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| {{Hepatitis B}} | | __NOTOC__ |
| {{CMG}}; {{AOEIC}} [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org]
| | {{HIV coinfection with hepatitis b}} |
| ==Overview==
| | '''For main chapter on AIDS, click [[AIDS|here]]''' |
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| Coinfection with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) is common due to shared routes of transmission. The impact of coinfection is especially important in regions with widespread use of ART.<ref name="pmid17521593">{{cite journal |author=Hoffmann CJ, Thio CL |title=Clinical implications of HIV and hepatitis B co-infection in Asia and Africa |journal=Lancet Infect Dis |volume=7 |issue=6 |pages=402–9 |year=2007 |month=June |pmid=17521593 |doi=10.1016/S1473-3099(07)70135-4 |url=http://linkinghub.elsevier.com/retrieve/pii/S1473-3099(07)70135-4 |accessdate=2012-03-29}}</ref> As the use of ART becomes more prevalent in parts of the world with high HBV endemicity and long term survival increases, it is likely that liver disease from [[Hepatitis B natural history#Chronic infection|chronic hepatitis B]] in HIV-infected population may emerge as a greater public health problem than before.<ref name="pmid17521593">{{cite journal |author=Hoffmann CJ, Thio CL |title=Clinical implications of HIV and hepatitis B co-infection in Asia and Africa |journal=Lancet Infect Dis |volume=7 |issue=6 |pages=402–9 |year=2007 |month=June |pmid=17521593 |doi=10.1016/S1473-3099(07)70135-4 |url=http://linkinghub.elsevier.com/retrieve/pii/S1473-3099(07)70135-4 |accessdate=2012-03-29}}</ref>
| | '''For main chapter on HIV, click [[HIV|here]]''' |
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| | '''For main chapter on Hepatitis B, click [[Hepatitis B|here]]''' |
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| ==Epidemiology==
| | {{CMG}}; {{AOEIC}} [[User:Ujjwal Rastogi|Ujjwal Rastogi, MBBS]] [mailto:urastogi@perfuse.org] |
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| In areas of low endemicity, such as North America, Australia and Europe, HBV and HIV infection are usually acquired in adulthood through [[Human Immunodeficiency Virus#Transmission|sexual]] or [[Human Immunodeficiency Virus#Transmission|percutaneous transmission]]. In areas of low endemicity, the prevalence of chronic coinfection is around 5-7% among HIV-infected individuals.<ref name="pmid16352363">{{cite journal |author=Alter MJ |title=Epidemiology of viral hepatitis and HIV co-infection |journal=J. Hepatol. |volume=44 |issue=1 Suppl |pages=S6–9 |year=2006 |pmid=16352363 |doi=10.1016/j.jhep.2005.11.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S0168-8278(05)00726-9 |accessdate=2012-03-29}}</ref> In countries with intermediate and high HBV endemicity, the main routes of transmission of HBV are perinatal or in early childhood; in these countries HBV coinfection rates are 10-20%.<ref name="pmid18492625">{{cite journal |author=Lee HC, Ko NY, Lee NY, Chang CM, Ko WC |title=Seroprevalence of viral hepatitis and sexually transmitted disease among adults with recently diagnosed HIV infection in Southern Taiwan, 2000-2005: upsurge in hepatitis C virus infections among injection drug users |journal=J. Formos. Med. Assoc. |volume=107 |issue=5 |pages=404–11 |year=2008 |month=May |pmid=18492625 |doi=10.1016/S0929-6646(08)60106-0 |url=http://linkinghub.elsevier.com/retrieve/pii/S0929-6646(08)60106-0 |accessdate=2012-03-29}}</ref><ref name="pmid18555534">{{cite journal |author=Nyirenda M, Beadsworth MB, Stephany P, Hart CA, Hart IJ, Munthali C, Beeching NJ, Zijlstra EE |title=Prevalence of infection with hepatitis B and C virus and coinfection with HIV in medical inpatients in Malawi |journal=J. Infect. |volume=57 |issue=1 |pages=72–7 |year=2008 |month=July |pmid=18555534 |doi=10.1016/j.jinf.2008.05.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S0163-4453(08)00167-9 |accessdate=2012-03-29}}</ref><ref name="pmid18551596">{{cite journal |author=Diop-Ndiaye H, Touré-Kane C, Etard JF, Lô G, Diaw P, Ngom-Gueye NF, Gueye PM, Ba-Fall K, Ndiaye I, Sow PS, Delaporte E, Mboup S |title=Hepatitis B, C seroprevalence and delta viruses in HIV-1 Senegalese patients at HAART initiation (retrospective study) |journal=J. Med. Virol. |volume=80 |issue=8 |pages=1332–6 |year=2008 |month=August |pmid=18551596 |doi=10.1002/jmv.21236 |url=http://dx.doi.org/10.1002/jmv.21236 |accessdate=2012-03-29}}</ref>
| | ==[[HIV coinfection with hepatitis b overview|Overview]]== |
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| ==Natural History== | | ==[[HIV coinfection with hepatitis b pathophysiology|Pathophysiology]]== |
