What's New — June 2008 Update
- Administering the hepatitis B virus (HBV) vaccination series to human immunodeficiency virus (HIV)-infected patients who are negative for hepatitis B surface antigen (HBsAb), unless they are chronically infected.
- Testing for HBsAb between 4 and 12 weeks after vaccination. Nonresponders (HBsAb <10 IU/L) should be revaccinated with another three-dose hepatitis B vaccine series. If a patient's CD4 count is <200 cells/mm3 or the patient has symptomatic HIV disease, revaccination may be deferred until several months after initiation of antiretroviral (ARV) therapy in an attempt to maximize the antibody response to the vaccine. However, revaccination should not be deferred in pregnant patients or patients who are unlikely to achieve an increased CD4 count.
- Initiating treatment active against HBV when HBV deoxyribonucleic acid (DNA) levels are >2000 IU/mL.
- Initiating ARV therapy when initiating treatment against HBV in HIV/HBV co-infected patients.
Baseline Evaluation, Screening, and Prevention of HIV/HBV Co-Infection
Baseline Hepatic Evaluation
As part of the baseline assessment of HIV-infected patients, clinicians should evaluate liver function, including aspartate aminotransferase (AST) and alanine aminotransferase (ALT).
Hepatitis Screening
As part of the baseline assessment, clinicians should ask HIV-infected patients about their HBV vaccination history and should obtain the following:
- HBV serologies: HBsAg, hepatitis B surface antibody (HBsAb), and hepatitis B core antibody (HBcAb) (immunoglobulin G [IgG] or total)
- Hepatitis A IgG and hepatitis C IgG
Clinicians should obtain an HBV DNA test for patients with negative HBsAb, negative HBsAg, and positive HBcAb to determine whether the patient has occult HBV infection (see Figure 3 in the original guideline document).
Prevention of HIV/HBV Co-Infection
Clinicians should counsel patients about behavior modifications that decrease their risk of acquiring HBV infection through unprotected sexual activity and injection drug use.
Vaccination
Clinicians should administer the HBV vaccination series to HIV-infected patients who are negative for HBsAb, unless they are chronically infected (see Figure 3 in the original guideline document).
Clinicians should test for HBsAb between 4 and 12 weeks after vaccination. Nonresponders (HBsAb <10 IU/L) should be revaccinated with another three-dose hepatitis B vaccine series. If a patient's CD4 count is <200 cells/mm3 or the patient has symptomatic HIV disease, revaccination may be deferred until several months after initiation of ARV therapy in an attempt to maximize the antibody response to the vaccine. However, revaccination should not be deferred in pregnant patients or patients who are unlikely to achieve an increased CD4 count (see Figure 3 in the original guideline document).
Key Point
Patients who are unlikely to achieve CD4 counts of ≥200 cells/mm3 after ARV therapy (e.g., patients with hepatitis C virus [HCV] co-infection), as well as HIV-infected pregnant women, are at risk for severe complications resulting from HBV infection.
|
Key Point
Patient education regarding HBV vaccination is important to ensure awareness of the continued risk for acquiring HBV until adequate surface antibody response is documented.
|
Hepatitis A Virus (HAV) Co-Vaccination
Clinicians should administer the HAV vaccine to HIV-infected patients who are negative for HAV IgG to prevent concurrent HAV infection.
Evaluation of Patients with Chronic HBV
Clinicians should evaluate the extent of liver disease in patients with chronic hepatitis by:
- Obtaining an HBV-related history
- Performing a physical examination for signs and symptoms of advanced liver disease
- Measuring serial ALT levels, prothrombin time/international normalized ratio (PT/INR), albumin, and platelet count
- Assessing inflammation, fibrosis, HBV replication, and risk of hepatocellular carcinoma (HCC)
- Obtaining hepatitis B envelope antigen (HBeAg), hepatitis B envelope antibody (HBeAb), and HBV DNA quantification (nucleic acid amplification)
If the baseline HBV DNA level is ≤2000 IU/mL in HBeAb-positive patients with elevated ALT, then clinicians should perform serial HBV DNA measurements at least annually.
Key Point
HBeAg negativity can be associated with greater HBV DNA replication and more rapid disease progression in patients carrying mutations in either the precore or the basic core promoter region of the HBV genome.
|
Counseling for HIV/HBV Co-Infected Patients
Alcohol Consumption
Clinicians should obtain a substance use and alcohol history for HIV/HBV co-infected patients and should refer patients with alcohol abuse or dependence for chemical dependency treatment.
Clinicians should educate HIV/HBV co-infected patients regarding the effects of alcohol on the course of HBV infection. Patients who have other underlying liver disease should be advised to abstain from alcohol.
