Hepatitis B x gene was sought in cancers and adjoining noncancerous liver. Group 1 showed better liver function parameters and milder active hepatitis than group 2. The proportion of patients with anti-hepatitis B virus antibody tended to be higher in group 1 than in group 2. The proportion of patients with hepatitis B x RNA in cancers was significantly higher in group 1 than in group 2. All group 1 patients had previous or occult hepatitis B virus infection. Previous or occult hepatitis B virus infection may be critical in development of hepatocellular carcinomas in hepatitis C virus-infected patients without hepatic fibrosis.

Aged↗

Promoting hepatic growth factor in the treatment of heavy type hepatitis and severe chronic hepatitis: a multicenter clinical study.

BACKGROUND: The mortality rate of heavy type hepatitis is high. No special treatment is available except general treatment. This multicenter clinical study was designed to observe the safety and efficacy of promoting hepatic growth factor (PHGF) in the treatment of heavy type hepatitis and severe chronic hepatitis. METHODS: 347 patients with heavy type hepatitis and 324 with severe chronic hepatitis were subjected to administration of 120 microg of PHGF per day for 4 weeks on the basis of general treatment. Those who were being effectively treated would last additional 2 to 4 weeks. Blood routine, urine routine, blood urea nitrogen (BUN), blood creatinine (Cr), blood ammonia, alpha fetoprotein (AFP), electrolyte, alanine transaminase (ALT), aspartate transaminase (AST), serum total bilirubin (TBIL), serum direct bilirubin (DBIL), prothrombin time activity (PTA), total protein (TP) and albumin (ALB) were detected in the patients before treatment, 2 weeks after treatment, and at the end of the treatment. Any side-effect would be recorded. RESULTS: In the patients with severe chronic hepatitis, the total effective rate of the treatment was 88.9%. The levels of ALT, AST and TBIL decreased significantly (P<0.001), whereas those of PTA and ALB increased significantly (P<0.001), and the level of AFP increased slightly. In patients with heavy type hepatitis, the total effective rate of this treatment was 78.4%, and patients at different stage showed different results. The total effective rates of patients with early, medium and terminal stage heavy type hepatitis were 89.9%, 84.8% and 27.5%, respectively. No severe side-effect was shown. CONCLUSION: PHGF is effective and safe in the treatment of patients with heavy type hepatitis and severe chronic hepatitis. But it should be administered early in patients with heavy type hepatitis so as to get better curative effects.

Acute Disease↗

[Is endemic hepatitis E infection present in developed countries?--Accumulating information about the hepatitis E virus and hepatitis E infection].

There are several new data on the acute viral hepatitis particularly on infectious non-A-non-C hepatitis viruses. The hepatitis E virus infection was originally thought to be limited only for certain geographic areas and humans. Recently, it has been demonstrated the genetic diversity and worldwide distribution of hepatitis E virus in human population, as well as, the circulation of the virus in many species of animals. It is evident, that hepatitis E virus can spread by fecally contaminated water (waterborne transmission), by meat of infected animals (food-borne transmission), by animal-human contact (zoonotic transmission), and even by transfusion (blood-borne transmission). The frequency of hepatitis E virus infections among the acute hepatitis cases with unknown origin is supposed to be more than 10%. In the differential diagnosis of hepatitis, possible hepatitis E virus infection must be now taken into account even in those areas and countries, like in Hungary, where the infection was previously thought to be non-endemic. To confirm the clinical diagnosis of hepatitis E virus infection, virus specific ELISA and molecular methods are now available. In the near future, a molecular epidemiological study will be organized for the detection of hepatitis E virus in Hungary in collaboration with 9 European countries.--This review covers all aspects of the hepatitis E virus infection including the characteristics and transmission of the etiological agent, the clinical symptoms, its epidemiology, laboratory diagnosis, and some possible control measures.

Developed Countries↗

[Correlation between hepatic microcirculation ultrastructural changes and hepatic dysfunction in chronic hepatitis B].

