Treatment for Acute HBV in a Person with HIV Seroconversion
Treatment for Acute HBV in a Person with HIV Seroconversion
Is treatment indicated for acute hepatitis B infection in a patient with HIV infection (CD4+ cell count: 630 cells/mcL) who experienced acute retroviral syndrome approximately 10 months ago? If so, what is your suggested management strategy?
Abdulhakeem Althaqafi, MD
Treatment of acute hepatitis B virus (HBV) in adults with antiviral drugs is generally not recommended. Less than 5% of these patients develop chronic hepatitis B (defined as persistence of hepatitis B surface antigen (HBsAg) in serum for longer than 6 months). Care at the time of acute HBV infection should be limited to avoid alcohol and the use of potential hepatotoxic drugs, among other lifestyle modifications, with close monitoring of liver function tests.
Acute hepatitis B in an HIV-infected person with preserved immune function ( CD4+ cell count: > 500 cells/mcL), as in is this case, should follow the same rules than in HIV-negatives. However, in HIV-positive persons with severe immunodeficiency (ie, CD4+ cell count < 200 cells/mcL), development of chronic HBV may be more frequent, and it could be argued that treatment with some antiretroviral agents like lamivudine and/or tenofovir (both agents also have anti-HBV activity) might be warranted. This is controversial, and no demonstration of higher HBV clearance in this setting has yet been proven.
Without any therapeutic intervention, your patient may progress to severe acute hepatitis B, which is very uncommon, unless HBV infection occurs with coinfection with hepatitis delta virus. Otherwise, most cases will clear HBV-DNA from serum within a few weeks. However, if clearance of HBV does not occur and persistence of HBsAg last with detectable HBV-DNA levels in blood, your patient should be diagnosed with active chronic hepatitis B.
Management of chronic hepatitis B in HIV-infected patients with elevated CD4+ cell counts and no criteria to initiate antiretroviral therapy depends on several variables. First, if there is positivity for hepatitis B e antigen (HBeAg), HBV-DNA, and elevated transaminase levels, treatment with adefovir 10 mg once daily may be considered. Interferon is generally not recommended in this setting, given the low response rate in HIV/HBV-coinfected patients and interferon's poor tolerability Alternatively, HBV therapy can be delayed until the initiation of antiretroviral therapy for HIV disease, at which time agents with both anti-HIV and anti-HBV activity (ie, lamivudine or emtricitabine plus tenofovir) can be enlisted with a third anti-HIV agent. In the remaining situations (normal alanine transaminase levels, low HBV-DNA, and negative HBeAg, specific anti-HBV therapy may not be indicated at all.
I hope these comments will help you to manage your patient appropriately. If you have any further doubts, I recommend the sources noted below.
Is treatment indicated for acute hepatitis B infection in a patient with HIV infection (CD4+ cell count: 630 cells/mcL) who experienced acute retroviral syndrome approximately 10 months ago? If so, what is your suggested management strategy?
Abdulhakeem Althaqafi, MD
Treatment of acute hepatitis B virus (HBV) in adults with antiviral drugs is generally not recommended. Less than 5% of these patients develop chronic hepatitis B (defined as persistence of hepatitis B surface antigen (HBsAg) in serum for longer than 6 months). Care at the time of acute HBV infection should be limited to avoid alcohol and the use of potential hepatotoxic drugs, among other lifestyle modifications, with close monitoring of liver function tests.
Acute hepatitis B in an HIV-infected person with preserved immune function ( CD4+ cell count: > 500 cells/mcL), as in is this case, should follow the same rules than in HIV-negatives. However, in HIV-positive persons with severe immunodeficiency (ie, CD4+ cell count < 200 cells/mcL), development of chronic HBV may be more frequent, and it could be argued that treatment with some antiretroviral agents like lamivudine and/or tenofovir (both agents also have anti-HBV activity) might be warranted. This is controversial, and no demonstration of higher HBV clearance in this setting has yet been proven.
Without any therapeutic intervention, your patient may progress to severe acute hepatitis B, which is very uncommon, unless HBV infection occurs with coinfection with hepatitis delta virus. Otherwise, most cases will clear HBV-DNA from serum within a few weeks. However, if clearance of HBV does not occur and persistence of HBsAg last with detectable HBV-DNA levels in blood, your patient should be diagnosed with active chronic hepatitis B.
Management of chronic hepatitis B in HIV-infected patients with elevated CD4+ cell counts and no criteria to initiate antiretroviral therapy depends on several variables. First, if there is positivity for hepatitis B e antigen (HBeAg), HBV-DNA, and elevated transaminase levels, treatment with adefovir 10 mg once daily may be considered. Interferon is generally not recommended in this setting, given the low response rate in HIV/HBV-coinfected patients and interferon's poor tolerability Alternatively, HBV therapy can be delayed until the initiation of antiretroviral therapy for HIV disease, at which time agents with both anti-HIV and anti-HBV activity (ie, lamivudine or emtricitabine plus tenofovir) can be enlisted with a third anti-HIV agent. In the remaining situations (normal alanine transaminase levels, low HBV-DNA, and negative HBeAg, specific anti-HBV therapy may not be indicated at all.
I hope these comments will help you to manage your patient appropriately. If you have any further doubts, I recommend the sources noted below.