HBV/HIV Co-infection

Management and Treatment

There are two main reasons for considering HBV therapy as a priority in HBV/HIV co-infected patients:

First, liver disease may progress more rapidly in those patients co-infected with HBV/HIV and could lead to serious liver disease complications such as cirrhosis and liver cancer at younger ages.
Second, there is a higher risk of developing hepatotoxicity following the initiation of antiretroviral therapy in HIV patients co-infected with HBV than in patients infected with HIV alone.

In patients infected with HBV, HIV can lead to higher rates of chronicity, decreased rates of anti-HBe and anti-HBs seroconversion, and increased viral replication, probably due to the impairment of the body’s immune responses.

As a consequence, HBV/HIV co-infection is associated with increased liver fibrosis progression and increased rate of liver decompensation, cirrhosis, liver cancer or liver failure. Therefore, it is recommended to avoid the development of severe immune deficiency (defined as <200 CD4 cells/mm 3) in HBV/HIV co-infected persons.

There is no evidence that HBV affects HIV disease progression or that HBV alters the response of HIV to antiretroviral therapy (ART). However, starting ART may be associated with an increased risk of liver inflammation in co-infected individuals, as evidenced by ALT ( Alanine Aminotransferase) flares or rising liver enzymes. This may reflect both an immune response against HBV and/or drug toxicity.

Six drugs have been approved so far for the treatment of chronic hepatitis B:

Interferon Alpha (Intron A) is given by injection several times a week for six months to a year, or sometimes longer. The drug can cause side effects such as flu-like symptoms, depression, and headaches. Approved 1991 and available only for adults.

Pegylated Interferon (Pegasys) is given by injection once a week usually for six months to a year. The drug can cause side effects such as flu-like symptoms and depression. Approved May 2005 and available only for adults.

Lamivudine (Epivir-HBV, Zeffix, or Heptodin) is a pill that is taken once a day, with few side effects, for at least one year or longer. Approved 1998 and available for both children and adults.

Adefovir Dipivoxil (Hepsera) is a pill taken once a day, with few side effects, for at least one year or longer. Approved September 2002 for adults. Pediatric clinical trials are in progress.

Entecavir (Baraclude) is a pill taken once a day, with few side effects, for at least one year or longer. Approved April 2005 for adults. Pediatric clinical trials are in progress.

Telbivudine (Tyzeka, Sebivo) is a pill taken once a day, with few side effects, for at least one year or longer. Approved October 2006 for adults.

Other drugs with anti-HBV activity such as tenofovir and emtricitabine are FDA approved for treatment of HIV infection and are frequently used in coinfected patients as anti-HBV agents.

The decision to treat chronic hepatitis B and the choice of drugs is controversial and likely to vary in different situations. Treatment recommendations include four main variables that should guide the selection of patients to be treated for HBV and of the drug of choice:

Transaminase levels (ALT, AST)
HBV DNA viral loads
HBV e-Antigen presence (HBeAg)
Liver fibrosis staging (liver biopsy)
Ultrasound of the liver

Guidelines for Management of HBV/HIV Co-infection

Guidelines for the management of chronic hepatitis B in HIV-coinfected individuals have recently been released as a special report of the First European Consensus Conference on the Treatment of Chronic Hepatitis B and C in HIV Co-Infected Patients, Journal of Hepatology, March 2005. These guidelines provide useful information about how to manage HBV-HIV Co-infected patients.