The author observed the ultrastructural changes of hepatic microcirculation and the function of the liver in 41 cases with chronic hepatitis B confirmed histologically. The main ultrastructural changes found in patients were swelling of the endothelium of hepatic sinusoids, hyperplasia of Kupffer cells and decrease of fenestrae in the endothelium. Proliferation of monocytes and fat-storing cells was also found in the lumina of hepatic sinusoids and space of hepatocytes and perisinusoid. The basement membrane in hepatic sinusoids and the base of hepatocytes were formed in the patients with marked pathologic changes of the liver, especially in CAH with cirrhosis. The observations also showed that whatever extent of hepatic microcirculation changes, all of them had more or less elevation of SGPT and ZnT or TT. As soon as hepatic function was impaired slightly, there occurred hepatic dysmicrocirculation. But in the cases of severe ultrastructural hepatic dysmicrocirculation serum gamma globulin elevation values and A/G ratio exchanges were much higher than those in the cases of slight changes. There was some significance on the judgment of sick condition, slight or severe. Values of the elevation of serum gamma globulin and A/G ratio exchanges were much more obvious than SGPT, ZnT and TT changes. These findings suggest that the extents of pathological changes and dysfunction of the liver in chronic viral hepatitis B are correlated to the extent of hepatic microcirculation impairment. So in the treatment of chronic hepatitis early administration of medicine to improve the liver microcirculation should be considered.

Adolescent↗

Sequence analysis of hepatitis B virus genomes from an infant with acute severe hepatitis and a hepatitis B e antigen-positive carrier mother.

It is well known that fulminant hepatitis B can occur in infants born to hepatitis B e antigen (HBeAg)-negative hepatitis B virus (HBV) carrier mothers, whereas fulminant hepatitis and severe hepatitis are uncommon in infants born to HBeAg-positive mothers. We have encountered an infant with severe acute hepatitis B born to a HBeAg-positive mother. The aim of this study was to determine whether HBV variants contribute to the pathogenesis of fulminant hepatitis and severe hepatitis in an infant born to an HBeAg-positive mother. The nucleotide sequence of HBV genomes from the infant and his HBeAg-positive carrier mother was analyzed. All HBV isolated from the infant and his mother were subtype adr. The sequences of the cloned HBV genomes, each including a part of the X and precore/core regions, isolated from the infant were almost identical (homology of 99.1-99.9%) to those from his mother. There was no mutation in any of the 17 clones examined at nucleotides 1762 and 1764 in the core promoter, which is reported to be associated with fulminant hepatitis. A point mutation at nucleotide 1758 in the second AT-rich region of the basic core promoter was present in all clones. None of the clones had a point mutation at nucleotide 1896 of the precore region. In this study, no specific HBV variants contributing to the development of neonatal severe hepatitis were found. There is a possibility that host factors rather than viral factors play an important role in some cases of severe neonatal hepatitis B.

Adult↗

Hepatocyte hepatitis B surface antigen. Diagnostic evaluation of patients with clinically acute hepatitis B surface antigen-positive hepatitis.

Patients who were diagnosed as having acute hepatitis B by conventional criteria were reevaluated by a correlative study of tissue hepatitis B surface antigen (HBsAg) and serologic tests for anti-hepatitis A virus, IgM, and/or anti-hepatitis B core antigen (anti-HBc) IgM. The results demonstrated that the diagnosis of acute hepatitis B in an endemic area was complicated by superinfection or reactivation of unrecognized hepatitis B carriers or chronic hepatitis B patients simulating acute hepatitis clinically. Anti-HBc IgM failed to discriminate newly infected acute hepatitis B from reactivation of chronic hepatitis B liver disease, especially when the enzyme-linked immunoassay index value was low. Our data suggest that a combination of different tissue HBsAg expression patterns usually indicate the presence of underlying chronic liver disease, while the tissue HBsAg was practically all negative in newly infected cases. Therefore, the study for tissue HBsAg expression by the immunoperoxidase method is an invaluable aid in identifying true acute hepatitis B in patients in an endemic area.

Acute Disease↗

Serum ferritin and hepatic glutathione concentrations in chronic hepatitis C patients related to the hepatitis C virus genotype.

