Case-Based Review

Management of Patients with HIV and Hepatitis B Coinfection

Journal of Clinical Outcomes Management. 2017 October;24(10)

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The American Association of Liver Diseases (AASLD) guidelines recommend hepatic ultrasound screening every 6 months in all patients with cirrhosis or chronic HBV who are at increased risk (Asian men over the age of 40 years, Asian women over the age of 50 years, African or North American blacks, and patients with family history of HCC) [61]. They should also be referred for an esophagogastroduodenoscopy to evaluate for esophageal varices. In addition, all HIV/HBV coinfected patients with decompensated liver disease should be evaluated for transplantation. HIV infection is not a contraindication for liver transplant with the use of ART. However, since transplantation does not cure HBV infection, post-transplant HBV immune globulin and HBV treatment are required. Contemporary data suggest comparable survival rates after transplant in coinfected patients compared to HBV-monoinfected patients [51].

Summary

Routine screening with HBsAg, anti-HBs, and anti-HBc serologies is recommended for all HIV-positive individuals. Patients without evidence of prior exposure or vaccination and those with isolated anti-HBc should be offered vaccination. HIV-positive adults should receive three or four 40 µg/mL doses of single agent vaccine depending on the recombinant vaccine type available. Anti-HBsAg titers should be checked 1 month after completion of the immunization series. If quantitative anti-HBsAg levels are < 10 IU/mL, patients should receive a second vaccine cycle.

Patients who test positive for HBsAg should be tested for HBeAg, anti-HBe, and HBV DNA levels and have AST and ALT levels checked as well. All patients with HIV/HBV coinfection should start treatment as soon as HIV infection is diagnosed. ART needs to include 2 drugs against HBV, and therefore a fixed-dose combination of TDF/emtricitabine or TAF/emtricitabine or the individual combination of TDF plus lamivudine should be used.

Coinfected patients on treatment should have liver function tests as well as HBV DNA every 12 weeks. In HBeAg-positive coinfected individuals who achieve HBV DNA suppression, HBeAg and anti-HBe testing should be performed every 6 to 12 months to assess for seroconversion. HBV virologic failure is defined as a greater than 1-log10 rise in HBV DNA levels or development of viremia in a patient with a previously suppressed DNA level on therapy. Those with virologic failure should be tested for HBV resistance thorough HBV genotype. Coinfected patients with cirrhosis should receive ultrasound screening every 6 months for evidence of HCC and esophagogastroduodenoscopy to evaluate for esophageal varices.