BORDERNETwork Training on

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BORDERNETwork Training on
HIV and HBV Co-Infections
Dr. med. Wolfgang Güthoff / Alexander Leffers,
M.A.
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This presentation arises from the BORDERNETwork
project which has received funding from the
European Union, in the framework of the Health
Program, and co-funding of the Ministry of
Environment, Health and Consumer Protection of
the Federal State of Brandenburg. The sole
responsibility of any use that may be made of the
information lies with the authors (SPI,
AIDS-Hilfe Potsdam e.V.)
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Table of Contents
Epidemiology HIV/HBV co-infection Diagnostic T
reatment
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HIV Infection and Chronic Hepatitis B
Overlapping HBV and HIV Epidemics
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HIV Infection and Chronic Hepatitis B

• HBV/HIV Co-infection prevalence depends on HBV
  epidemic
• 5 - 7 co-infections in low prevalence countries
• 10 - 20 co-infections in high prevalence
  countries
• Despite ART - increasing risk of liver related
  death in this group
• the natural course of HBV - infection in HIV/HBV
  co-infected patients is different

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Increased Liver Mortality in HIV /HBV
Co-infected Patients

• Increased rates of chronic hepatitis after
  infection
• Higher levels of HBVDNA viraemia
• Faster progression to liver cirrhosis
• Increased rate of liver cancer development

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HIV / HBV Co-infection

• There are two main reasons for considering HBV
  therapy as a priority in HBV/HIV co-infected
  patients
• Liver disease may progress more rapidly in those
  patients and could lead to serious liver disease
  complications such as cirrhosis and liver cancer
  at younger ages.
• 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.

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HIV / HBV Co-infection

• Because HIV infection can accelerate progression
  of liver disease,
• treatment of chronic hepatitis B is generally
  recommended in patients with
• HBV replication ( gt2000 IU/ml )
• Liver inflammation signs ( elevated ALAT )
• Fibrosis ( liver biopsy Metavir 2, or high
  elastography )

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HIV / HBV Co-infection

• Patients without ART indication
• use only substances without HIV activity (Peg
  Ifn, Adefovir, Telbivudine)
• avoid Tenofovir, 3TC and FTC
• avoid also Entecavir ( induction of HIV reverse
  transcriptase mutation M184V is possible )

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Treatment of Hepatitis B in co-infected patients
without ART indication

• Treatment with pegylated interferon should be
  considered in special circumstances
• HIV treatment is not needed (high number of CD4
  cells)
• HBe Ag positive
• HBsAg genotype A
• Elevated ALAT
• Low level of HBVDNA
• ( poor data and no encouraging results )

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Treatment of Hepatitis B in co-infected patients
without ART indication

• Alternatively to peg. Interferon patients can be
  treated with HBV polymerase inhibitors
• Telbivudine
• Adefovir
• Telbivudine was preferred by most experts more
  than Adefovir (greater antiviral efficacy)
• But always check possibility of early HAART
  including Tenofovir FTC or 3TC (it is
  preferred - EACS 2011)

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Treatment Algorithm for HBV in HIV Co-infected
Patients
Source EACS 2011
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HIV / HBV Coinfection - Treatment Algorithm for
HBV in Patients with ART
Indication for HIV treatment
gt2000 IU/µl HBV DNA
Patients with cirrhosis
lt2000 IU/µl HBV DNA
Patients without HBV-associated 3TC resistance
Patients with HBV-associated 3TC resistance
HAART regimen of choice (in case of HBV
polymerase inhibitor maintain full suppression)
HAART including TDF 3TC or FTC
HAART including TDF 3TC or FTC
Substitute one NRTI with Tenofovir or add
Tenofovir
In case of liver decompensation refer for
evaluation for LT
Source EACS 2011
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Treatment of HIV / HBV Co-infection

• Gold standard ART contains Tenofovir
  Emtricitabine or Lamivudine
• There is a problem in patients with virological
  failure to this first line ART
• if these patients are switched from Tenofovir /
  Emtricitabine to another drug, they will be
  vulnerable for hepatitis B liver inflammation
  flare
• Possibility Continue Tenofovir and add
  Zidovudine

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HIV / HBV Co-infection - Conclusions

• Best solution Early start of ART
• If ART is not indicated Limited treatment
  options with only Adefovir and Telbivudine
• (Alternative Interferon)
• Treatment of choice with patients on ART
  Tenofovir
• 3TC or FTC mono-therapy should never be
  considered

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HIV / HBV Co-infection - Conclusions

• Treatment of Hepatitis B follows the same rules
  as HIV
• full suppression of viral replication to avoid
  the development of drug resistance
• successful therapy leads to inhibition of
  inflammation activity and reversion of fibrosis
• final goal immune control of infection

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HIV / HBV Co-infection

• Dont forget
• HIV patients not infected with Hepatitis B should
  be vaccinated against HBV
• successful response in 33 of patients with CD4 gt
  300/µl
• successful response in 80 of patients with CD4 gt
  500/µl

Rey D et al. Vaccine 18,116182000)
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