BACKGROUND/AIMS: Increased serum ferritin is thought to be responsible for activation of glutathione turnover in patients with chronic hepatitis C. The aim of the study was to evaluate a possible correlation between levels of serum ferritin and concentrations of hepatic, plasmatic and lymphocytic glutathione in a selected cohort of chronic hepatitis C patients in relation to the hepatitis C virus genotype. METHODS: The study considered 130 chronic hepatitis C patients and 23 control subjects. Hepatic glutathione was determined from biopsy liver specimens by high performance liquid chromatography. Total Iron Score was assessed by scoring iron separately within hepatocytes, sinusoidal cells and portal tracts. Blood samples were tested for determination of serum ferritin, and plasmatic and lymphocytic glutathione levels. Hepatic and erythocyte malonyldialdehyde were also determined along with peripheral blood mononuclear cell cytotoxic assay. RESULTS: Patients with genotype 1b showed higher levels of serum ferritin compared to patients with genotype 2a/2c and 3a and to controls, along with a significant reduction of the concentrations of hepatic, plasmatic and lymphocytic glutathione and peripheral blood mononuclear cell cytotoxic activity. The levels of serum ferritin correlated significantly to Total Iron Score, to hepatic, plasmatic and lymphocytic glutathione, to hepatic and erythrocyte malonyldialdehyde and to peripheral blood mononuclear cell cytotoxic activity. CONCLUSIONS: The levels of serum ferritin correlate significantly to lipoperoxidation markers in chronic hepatitis C patients. The increased production of free radicals with a reduced peripheral blood mononuclear cell cytotoxic activity may represent, especially in patients with genotype 1b, a factor underlying the resistance to interferon therapy and may influence the evolution of the liver disease by enhancement of the cytopathic effect of hepatitis C virus.

Adult↗

Detection of hepatitis B and hepatitis C viral sequences in fulminant hepatic failure of unknown etiology.

In a significant number of patients, the etiology of fulminant hepatic failure (FHF) is unknown. To determine whether hepatitis B virus (HBV) and hepatitis C virus (HCV) play a role in patients without serologic markers of HBV and HCV infection, the authors examined tissue samples from 15 liver explants with massive hepatic necrosis for the presence of viral sequences by the polymerase chain reaction (PCR). The specimens were derived from nine patients with FHF of unknown etiology; two with serum hepatitis B surface antigen (HBsAg); two with antibodies to HCV; one with antibodies to hepatitis A virus (HAV) and anti-HBc of the IgM class; and one with isoniazid toxicity. Nucleic acids were extracted from frozen liver samples. RNA was used as a template for reverse transcription, followed by double PCR with nested primers for the 5'-untranslated region of HCV. DNA was tested by single PCR for S gene sequences of HBV. Hepatitis B virus sequences were detected in the specimens of the two HBsAg positive patients, the anti-HAV/anti-HBc positive patient, and three of nine patients with FHF of unknown etiology. Hepatitis C virus sequences were present in the explant of one patient with FHF of unknown etiology, but not in the two patients with antibodies to HCV. In two specimens with molecular findings of HBV infection (1 from a patient with serum HBsAg and 1 without), there was immunohistochemical evidence of coinfection or superinfection with hepatitis delta virus (HDV). In conclusion, in this patient population, HBV, alone or with HDV or HAV, causes fulminant hepatic failure more often than HCV infection. However, in the majority of patients, the etiology of fulminant hepatic failure remains unknown.

Adult↗

Hepatitis delta virus infection and Labrea hepatitis. Prevalence and role in fulminant hepatitis in the Amazon Basin.

To define more exactly the epidemiology of delta virus infection and confirm its role in causing fulminant Labrea hepatitis in the Amazon Basin, we studied the prevalence of delta virus infection among persons with acute and chronic hepatitis B virus infection in the Boca do Acre district of the southern Amazon Basin. Delta virus infection was found in 24% of asymptomatic hepatitis B virus carriers, 29% of acute nonfulminant hepatitis B cases, 74% of fulminant hepatitis B cases, and 100% of chronic hepatitis B cases. Chronic delta virus infection occurred primarily in older children and adults, while acute and fulminant delta virus infection occurred in young children as well. In fulminant hepatitis cases, delta virus superinfection of hepatitis B virus carriers was the most common serological pattern; histopathologic examination showed features identical to those described in fulminant hepatitis cases of similar etiology in Colombia and Venezuela. Delta virus infection is highly endemic in the southern Amazon Basin and is the principal cause of Labrea hepatitis.

