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Brief Summary

GUIDELINE TITLE

Hepatitis B virus.

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Hepatitis B virus. New York (NY): New York State Department of Health; 2004 Sep. 12 p.

GUIDELINE STATUS

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

BRIEF SUMMARY CONTENT

 
RECOMMENDATIONS
 EVIDENCE SUPPORTING THE RECOMMENDATIONS
 IDENTIFYING INFORMATION AND AVAILABILITY
 DISCLAIMER

 Go to the Complete Summary

RECOMMENDATIONS

MAJOR RECOMMENDATIONS

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary. The recommendations that follow are based on the previous version of the guideline.

Clinical Syndromes

Clinicians should obtain baseline hepatic function tests as well as hepatitis B virus (HBV) serologies for all human immunodeficiency virus (HIV)-infected patients to determine their HBV infection status; these include hepatitis B surface antigen (HbsAg), the antibody to hepatitis B surface antigen (anti-HBs) (HBsAb), and the immunoglobulin G antibody to hepatitis B core antigen (IgG anti-HBc) (HBcAb).

Clinicians should strongly encourage all HIV-infected patients who do not have serologic evidence of prior HBV infection or who have not previously received the complete series of HBV vaccination to receive the hepatitis B vaccination series. Serologic testing for anti-HBs 1 to 2 months after the third dose should be performed. If the patient did not respond to the vaccine series, the clinician should administer a second series when the patient's CD4 count is >200 cells/mm3.

In the setting of unexplained elevations in serum liver enzymes, clinicians should consider obtaining an HBV deoxyribonucleic acid (DNA) viral load, even in the absence of serologic evidence of active hepatitis B virus replication (reactive HBsAg or hepatitis Be antigen [HBeAg]).

Prevention

Clinicians should counsel HIV/HBV co-infected patients regarding transmission.

Due to the limited efficacy of HBV vaccine in the HIV-infected population, all patients should be given counseling concerning behavior modifications to decrease the risk of acquiring HBV infection through sexual activity and injection drug use.

Pre-Exposure HBV Prophylaxis

Pre-vaccination screening for HIV-infected patients should include HBsAg, HBsAb, and HbcAb IgG.

The clinician should ideally administer the hepatitis vaccination in HIV-infected patients early in the course of HIV disease, before severe immune suppression has occurred.

The clinician should test for HbsAb 1 to 2 months after completion of the third vaccine dose.

Post-Exposure HBV Prophylaxis

Administration of prophylactic hepatitis B immune globulin (HBIG) and the initiation of the hepatitis B vaccine series (at different sites) are recommended when the non-HBV-immune patient sustains a blood or body fluid exposure to a source with acute or chronic HBV (see Table 4 in the original guideline document).

Following an HBV exposure, determination of the source patient's HBV serologic status should be sought.

Prophylaxis for Perinatal HBV Transmission

Administration of prophylactic HBIG and the initiation of the hepatitis B vaccine series (at different sites) are recommended within 12 hours of birth.

Treatment of Chronic HBV Infection

HIV-infected patients with active hepatitis B disease should be considered for therapy.

The clinician should consult with a specialist with experience in treating hepatitis B in patients with HIV infection to determine whether HBV therapy should be initiated, which therapy should be given, and how the patient should be monitored clinically once treated.

The drug regimen of choice is currently unknown because no randomized comparative trials have been conducted in this patient population. Options include interferon alfa-2b, lamivudine, or adefovir; there are insufficient data to recommend combinations of drugs at this time.

In HIV/HBV co-infected patients receiving highly active antiretroviral therapy (HAART) (with or without lamivudine) or interferon, clinicians should periodically measure hepatic transaminases during the course of treatment because of the potential for a flare of hepatitis. Clinicians should closely monitor hepatic function in HIV/HBV co-infected patients who discontinue lamivudine, emtricitabine, and tenofovir.

Lamivudine

If lamivudine is given for treatment of hepatitis B, it should never be used alone. Rather, it should be used in combination with other HIV-active antiretroviral agents as a component of HAART. The recommended dose is 150 mg twice daily or 300 mg once daily.

If lamivudine is discontinued as part of a change in the HAART regimen in patients being treated for HBV, a significant flare of alanine aminotransferase (ALT) may result; therefore, continuing lamivudine should be considered even when HIV resistance to it has developed.

Choosing Therapy for Patients With HBV/HIV Co-Infection

Before initiating therapy for HIV or HBV in co-infected persons, the clinician should consider possible consequences a specific regimen will have on future treatment options for both HIV and HBV.

CLINICAL ALGORITHM(S)

None provided

EVIDENCE SUPPORTING THE RECOMMENDATIONS

TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not stated.

