Treatment and Monitoring of Persons with HBV/HIV Co-infection

Treatment Indication

  1. All persons with HBV/HIV co-infection should receive ART that includes TDF or TAF unless history of tenofovir intolerance
  2. Stopping anti-HBV active ART should be avoided in persons with HIV/HBV co-infection because of the high risk of severe hepatitis flares and decompensation following HBV reactivation hepatitis

Treatment Selection

  1. If TDF or TAF is strictly contraindicated, entecavir may be prescribed in persons with no prior 3TC exposure and together with fully active ART
  2. Persons with liver cirrhosis and low CD4 count require careful surveillance in the first months after starting ART in order not to overlook immune reconstitution syndrome and subsequent liver decompensation due to flares of liver enzymes (for management of cirrhotic persons, see Liver Cirrhosis: Classification and Surveillance, Liver Cirrhosis: Management, Non-Alcoholic Fatty Liver Disease (NAFLD), Diagnosis and Management of Hepatorenal Syndrome/Acute Kidney Injury (HRS-AKI), and Dose Adjustment of ARVs for Impaired Hepatic Function). Please note that diagnosis of cirrhosis may be difficult in persons already on HBV treatment
  3. Caution is warranted to switch from a TDF/TAF-based regimen to drugs with a lower genetic barrier, e.g. FTC or 3TC, in particular in 3TC-pretreated cirrhotic persons as viral breakthrough due to archived YMDD mutations is likely to happen. This has also been described in individuals with previous 3TC HBV-resistance who have been switched from TDF to entecavir. Therefore, HBV-DNA and transaminases should be checked regularly.
  4. Prior to ART simplification with a regimen without TDF/TAF, HBV status should be re-checked. In PLWH with isolated anti-HBc, relapse of HBV-DNA is possible, therefore transaminases and HBV-DNA should be checked regularly. PLWH with positive HBsAg should remain on TDF or TAF containing ART.
  5. For HBV/HIV co-infected persons with BMD changes or CKD, see recommendations for Dose Adjustment of ARVs for Impaired Renal Function, Bone Disease: Screening and Diagnosis, Vitamin D Deficiency: Diagnosis and Management, Approach to Fracture Reduction in PLWH, Kidney Disease: Definition, Diagnosis and Management, ARV-associated Nephrotoxicity, and Indications and Tests for Proximal Renal Tubulopathy (PRT)

Treatment Goal

  1. The optimal treatment duration for nucleos(t)ide analogues with anti-HBV activity has not yet been determined and experts recommend life-long therapy. In those on ART where the nucleoside backbone needs changing, anti-HBV therapy may be stopped cautiously after confirmed HBsAg-seroconversion. In PLWH with liver cirrhosis, stopping of effective anti-HBV treatment is not recommended, in order to avoid liver decompensation due to flares of liver enzymes

Treatment Monitoring

  1. Liver blood tests should be performed every 3 months during the first year and every 6-12 months thereafter
  2. HBV-DNA should be determined every 3-6 months during the first year and every 12 months thereafter HBsAg should be checked at 12 months intervals at least until loss of HBsAg(i)

HBV Reactivation

11. In HBs-Ag negative, anti-HBc positive persons undergoing immunosuppression:

  • Those treated with severe immunosuppressive therapy (chemotherapy for lymphoma/leukaemia or stem-cell or solid-organ transplantation) should receive TDF/TAF therapy to prevent HBV reactivation. For persons with other markers of possible HBV exposure including isolated anti-HBs positivity (without a history of vaccination) careful monitoring for HBV reactivation is required
  • In persons treated with B-cell-depleting agents (rituximab, ofatumumab, natalizumab, alemtuzumab, ibritumomab) TDF/TAF should be part of the ART. If TDF/TAF is contraindicated, second line options include ETV, 3TC and FTC. However, cases of reactivation due to 3TC resistance have been described
  • In those not treated with HBV-active ART who receive other immunosuppressive therapy (e.g. TNF-alpha inhibitor), careful monitoring with HBV-DNA and HBsAg is required for HBV reactivation. If this is not possible, addition of TDF/TAF is recommended

i  Quantitative HBsAg < 1000 IU/mL predicts HBsAg loss