Hepatitis B Virus and HIV Coinfection: Results of a Survey on Treatment Practices
and Recommendations for Therapy
Hepatitis
B Virus Image
HIV
3-D Image
As
new therapies have become available that can treat both hepatitis
B virus (HBV) infection and HIV infection,
various consensus panels have updated or published new treatment guidelines for
HIV-HBV coinfected patients. The inconsistencies
among the different sets of guidelines and the increasing use of tenofovir
(Viread) off-label for the treatment of HBV infection is a reflection of the
complexities involved in treating such individuals.
There
are few data evaluating the use of the various sets of guidelines by practicing
clinicians. To address this important issue, Dr. Paul Gaglio and colleagues of
the Terry Beirn Community Programs for Clinical Research on AIDS (CPCRA) Hepatitis
Working Group conducted a survey on how clinicians "in the real world"
are managing HIV-HBV coinfected patients.
The
survey was sent to providers in CPCRA network, a federally funded, national network
of community-based clinical treatment centers. These sites are comprised of geographically
diverse facilities that include community clinics, academic and federal hospital
outpatient practices, and the offices of private physicians.
The survey
sought to define various issues regarding HIV-HBV coinfection, including the following:
Threshold
for HBV viremia (viral load) to initiate therapy;
•
Differences
in treatment recommendations regarding hepatitis B "e" antigen-positive
versus "e" antigen-negative HBV infection;
•
Treatment
choices for HBV infection in patients receiving or not receiving concurrent anti-HIV
therapy.
Following
is a summary of the survey results, which appear in the September 1, 2007 issue
of Clinical Infectious Diseases [1].
Results
•
Of
161 sites, 78 completed the survey (a response rate of 48.4%).
•
86%
vaccinated HIV-infected patients who were not immune to HBV infection.
•
98.7%
screened patients for HBV infection and 91% for hepatocellular carcinoma.
•
79%
made treatment decisions without referral to a hepatologist or gastroenterologist.
•
42%
of the sites initiated therapy when patients' ALT and AST levels were elevated
and HBV DNA level was >105 copies/mL.
•
49%
of the sites initiated therapy in the presence of any detectable HBV DNA level.
•
Antiviral
treatment choices for patients who were not concurrently receiving antiretroviral
therapy were lamivudine (Epivir-HBV)
plus tenofovir (Viread), adefovir (Hepsera),
or interferon.
•
Patients
concurrently receiving antiretroviral therapy received lamivudine plus tenofovir
preferentially, followed by tenofovir plus emtricitabine (Emtriva), adefovir,
or interferon.
•
The
survey did not include entecavir (Baraclude) or
telbivudine (Tyzeka) as therapeutic options
for HBV-infected patient, because the survey preceded approval of these drugs.
•
Decisions
regarding the performance of liver biopsy, threshold to initiate therapy, and
criteria to discontinue therapy varied, reflecting inconsistencies in available
treatment guidelines.
•
Treatment
decisions reflected concerns regarding future drug resistance in patients who
are naive to antiretroviral therapy and the emergence of drug resistance in patients
receiving antiretroviral therapy.
•
The
vast majority of participants in the survey recommended therapy for patients with
"wild type" ("e" antigen-positive) HBV infection, abnormal
liver enzyme levels, and an HBV DNA level >105 copies/mL, as well as for HBV
"e" antigen-negative patients with abnormal liver enzyme levels and
an HBV DNA level >104 copies/mL, in accordance with recently published guidelines
for HBV-monoinfected patients [2].
After
reviewing and assessing the survey responses, the study authors formulated recommendations
that included the following:
•
Future
consensus conferences on coinfection with HBV and HIV should make recommendations
that address issues regarding requirement for liver biopsy and the threshold of
HIV DNA level to initiate therapy, and to clearly define when HBV therapy can
be discontinued in coinfected patients.
•
All
patients with detectable HBV DNA arguably should be treated.
•
Patients
coinfected with HBV and HIV who are not receiving antiretroviral therapy and are
not anticipated to require antiretroviral therapy in the near future should be
treated with an anti-HBV drugs that do not target HIV infection or that are dosed
in a manner that does not affect HIV replication (i.e., interferon, adefovir,
or entecavir). [NOTE: recent data suggest that entecavir
is in fact active against HIV, and guidelines have recently been revised to
state that entecavir
should not be used in such patients.
•
Coinfected
patients receiving antiretroviral therapy should receive therapies that are effective
against both viruses; lamivudine plus tenofovir or emtricitabine plus tenofovir
are potential choices.
•
Effective
therapy against HBV infection should not be discontinued unless another drug with
activity against HBV infection is substituted or the patient has achieved seroconversion
from HBV surface antigen to surface antibody.
Department
of Medicine, Columbia University College of Physicians and Surgeons, New York,
New York; Divisions of Gastroenterology, Hepatology, and Infectious Diseases,
Virginia Commonwealth University School of Medicine, Richmond; Social and Scientific
Systems, Silver Springs, Maryland; and Department of Medicine, Temple University
School of Medicine, Philadelphia, Pennsylvania.
08/10/07
References
1.
P J Gaglio, R Sterling, E Daniels, and others (for the Terry Beirn Community Programs
for Clinical Research on AIDS Hepatitis Working Group). Hepatitis B Virus and
HIV Coinfection: Results of a Survey on Treatment Practices and Recommendations
for Therapy. Clinical Infectious Diseases 45(5): 618-623. September 1,
2007.
2. E B
Keeffe, D T Dieterich, S H Han, and others. A treatment algorithm for the management
of chronic hepatitis B virus infection in the United States: an update. Clinical
Gastroenterology and Hepatology 4: 936-962. 2006.
