Treatment of Hepatitis B in HIV Co-infection
Yes, you absolutely need to treat Hepatitis B when a patient has HIV co-infection—simultaneous treatment for both viruses is recommended, using a tenofovir-based antiretroviral regimen combined with emtricitabine or lamivudine. 1
Why Treatment is Mandatory
HBV/HIV co-infection significantly worsens outcomes compared to HBV alone:
- The incidences of cirrhosis and hepatocellular carcinoma (HCC) are substantially higher in co-infected patients than in those with HBV monoinfection 1, 2
- HIV accelerates liver disease progression in HBV-infected patients 2
- Before the era of highly active antiretroviral therapy (HAART), HIV-positive patients with chronic hepatitis B were at markedly increased risk of cirrhosis 1
Treatment Algorithm
Step 1: Assess Treatment Indications
All HBV/HIV co-infected patients should be evaluated to determine if there is an indication for either HIV or HBV treatment, or both 2
- The indications for HBV therapy are the same as in HIV-negative patients, based on HBV DNA levels, serum ALT levels, and histological lesions 1
- However, with current HIV treatment strategies, HAART initiation is now recommended regardless of CD4+ T cell count 1
Step 2: Select Appropriate Therapy
Most co-infected patients should be simultaneously treated for both HIV and HBV from the start 1
The preferred regimen includes:
- Tenofovir-based antiretroviral therapy combined with emtricitabine or lamivudine plus a third agent active against HIV 1, 2
- This approach is recommended irrespective of immunological, virological, or histological considerations 1
- The rationale for early dual anti-HIV and anti-HBV therapy has simplified recommendations, widening the use of tenofovir and emtricitabine or lamivudine in co-infected patients 1
Step 3: Special Circumstances (Small Subset of Patients)
For the rare patient with CD4 count >500/mL who requires only HBV treatment before HIV therapy:
- Use agents without HIV activity: pegylated interferon, adefovir, or telbivudine 1
- Critical caveat: If these nucleoside analogues with low barrier to resistance do not achieve undetectable HBV DNA after 12 months, HIV treatment must be initiated 1
Critical Safety Warnings
Never use certain drugs as monotherapy in co-infected patients:
- Lamivudine, entecavir, and tenofovir have activity against both HIV and HBV and are contraindicated as single agents for hepatitis B in co-infected patients because of the risk of HIV resistance 1
- All HBsAg-positive patients must be screened for HIV before these drugs are used in the treatment of HBV infection 1
- The FDA boxed warning for entecavir specifically states it is not recommended for patients co-infected with HIV and HBV who are not also receiving HAART, due to potential development of resistance to HIV nucleoside reverse transcriptase inhibitors 3
Preventing HBV Reactivation
When HAART regimens are changed, antiviral agents effective against HBV must be included to avoid HBV reactivation, except in patients who meet criteria for cessation of antiviral treatment for HBV 1
Long-term Outcomes with Proper Treatment
The risk of developing cirrhosis is negligible in HBV/HIV co-infected patients on long-term tenofovir combined with emtricitabine or lamivudine therapy 1