When to initiate hepatitis B virus (HBV) therapy in the setting of HIV?
HBV-HIV coinfection represents a significant problem in HIV care. As HAART has improved the prognosis in HIV and AIDS, significant increases in morbidity and mortality resulting from liver disease have been observed. HBV and HIV are acquired by similar mechanisms and thus coinfection is common.
Patients with coinfection of HIV and HBV have higher HBV DNA levels and are less likely to convert from hepatitis B e antigen–positive to hepatitis B e antibody–positive, indicating a poorer response to HBV therapy. Patients with a HBV DNA greater than 2000 IU and F2 or greater fibrosis on biopsy should receive HBV treatment . If a patient has cirrhosis, he or she should be treated if HBV DNA is greater than 200.
For patients with a high CD4 count, HBV monotherapy that is not active against HIV should be first-line therapy. When initiating HAART, HBV also should be treated with two antiviral agents active against HBV. If CD4 counts are between 350 and 500 cells/mL, one can elect to treat both HIV and HBV. HAART with two agents active against HBV should be used instead of HBV monotherapy in these individuals.
Why is it important to know the HBV treatments that are also active in treating HIV?
Initiating HBV monotherapy that is also active in treating HIV can result in HIV resistance, potentially limiting HAART options. Furthermore, if HAART is initiated without concurrent HBV treatment, immune reconstitution can result in a potentially life-threatening flare of untreated HBV.
The below table shows treatments active against HBV and HIV or HBV alone.
|Treats HIV and HBV||Treats HBV without HBV Resistance|
|Tenofovir||Adefovir (at 10-mg dosing)|
|Emtricitabine||Telbivudine (in vitro)|
|Entecavir (in vivo)|
HBV, hepatitis B virus; HIV, human immunodeficiency virus; PEG-IFN, pegylated interferon.