Acute Disease↗

Post-transfusion hepatitis: impact of non-A, non-B hepatitis surrogate tests. Canadian Post-Transfusion Hepatitis Prevention Study Group.

Canada has not introduced the non-A, non-B (NANB) surrogate marker tests (antibodies to hepatitis B core antigen and alanine aminotransferase) to screen donated blood. We evaluated the effect of NANB surrogate markers in reducing post-transfusion hepatitis in a prospective randomised intervention study. From 1988 to 1992, 4588 subjects were enrolled into two study groups that received allogeneic blood from which units positive for NANB surrogate markers were either withheld (n = 2311) or not withheld (n = 2277). We also assessed a simultaneous non-randomised cohort (n = 650) of subjects who received only syngeneic blood. All subjects were followed up for 6 months and assessed for the presence of post-transfusion hepatitis due to hepatitis A, B, C, non ABC, Epstein-Barr virus (EBV) and cytomegalovirus (CMV). Withholding of blood containing NANB surrogate positive units reduced the overall post-transfusion hepatitis rate by 40% (p = 0.065) and the hepatitis C rate by 70% (p = 0.05). Most of the benefit of NANB surrogate testing was due to reduced frequency of hepatitis C virus after transfusion before all donor blood was screened for anti-HCV. During this time the overall post-transfusion hepatitis rate per 1000 transfusion recipients was 20.2 in the no-withhold group compared with 5.0 in the withhold group (p = 0.05), and the HCV hepatitis rate was 12.6 and 0 respectively (p = 0.06). After the introduction of HCV screening, the overall post-transfusion hepatitis rates were 8.6 and 6.8 per 1000 (p = 0.55) respectively.(ABSTRACT TRUNCATED AT 250 WORDS)

Alanine Transaminase↗

Aetiology of icteric hepatitis and fulminant hepatic failure in children and the possible predisposition to hepatic failure by sickle cell disease.

The aetiological agents of acute icteric hepatitis and fulminant hepatic failure were investigated in 47 children less than 12 years of age presenting at our hospital during the period January to December 1987. Hepatitis A virus was the aetiological agent in 72%, hepatitis B virus in 11%, cytomegalovirus in 2% and non A non B in 15%. These results confirm the endemicity of these viruses in the Saudi population and that they can be contracted in early life and could lead to severe hepatitis. Three of the patients who had hepatitis A virus infection developed fulminant hepatic failure and two of them died. Two of the patients who developed fulminant hepatic failure were also suffering from sickle cell disease. This raises the question of a possible predisposition to hepatic failure in sickle cell disease upon infection with hepatitis A virus.

Acute Disease↗

Clinical hepatitis after transplantation of hepatitis C virus-positive kidneys: HLA-DR3 as a risk factor for the development of posttransplant hepatitis.

BACKGROUND: Exposure to hepatitis C virus (HCV) and subsequent infection after renal transplantation lead to significant clinical hepatitis in approximately 50% of graft recipients. METHODS: One hundred thirty-two consecutive renal allotransplant patients, who underwent transplantation of kidneys from HCV-positive cadaveric donors, were studied to investigate the relationship between donor and recipient HLA type and the risk of developing clinical hepatitis. Specific attention was directed toward the DR3 and DR4 alleles, as these had previously been associated with worse prognoses in autoimmune and viral hepatitis. RESULTS: Overall, 42% of patients receiving kidneys from donors seropositive for HCV developed clinical hepatitis. This was unrelated to preoperative recipient HCV serum reactivity (P=0.65). Patients receiving kidneys from seropositive donors with HCV RNA as detected by PCR were more likely to develop hepatitis than those receiving kidneys from PCR-negative donors (56% vs. 11%; P=0.005). The presence of the DR3 allele was associated with a significant risk of clinical hepatitis (P=0.025); 80% of DR3-positive recipients (n=34) progressed to hepatitis compared with 42% of DR3-negative patients. No other recipient HLA type was significantly related to prognosis. All patients receiving a donated kidney that expressed the B41 allele developed hepatitis, compared with 55% of recipients of non-B41 grafts (P=0.039). No association between the development of clinical hepatitis and HLA compatibility was found. CONCLUSIONS: These results suggest that both HLA type and viral presence as assayed by polymerase chain reaction, influence the risk of disease progression after transplantation of HCV-positive kidneys. Application of these associations may decrease the relative risk of a recipient contracting HCV hepatitis after cadaveric renal transplantation.