IDENTIFYING INFORMATION AND AVAILABILITY

BIBLIOGRAPHIC SOURCE(S)

  • New York State Department of Health. Hepatitis B virus. New York (NY): New York State Department of Health; 2004 Sep. 12 p.

ADAPTATION

Not applicable: The guideline was not adapted from another source.

DATE RELEASED

2003 Mar (revised 2004 Sep)

GUIDELINE DEVELOPER(S)

New York State Department of Health - State/Local Government Agency [U.S.]

SOURCE(S) OF FUNDING

New York State Department of Health

GUIDELINE COMMITTEE

Medical Care Criteria Committee

COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

Committee Chair: Amneris Luque, MD, Associate Professor of Medicine, University of Rochester Medical Center, Rochester, NY; Medical Director, AIDS Center, Strong Memorial Hospital

Vice Committee Chair: Sheldon Brown, MD, Liaison, Department of Veterans Affairs Medical Center; Associate Professor of Medicine, Mount Sinai School of Medicine, New York, NY; Chief, Infectious Disease Section, Bronx Veteran Affairs Medical Center (111F)

Committee Members: Bruce Agins, MD, MPH, Assistant Professor of Medicine, Cornell University Medical College, New York, NY; Medical Director, AIDS Institute, New York State Department of Health; Doug Fish, MD, Head, Division of HIV Medicine, Assistant Professor of Medicine, Albany Medical College; Charles Gonzalez, MD, Assistant Professor of Medicine, New York University School of Medicine, New York, NY; Clinical Investigator, AIDS Clinical Trials Unit, New York University Medical Center - Bellevue Hospital Center; Harold Horowitz, MD, Professor of Medicine, New York Medical College, Valhalla, NY 10595-1696; Medical Director, AIDS Care Center, Division of Infectious Diseases, Westchester Medical Center; Marc Johnson, MD, Attending Physician, New York Hospital Queens, Flushing, NY; Assistant Professor of Medicine, Mount Sinai School of Medicine, New York, NY; Medical Director, New York Hospital Queens Primary Care at ACQC; Jessica Justman, MD, Associate Professor of Clinical Medicine, Albert Einstein College of Medicine, Bronx, New York; Associate Director, Center for Infectious Disease Epidemiologic Research, Mailman School of Public Health, Columbia University; Sharon Mannheimer, MD, Assistant Professor of Clinical Medicine, Columbia University College of Physicians and Surgeons, New York, New York; Division of Infectious Diseases, Harlem Hospital Center; Neal Rzepkowski, M.D., HIV Care Consultant, New York State Department of Corrections, WENDE HUB; HIV Care Provider, Erie County Medical Center Rural Outreach Clinics, Chautouquez County Department of Health HIV Clinics; Kent Sepkowitz, MD, Memorial Sloan-Kettering Cancer Center; Rona Vail, MD, HIV Clinical Director, Callen-Lorde Community Health Center; Barry Zingman, MD, Medical Director, AIDS Center, Montefiore Medical Center

Liaisons: Barbara Chaffee, MD, MPH, HIV Quality of Care Advisory Committee, Clinical Associate Professor of Internal Medicine, Upstate Medical Center Clinical Campus at Binghamton, Binghamton, New York, Medical Director, Internal Medicine, Binghamton Family Care Center, United Health Services Hospital; Joseph R. Masci, MD, New York City Health and Hospitals Corporation, Associate Medical Director, HIV Services, Queens Health Network, New York, New York, Professor of Medicine, Mount Sinai School of Medicine, New York, New York, Director of Medicine, Elmhurst Hospital Center; Noemi Nagy, Consumer Quality Advisory Committee

FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

GUIDELINE STATUS

Note: This guideline has been updated. The National Guideline Clearinghouse (NGC) is working to update this summary.

GUIDELINE AVAILABILITY

Electronic copies of the updated guideline: Available from the New York State Department of Health AIDS Institute Web site.

Print copies: Available from Office of the Medical Director, AIDS Institute, New York State Department of Health, 90 Church Street, New York, NY 10007-2919; Telephone: (212) 268-6108

AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

Print copies: Available from Office of the Medical Director, AIDS Institute, New York State Department of Health, 90 Church Street, New York, NY 10007-2919; Telephone: (212) 268-6108

This guideline is available as a Personal Digital Assistant (PDA) download from the New York State Department of Health AIDS Institute Web site.

PATIENT RESOURCES

None available

NGC STATUS

This summary was prepared by ECRI on January 21, 2004. This NGC summary was updated by ECRI on October 19, 2005.

COPYRIGHT STATEMENT

DISCLAIMER

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