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Assessment of HBV status is warranted in all HIV patients.
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HBV vaccination should be given to all susceptible HIV patients.
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Treatment of HIV including anti-HBV active agents should be given to all HIV-HBV coinfected individuals, regardless of CD4 counts.
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Although tenofovir is the drug of choice in HIV-HBV coinfected individuals, lamivudine as the only active anti-HBV agent may be considered in certain scenarios.
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Periodic assessment of liver fibrosis using noninvasive tools is warranted in all
Hepatitis B in HIV-Infected Patients
Section snippets
Key points
Epidemiology
Of the nearly two billion people have been infected with the hepatitis B virus (HBV), nearly 15% remain chronically positive for the HBV surface antigen (HBsAg). Overall, progressive liver disease, including development of liver cancer, occurs lifelong in 15% to 40% of chronic HBsAg carriers in the absence of antiviral treatment.1 As in the case of HIV, HBV is mainly transmitted by perinatal, parenteral, and sexual contacts, which explains why HIV and HBV coinfection is relatively common.2
Clinical outcome
Most individuals exposed to HBV (≈85%) attain HBsAg seroconversion within the first 6 months, and develop HBcAb+ with or without HBsAb+. These patients have resolved, but not cured, HBV infection because integrated, episomal HBV-DNA remains in the hepatocytes. If the patient experiences potent immune suppression for any reason, HBV reactivation may occur.9
Patients with HBsAg detectable in serum for longer than 6 months are considered to have CHB. During the first years of CHB, HBeAg is
Diagnosis
All HIV-infected persons must be tested for HBV markers of current (HBsAg+) or past infection (HBcAb+ with or without HBsAb+). Testing must be refreshed in patients with special features such as unexplained ALT elevations, visits or living in endemic areas, household contact with HBsAg+ persons, IDUs, multiple sexual contacts, history of sexually transmitted diseases, MSM, prison inmates, pregnant women, and chronic HCV individuals.33
Because fulminant viral hepatitis is more common in patients
Treatment
In HIV patients with CHB, HBV therapy is indicated in all individuals with cirrhosis, CD4 counts less than 500 cells/μL, serum HBV-DNA greater than 2000 IU/mL, and/or elevated liver enzymes (Fig. 1).31 Most experts recommend therapy irrespective of CD4 counts, given the accelerated progression of liver disease in HIV patients. For most patients, the best option is triple combination of antiretrovirals, including two reverse transcriptase inhibitors with anti-HBV activity; that is, TDF plus LAM
Vaccination
Universal infant HBV vaccination was recommended by the World Health Organization in 1992.66 HIV-infected adults without protective HBsAb titers should be vaccinated. The response rate and durability of the vaccine is poorer in HIV+ persons compared with HIV-negative persons,67, 68 and they are influenced by both CD4 counts and plasma HIV-RNA levels.69 Accordingly, in patients with low CD4 counts (<200 cells/μL) and uncontrolled HIV replication, the success of HBV immunization is low. In these
HDV
HDV infection only occurs in subjects with CHB because this agent requires HBsAg to complete replication at the hepatocyte. Approximately 5% of patients with CHB worldwide exhibit HDV coinfection, with large geographic disparities, peaking to 8% or higher in some areas of the Mediterranean basin, Eastern Europe, and Latin America.72 The prevalence of HDV among HIV-HBV coinfected patients is approximately 15% in Western Europe.73 It is going down because IDU has declined dramatically and HBV
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Cited by (20)
Immune reconstitution syndrome with initiation of treatment of HBV/HIV co-infection: Activity flare associated with E antigen seroconversion
2019, Annals of HepatologyCitation Excerpt :Hepatitis Be antigen (HBeAg) to antibody (HBeAb) seroconversion rates are significantly lower in coinfected populations.5 In addition, HIV/HBV co-infected patients experience more rapid progression of fibrosis and subsequent complications including cirrhosis, hepatocellular carcinoma and need for liver transplantation.6 Such rapid progression is evident even in patients with lower HBV viral loads and alanine aminotransferase (ALT) levels.7
Long-term protection after hepatitis B vaccination in people living with HIV
2017, VaccineCitation Excerpt :The prevalence of co-infection remains commonplace, since both viruses have the same routes of transmission [3–5]. Hepatitis B has a greater morbidity and mortality in people living with HIV (PLHIV) with elevated risk of liver cirrhosis and hepatocellular carcinoma [6–8]. Due to the greater incidence of hepatic disease and worse prognosis in co-infected patients and considering the shared routes of transmission of these viruses, screening and vaccination for hepatitis B in PLHIV is recommended [9].
CD4/CD8 ratio as a predictor of the response to HBV vaccination in HIV-positive patients: A prospective cohort study
2016, VaccineCitation Excerpt :Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) share transmission mechanisms and therefore co-infection is frequent [2]. The natural history of HBV in HIV patients is characterized by a more aggressive course with a higher incidence of chronic infection and a higher HBV viral load, more HBV reactivation episodes, a higher incidence of cirrhosis and hepatocellular carcinoma [3] and more liver-related mortality [4]; thus, HBV co-infection is currently considered a reason to initiate HAART among patients living with HIV [5]. Similarly, HBV affects the evolution of HIV disease, resulting in earlier initiation and more adverse events associated with HAART [6,7].
Monitoring the emergence of HBV resistance mutations by HBV-RNA pyrosequencing
2016, Brazilian Journal of Infectious DiseasesHuman Immunodeficiency Virus and Coinfection with Hepatitis B and C
2014, Infectious Disease Clinics of North AmericaCitation Excerpt :Anti-HBs titers should be obtained 1 month after completing the series.76 If immunity is not achieved, as defined by the development of anti-HBsAb, revaccination using a double dose and/or 3 to 4 doses can be used.140 At our institution, if there is no response to the initial vaccine series, then we are in the habit of repeating the vaccination series at a double dose.