Hepatitis D and E

Hepatitis D and E in PLWH

Hepatitis Delta Virus (HDV)

  1. HDV antibodies should be screened for in all HBsAg positive PLWH
  2. In PLWH with positive HDV antibodies, HDV-RNA should be measured in order to assess activity of the disease
  3. In PLWH with chronic HDV co-infection and significant liver fibrosis (≥ F2), long-term (at least 12 months) treatment with PEG-IFN might be considered in association with TDF-based ART
  4. Non-invasive fibrosis markers (transient elastography and serum markers) should be used with caution in PLWH with chronic HDV infection as there are no well-established thresholds
  5. Because of its anti-HBV activity, TDF/TAF should be added, as part of ART, to PEG-IFN in order to reduce HBV-DNA load
  6. Bulevirtide is a new treatment option for HDV which should also be considered if available
  7. PLWH should be referred to university centers for treatment and if possible enrolled in trials on new drugs active against HDV
  8. Treatment efficacy should be monitored with HBV-DNA and HDV-RNA measurements, when available, and with follow-up of biochemical and liver fibrosis estimates
  9. Persistent off-treatment HDV-RNA negativity and anti-HBs seroconversion are the ideal goals of antiviral treatment for HDV even if they can only be obtained in a minority of PLWH. Histological remission of liver disease is a less ambitious but more likely achievable goal
  10. In PLWH with HDV and ESLD or HCC, liver transplantation from HBsAg negative donors should be strongly considered. Transplant with anti-HBV prophylaxis post-OLTX cures HBV and HDV infection

Hepatitis E Virus (HEV)

  1. Screening for HEV infection is warranted in PLWH with symptoms consistent with acute hepatitis, unexplained flares of aminotransferases (even if suspected drug induced liver injury), unexplained elevated liver function tests, neuralgic amyotrophy, Guillain-Barrè, encephalitis or proteinuria
  2. Screening should include anti-HEV IgG and IgM and HEV-RNA in blood and if possible in stool
  3. Treatment with RBV (600 mg daily) may be considered in cases of severe acute HEV, acute-on-chronic liver failure, extrahepatic HEV related disease or in persons with persisting HEV replication three months after first detection of HEV-RNA. RBV should be given for a duration of 12 weeks followed by HEV-RNA measurements in serum and stool. If HEV-RNA is undetectable in both, RBV can be stopped. In PLWH in whom HEV-RNA is still detectable in serum and/or stool, RBV may be continued for an additional three months. In the setting of chronic HEV infection in immunosuppressed persons, reduction in immunosuppression should be considered