Alleles↗

Hepatic expression patterns of the large and middle hepatitis B virus surface proteins in viremic and nonviremic chronic hepatitis B.

The envelope of hepatitis B virus consists of large, middle, and small hepatitis B surface proteins. Recent data from in vitro studies suggest that intracellular expression and distribution of the three polypeptides may be variable. These observations in artificial expression systems prompted this analysis of the occurrence and distribution of the three hepatitis B surface proteins in the liver tissue of substantial viremic (hepatitis B virus DNA- and hepatitis B e antigen-positive) and low-viremic or nonviremic (hepatitis B virus DNA-negative, anti-hepatitis B e antigen-positive) carriers by specific monoclonal antibodies against large, middle, and small proteins. Patients with an active form of viral replication showed a prevalence of middle and small hepatitis B surface proteins in the liver. In nonviremic carriers, the large hepatitis B surface protein was the predominant intrahepatic antigen, a finding that was confirmed at the ultrastructural level by staining of the entire filaments of the viral envelope material in ground glass hepatocytes. The present data are thus consistent with observations in hepatitis B virus-transgenic mice and in transfected cell systems, suggesting that the different patterns of the envelope proteins in the liver may be due to different processing at the translational level.

Antibodies, Monoclonal↗

Hepatitis C virus RNA and hepatitis B virus DNA in serum and liver of patients with fulminant hepatitis.

BACKGROUND: The role of hepatitis C virus (HCV) in the development of fulminant hepatitis is poorly understood. METHODS: The polymerase chain reaction was used to detect HCV RNA and hepatitis B virus (HBV) DNA in serum and liver of 40 patients with fulminant or subfulminant hepatitis. RESULTS: HCV RNA was detected in none of the 23 subjects with hepatitis B surface antigen (HBsAg)-negative hepatitis of unknown etiology. HBV DNA was found in 1 of these 23 subjects. In contrast, 8 of the 17 patients with HBsAg-positive hepatitis were HCV RNA positive. Among the latter, 5 had immunoglobulin (Ig) M antibody to hepatitis B core antigen (anti-HBc) and thus were acutely coinfected by HBV and HCV, whereas 3 others without IgM anti-HBc had superinfection by HCV. The active replication of HCV in the liver was shown by detection of high titers of HCV RNA and of negative-stranded HCV RNA. CONCLUSION: This investigation therefore shows no evidence of a role for HCV infection in sporadic cases of fulminant hepatitis without defined etiology. However, it suggests that HCV might be implicated in a significant number of patients with HBV-related fulminant hepatitis.

Adolescent↗

The clinical features of chronic hepatitis C are not affected by the coexistence of hepatitis B virus DNA in patients negative for hepatitis B surface antigen.

Hepatitis B virus (HBV) DNA has been detected in the sera of hepatitis patients who are negative for hepatitis B surface antigen (HBsAg) by polymerase chain reaction (PCR). The purpose of the present study was to clarify the clinical characteristics of patients with chronic hepatitis C who are negative for serum HBsAg and positive for HBV DNA. The subjects included 49 patients with chronic hepatitis C who were negative for serum HBsAg and 119 blood donors who served as healthy controls. Serum samples were tested for the presence of HBV DNA by the nested PCR method. Serum HBV DNA was detected in 18 (37.7%) of the 49 chronic hepatitis C patients and in none (0%) of the 119 blood donors. Among the hepatitis C patients, HBV DNA was detected in 20.7% of those who were negative for all HBV-associated markers and in 57.1% of those who were positive for one or more HBV-associated marker. The HBV DNA-positive rate among those in each F stage did not significantly differ. The liver function parameters of the HBV DNA-positive and the HBV DNA-negative chronic hepatitis C patients did not significantly differ. These results suggest that hepatitis C virus is frequently coinfected with serum HBsAg-negative HBV, and that the incidence of HBV infection in blood donors is low. However, it is considered that HBsAg-negative HBV infection does not modify the blood biochemical features of chronic hepatitis C.

