Multidisciplinary Collaborative Integrated Management of Increasingly Prominent HIV Complications in the Post-cART Era

L Lin; TS Li


HIV Medicine. 2020;21(11):683-691. 

In This Article

Liver: Coinfection and Medication

In 2006, stavudine (d4T) + lamivudine (3TC) + nevirapine (NVP) and zidovudine (ZDV) + 3TC + NVP, the initially recommended first-line regimens, were included in the first Chinese National Guidelines for HIV/AIDS Diagnosis and Treatment in China. According to data released by the China Centers for Disease Control and Prevention (CDC) in 2009, 43.9% of patients developed treatment-related hepatotoxicity, most of which occurred in the first 3 months, resulting in both a high incidence of adverse reactions and poor adherence. NVP is the leading cause of hepatotoxicity; the international guidelines for HIV/AIDS treatment usually suggest the use of NVP at the baseline CD4 count level. The use of NVP is not recommended for women with CD4 count > 250 cells/μL and men with CD4 count > 400 cells/μL; however, this conclusion does not seem to apply to Chinese AIDS patients. The CACT data showed that NVP was not recommended for baseline CD4 > 250 cells/μL in Chinese patients regardless of sex, which reduced the incidence of hepatotoxicity by 50% in clinical practice.[2]

People living with HIV often show either hepatitis B (HBV) or C (HCV), coinfection with the former being more prevalent in China. The average HIV/HBV coinfection rate in China is 9.5%, with eastern China showing the highest at 14.6%.[3,4] The interaction between HIV and HBV is reciprocal. HIV accelerates the progression of HBV-related liver disease, and HBV is associated with faster HIV progression. HIV/HBV coinfection was associated with an increased risk of liver fibrosis in PLWH prior to cART, which was associated with a significantly lower fibrosis score.[5] HIV/HBV coinfection does not influence the antiviral effect of HIV. Higher HBV DNA inhibition rates were obtained if baseline HBV DNA was > 20 000 IU/mL or HBeAg-positive coinfected subjects received cART-based tenofovir (TDF) + 3TC. However, in coinfected patients with HBV DNA < 20 000 IU/mL or HBeAg-negative, mono-3TC-based treatment was also effective over the 48-week observation period.[6]

The following points should be given attention in the course of HIV/AIDS antiviral therapy-induced hepatotoxicity: prevention over treatment, baseline liver function test, using CD4 count and coinfection to evaluate liver condition, follow-up and monitoring, regular follow-up, and increased follow-up during the 6-week high-risk period prior to cART treatment, rational selection and adjustment for cART, the emphasis placed on selecting initial treatment, and timely adjustment of cART regimen in patients with – or at risk of – hepatotoxicity.