Jaundice is the yellow discoloration of the skin and the whites of the eyes. This yellowing is caused by an excessive buildup of bilirubin, a yellowish pigment produced when red blood cells are broken down. The liver processes bilirubin, removing it from the blood and secreting it into the digestive tract. Human Immunodeficiency Virus (HIV) is a chronic condition managed with daily medication. Both the virus and the medicines used to treat it can impact liver function, and disruptions to bilirubin processing can result in jaundice.
Does the HIV Virus Directly Cause Jaundice
The HIV infection itself rarely causes jaundice directly in the current era of effective treatment. The virus primarily targets and destroys CD4+ T-cells, the main coordinators of the body’s immune response. Although HIV does not directly infect liver cells, it can cause generalized liver inflammation over time.
In advanced, untreated HIV disease, the severe immune deficiency known as AIDS can lead to generalized liver dysfunction. This dysfunction may manifest as hepatitis or as an AIDS-related cholangiopathy, a disease affecting the bile ducts. These conditions disrupt bilirubin processing, causing it to accumulate and lead to jaundice.
Jaundice Caused by HIV Medication
A common cause of jaundice in people living with HIV is a side effect of certain antiretroviral medications, known as drug-induced liver injury (DILI). The liver is responsible for metabolizing medications, and some antiretroviral drugs can place significant stress on this organ. This hepatotoxicity can range from asymptomatic elevations in liver enzymes to symptomatic hepatitis, which can include jaundice.
A specific type of drug-related jaundice, called unconjugated hyperbilirubinemia, is particularly associated with certain protease inhibitors (PIs), namely atazanavir and indinavir. These drugs interfere with an enzyme in the liver needed to process bilirubin, causing the pigment to build up in the blood. This hyperbilirubinemia often causes visible jaundice but is generally not associated with true liver cell injury, meaning it is more of a cosmetic issue than a sign of serious liver damage.
While modern regimens are much safer, monitoring liver function remains a routine part of care, especially when starting or changing therapy. If true hepatocellular injury occurs, it can lead to acute hepatitis and jaundice, requiring the discontinuation of the offending drug.
Co-Infections That Lead to Jaundice in HIV Patients
The most frequent and serious causes of jaundice in people living with HIV are co-infections with other viruses that directly attack the liver. Hepatitis B virus (HBV) and Hepatitis C virus (HCV) are the most common culprits, as they share transmission routes with HIV. Co-infection with either HBV or HCV significantly accelerates the progression of liver disease compared to infection with only the hepatitis virus.
The presence of HIV impairs the immune system’s ability to fight these viruses, leading to faster development of liver scarring (fibrosis) and cirrhosis. This accelerated liver damage leads to liver failure, which is a major cause of impaired bilirubin processing.
Other infections, classified as opportunistic infections, can also affect the liver and bile ducts in individuals with very low CD4 cell counts. These include infections like Mycobacterium avium complex (MAC) or Cytomegalovirus (CMV), which can cause inflammation or blockages in the biliary system. Jaundice in this context is a sign of advanced immunosuppression, indicating that the secondary infection is directly disrupting the structure and function of the liver and bile ducts.
What to Do If Jaundice Occurs
The appearance of jaundice should prompt an immediate medical evaluation. A healthcare provider must determine the cause, as treatment varies widely depending on whether it is a harmless drug side effect or a sign of severe liver disease.
The diagnostic process typically involves blood tests to measure total and direct bilirubin levels, as well as liver enzymes like alanine aminotransferase (ALT) and aspartate aminotransferase (AST). These lab results help distinguish between benign hyperbilirubinemia caused by PIs and true drug-induced hepatitis or viral co-infection. Testing will also screen for Hepatitis A, B, and C, and may include an abdominal ultrasound to check for biliary obstruction.
It is important that a person never stops antiretroviral therapy without explicit instruction from their doctor. Abruptly discontinuing medication can lead to HIV rebound and potentially cause a dangerous flare-up of co-existing hepatitis.