How are coexisting HIV and HBV infections treated?

Updated: May 07, 2020
  • Author: Shirin A Mazumder, MD, FIDSA; Chief Editor: Michelle R Salvaggio, MD, FACP  more...
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In patients with HIV and HBV coinfection, HBV infection should be treated only in conjunction with HIV infection. Treatment of HBV infection alone without addressing the HIV infection will lead to emergence of HIV strains that are resistant to nucleoside reverse-transcriptase inhibitors (NRTI). [15]

Only tenofovir is fully active for treatment in patients with known or suspected lamivudine-resistant HBV infection. [16] Tenofovir is considered a first-line agent in patients with chronic HBV infection because the virologic efficacy is high and the risk of HBV resistance is low. Tenofovir is available in two preparations, tenofovir disoproxil fumarate (TDF) and tenofovir alafenamide (TAF). TDF can lead to renal impairment and bone loss. The TAF formulation is associated with less renal toxicity and less effect on bone density. [17]

In treatment-naive patients with HIV/HBV coinfection, a regimen containing TDF plus FTC or TDF plus 3TC should be used as the backbone of HIV therapy.

If TDF cannot be used, entecavir may be used to treat HBV infection; however, owing to its weak activity against HIV, [6] this is not considered an active component of the antiretroviral regimen. Lamivudine-resistant strains of HBV may rapidly develop resistance; therefore, a higher dose (1 g/day) is recommended with more frequent HBV viral load monitoring.

Emtricitabine and lamivudine show efficacy against HBV infection in both hepatitis B e antigen (HBeAg)–positive and HBeAg-negative patients, but these medications are associated with greater development of resistance. Adefovir has weaker antiviral activity than tenofovir in both HBeAg-positive and HBeAg-negative patients with chronic HBV infection. It has been found to be safe in HIV and associated with lower rates of resistance mutations compared with lamivudine. [18]

If the HIV therapy requires modification (eg, due to HIV virologic failure), the HBV-active antiretroviral must be continued and new antiretrovirals added to achieve HIV viral suppression.

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