Transmission
Clinicians should assess for HBV transmission risk behaviors and advise household contacts of HBV carriers to be vaccinated for HBV and to avoid sharing objects that may be contaminated with blood, such as razors or toothbrushes, until their immunity has been confirmed.
Clinicians should encourage all sexually active patients who are positive for HBsAg to use effective barrier protection consistently and correctly, including latex or polyurethane condoms and dental dams, to reduce the risk of transmission of HIV and HBV.
Clinicians should refer active injection drug users for substance use treatment, including opioid substitution therapy. Active injection users who are not ready for treatment should be referred to needle exchange programs.
Treatment of Acute HBV Infection
Patients with acute HBV infection accompanied by fulminant liver disease should receive treatment with lamivudine. Initiation of ARV therapy is not recommended during fulminant hepatitic liver disease.
Clinicians should not treat patients with fulminant hepatitis with adefovir or tenofovir.
Key Point
In an HIV-infected patient with fulminant hepatic failure induced by acute HBV infection, treatment with lamivudine therapy alone is indicated. In patients with less severe hepatic injury from acute HBV infection, and for whom ARV therapy may be indicated, ARV therapy should be deferred until resolution of the acute hepatic insult.
|
Treatment of Chronic HBV Infection
Clinicians treating HIV/HBV co-infected patients should:
- Initiate treatment active against HBV when HBV DNA levels are >2000 IU/mL
- Consider HBV treatment in patients with detectable HBV DNA ≤2000 IU/mL who also have elevated ALT levels above baseline or fibrosis or inflammation
- Consult with a specialist experienced in the treatment of hepatitis and HIV to discuss treatment decisions, including changes to a patient's existing ARV regimen when HBV treatment is indicated, and to establish a schedule for monitoring
When initiating treatment against HBV in HIV/HBV co-infected patients, clinicians should:
- Initiate ARV therapy
- Use a standard ARV regimen that includes two drugs that are also active against HBV (see Figure 4 in the original guideline document)
Clinicians should avoid discontinuing either HBV or HIV treatment whenever possible and should monitor ALT closely if discontinuation of HBV treatment is unavoidable.
When ARV regimens need to be changed for HIV considerations, the agents active against HBV should be continued whenever possible to avoid risk of reactivation of HBV.
Patients Eligible for Both HBV and HIV Treatment
Clinicians should treat patients who are eligible for both HBV and HIV treatment with an ARV regimen that contains tenofovir plus lamivudine or emtricitabine if such treatment is not contraindicated because of renal insufficiency or fulminant hepatic disease. If the ARV regimen needs to be changed because of HIV resistance to any of these agents, then these agents should still be continued as part of anti-HBV treatment (see Figure 4 in the original guideline document).
Patients with lamivudine or emtricitabine resistance to HBV should receive an alternative ARV regimen with optimal combined anti-HBV activity (see Figure 4 in the original guideline document).
Clinicians should monitor ALT during initiation of or changes to the ARV regimen, especially in patients with cirrhosis.
Key Point
Agents with dual activity against HBV and HIV can simplify treatment regimens because a single agent can be used as part of a regimen to treat both viruses.
|
Patients with Co-Infection Receiving HBV Treatment but Not HIV Treatment
Clinicians should use pegylated interferon-alfa 2a for the treatment of HBV in HIV-infected patients who decline ARV treatment. No drug other than interferon should be used alone for the treatment of chronic HBV in patients with HIV.
Patients with Co-Infection Eligible for HIV Treatment but Not HBV Treatment
For patients who require HIV treatment and in whom HBV treatment is not indicated, lamivudine or emtricitabine should not be used without tenofovir.
Patients with Cirrhosis
Patients with hepatitis who develop symptomatic cirrhosis should be managed by a clinician experienced in the management of cirrhosis, preferably a hepatologist.
Clinicians should refer HIV/HBV co-infected patients with known cirrhosis for endoscopy every 1 to 2 years to monitor for esophageal varices.
Patients at Risk for Hepatocellular Carcinoma
In patients with chronic HBV who are at higher risk for HCC, clinicians should:
- Screen serum alfa-fetoprotein every 3 to 6 months
- Perform annual imaging with either a triple-phase computed tomography (CT) scan of the abdomen, magnetic resonance imaging (MRI) scan of the abdomen, or hepatic ultrasound, depending on the imaging protocol of the institution
- Perform imaging every 6 months if cirrhosis is present
Monitoring Treatment Response
After initiation of HBV treatment, clinicians should obtain HBV DNA levels and should assess for HBeAg and HBsAg seroconversion every 3 to 6 months.