Adult↗

Hepatitis C virus antibody and hepatitis C virus replication in chronic hepatitis B patients.

We assessed hepatitis C virus infection in 156 chronic hepatitis B patients using second-generation hepatitis C virus antibody (anti-HCV). Active virus replication was further investigated in anti-HCV-positive cases by means of polymerase chain reaction assay for the detection of serum hepatitis C virus RNA. Anti-HCV prevalence was higher in patients negative for hepatitis B e antigen (HBeAg) (10/48, 21%) than in HBeAg-positive patients (10/108, 9%) (p < 0.05), and the reactivity (cut-off index) in anti-HCV enzyme-linked immunosorbent assay of the positive cases was significantly higher in HBeAg-negative patients (4.1 +/- 0.1) than in -positive ones (3.6 +/- 0.6) (p < 0.05). The prevalence of hepatitis C virus RNA in anti-HCV-positive cases was also higher in the HBeAg-negative group (9/10, 90%) than in the -positive group (3/10, 30%) (p < 0.01). Viremia was found in association with high reactivity in anti-HCV ELISA (cut-off index > 3.5) in both groups. Nine (90%) of 10 such cases were viremic in the HBeAg-negative group compared with three (43%) of seven in the HBeAg-positive group (p < 0.05). These results suggest that hepatitis C virus replication may be influenced by hepatitis B virus replicative states, indicating possible interference between hepatitis B and C viruses.

Adult↗

Hepatitis G virus infection in hepatitis C virus-positive patients co-infected or not with hepatitis B virus and/or human immunodeficiency virus.

This was a retrospective study to evaluate the prevalence and impact of hepatitis G virus (HGV) infection in hepatitis C virus (HCV)-positive drug addicts, according to the serological status of hepatitis B virus (HBV) and human immunodeficiency virus (HIV) coinfection. Two hundred and thirty-five randomly selected intravenous drug addicted patients (147 French, 88 Italian) were studied. All patients were positive for antibodies to HCV (anti-HCV). HGV RNA positivity was measured by reverse transcriptase-polymerase chain reaction (RT-PCR). Comparisons of HCV RNA positivity rate, and biological and histopathological variables, were made between HGV RNA-positive and negative patients, according to their HBV and HIV status. HGV prevalence was around 30% in both French and Italian groups. No clear association between HGV infection and a particular HCV genotype was observed. The rate of HCV RNA positivity did not differ between HGV-positive and HGV-negative patients after stratification for hepatitis B surface antigen (HBsAg) and HIV positivity. Histological severity of the underlying chronic hepatitis did not differ according to the HGV status; however, in HIV-positive HBsAg-negative patients, the hepatitis activity was moderately increased in HGV-positive patients. A striking negative influence of HBsAg positivity on HCV replication was observed in HIV-negative patients; an HCV RNA-positive rate of 25% was found in HBsAg-positive patients vs 86% in HBsAg-negative patients; similar significant results were observed in HIV-positive patients, although to a lesser extent. The underlying chronic hepatitis was significantly more severe in HBsAg-positive than in HBsAg-negative HIV-negative patients. Hence, HGV infection is highly prevalent in anti-HCV positive drug addicts but the co-infection with HCV does not seem to influence HCV replication nor to worsen the underlying chronic hepatitis, in HIV-negative patients at least. Reciprocal influence between HBV, HCV and HIV appears rather complex, HBsAg carriage seeming to exert per se a negative effect on HCV replication, particularly in HIV-negative patients, suggesting that interactions between hepatitis viruses should always be analysed in the light of HIV status.

Adult↗