What are DHHS guidelines for antiretroviral therapy of HIV infection with HBV coinfection?

Updated: Apr 18, 2019
  • Author: R Chris Rathbun, PharmD, BCPS (AQ-ID), AAHIVP; Chief Editor: John Bartlett, MD  more...
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Approximately 10% of individuals infected with HIV have HBV coinfection. [121] Treatment for each disease can be challenging because of accelerated disease progression and lower treatment response rates for HBV infection and increased rates of hepatotoxicity with antiretroviral therapy. Patients with HIV and HBV coinfection often have higher HBV DNA, lower HBeAg seroconversion rates, and an increased risk of liver-related mortality. [122, 123, 124, 125]

Additionally, acute hepatic flares due to antiretroviral therapy are more likely in the presence of HBV owing to the compromised state of the liver and immune reconstitution reactions that can occur with treatment initiation at low CD4 counts. [123] Nonetheless, overlapping therapies exist and are integrated into a treatment regimen that is optimal for both HIV infection and HBV infection.

The goals of therapy for HIV and HBV coinfection reflect those of HIV and HBV monoinfection. However, unlike those with HBV mono-infection, patients infected with both HIV and HBV should have treatment initiated for both infections as soon as possible rather than waiting for worsened clinical outcomes. Treatment should continue indefinitely. [118]

Most often, a combination of 3 antiretrovirals, including 2 with anti-HBV activity, is recommended in patients with HIV and HBV coinfection when treatment is indicated for either disease in order to prevent the development of antiretroviral drug resistance. Both HIV and HBV can acquire resistance to NRTIs, so therapy must be tailored to retain virologic control. [118]

An antiretroviral regimen for a patient infected with HIV and HBV should consist of tenofovir (either alafenamide or disoproxil fumarate) along with either emtricitabine or lamivudine; emtricitabine is coformulated with tenofovir in several fixed dose combination tablets, so this combination is used frequently. The decision to use tenofovir AF versus tenofovir DF should be based on renal function and potential risks of bone mineral density changes as tenofovir AF has proven non-inferior in HBV mono-infected patients. [126, 127]  Further, coinfected patients were able to maintain HBV and HIV suppression after switching from tenofovir DF-based antiretroviral regimens to tenofovir AF/emtricitabine/elvitegravir/cobicistat. [128]  Should a situation arise in which a patient cannot take either tenofovir AF or DF, entecavir may be initiated but should not be counted as one of the 3 antiretrovirals necessary to treat HIV. Neither lamivudine nor emtricitabine should be used as HBV monotherapy due to the potential for rapidly-developing resistance. [118]

If either virus acquires resistance, additional medications should be added to the current regimen rather than substituted in order to maintain virologic control of the remaining drug-susceptible virus. Due to limited data available on the use of either adefovir or telbivudine in coinfected patients, along with increased risk of toxicities, neither is not currently recommended in this population. [118]

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