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| The rate of progression and complications from viral hepatitis are accelerated in patients with HIV coinfection.<ref name="pmid16964824">{{cite journal |author=Puoti M, Cozzi-Lepri A, Paraninfo G, Arici C, Moller NF, Lundgren JD, Ledergerber B, Rickenbach M, Suarez-Lozano I, Garrido M, Dabis F, Winnock M, Milazzo L, Gervais A, Raffi F, Gill J, Rockstroh J, Ourishi N, Mussini C, Castagna A, De Luca A, Monforte A |title=Impact of lamivudine on the risk of liver-related death in 2,041 HBsAg- and HIV-positive individuals: results from an inter-cohort analysis |journal=Antivir. Ther. (Lond.) |volume=11 |issue=5 |pages=567–74 |year=2006 |pmid=16964824 |doi= |url= |accessdate=2012-03-29}}</ref><ref name="pmid19399813">{{cite journal |author=Thio CL |title=Hepatitis B and human immunodeficiency virus coinfection |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S138–45 |year=2009 |month=May |pmid=19399813 |doi=10.1002/hep.22883 |url=http://dx.doi.org/10.1002/hep.22883 |accessdate=2012-03-29}}</ref> After acquiring HBV infection, HIV infected individuals are 6 times more likely to develop chronic hepatitis B than HIV negative individuals.<ref name="pmid2019762">{{cite journal |author=Bodsworth NJ, Cooper DA, Donovan B |title=The influence of human immunodeficiency virus type 1 infection on the development of the hepatitis B virus carrier state |journal=J. Infect. Dis. |volume=163 |issue=5 |pages=1138–40 |year=1991 |month=May |pmid=2019762 |doi= |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=2019762 |accessdate=2012-03-29}}</ref><ref name="pmid1825315">{{cite journal |author=Hadler SC, Judson FN, O'Malley PM, Altman NL, Penley K, Buchbinder S, Schable CA, Coleman PJ, Ostrow DN, Francis DP |title=Outcome of hepatitis B virus infection in homosexual men and its relation to prior human immunodeficiency virus infection |journal=J. Infect. Dis. |volume=163 |issue=3 |pages=454–9 |year=1991 |month=March |pmid=1825315 |doi= |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=1825315 |accessdate=2012-03-29}}</ref><ref name="pmid10795602">{{cite journal |author=Gatanaga H, Yasuoka A, Kikuchi Y, Tachikawa N, Oka S |title=Influence of prior HIV-1 infection on the development of chronic hepatitis B infection |journal=Eur. J. Clin. Microbiol. Infect. Dis. |volume=19 |issue=3 |pages=237–9 |year=2000 |month=March |pmid=10795602 |doi= |url=http://link.springer.de/link/service/journals/10096/bibs/0019003/00190237.htm |accessdate=2012-03-29}}</ref> This was more
| | ==[[HIV coinfection with hepatitis b causes|Causes]]== |
| likely to occur in HIV infected men with lower CD4 cells. Decreased rates of clearance of [[Hepatitis B laboratory tests#Lab Tests|HBeAg]] and increased HBV replication are also seen, with higher HBV DNA viral load.<ref name="pmid10094979">{{cite journal |author=Colin JF, Cazals-Hatem D, Loriot MA, Martinot-Peignoux M, Pham BN, Auperin A, Degott C, Benhamou JP, Erlinger S, Valla D, Marcellin P |title=Influence of human immunodeficiency virus infection on chronic hepatitis B in homosexual men |journal=Hepatology |volume=29 |issue=4 |pages=1306–10 |year=1999 |month=April |pmid=10094979 |doi=10.1002/hep.510290447 |url=http://dx.doi.org/10.1002/hep.510290447 |accessdate=2012-03-29}}</ref><ref name="pmid9108941">{{cite journal |author=Gilson RJ, Hawkins AE, Beecham MR, Ross E, Waite J, Briggs M, McNally T, Kelly GE, Tedder RS, Weller IV |title=Interactions between HIV and hepatitis B virus in homosexual men: effects on the natural history of infection |journal=AIDS |volume=11 |issue=5 |pages=597–606 |year=1997 |month=April |pmid=9108941 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0269-9370&volume=11&issue=5&spage=597 |accessdate=2012-03-29}}</ref><ref name="pmid3643160">{{cite journal |author=Krogsgaard K, Lindhardt BO, Nielson JO, Andersson P, Kryger P, Aldershvile J, Gerstoft J, Pedersen C |title=The influence of HTLV-III infection on the natural history of hepatitis B virus infection in male homosexual HBsAg carriers |journal=Hepatology |volume=7 |issue=1 |pages=37–41 |year=1987 |pmid=3643160 |doi= |url= |accessdate=2012-03-29}}</ref> In addition, HIV infected individuals are more likely to lose previously developed protective anti-HBs antibody and develop acute hepatitis B infection; This risk is also associated with lower CD4 counts.<ref name="pmid3807959">{{cite journal |author=Biggar RJ, Goedert JJ, Hoofnagle J |title=Accelerated loss of antibody to hepatitis B surface antigen among immunodeficient homosexual men infected with HIV |journal=N. Engl. J. Med. |volume=316 |issue=10 |pages=630–1 |year=1987 |month=March |pmid=3807959 |doi=10.1056/NEJM198703053161015 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198703053161015?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-03-29}}</ref><ref name="pmid3146272">{{cite journal |author=Laukamm-Josten U, Müller O, Bienzle U, Feldmeier H, Uy A, Guggenmoos-Holzmann I |title=Decline of naturally acquired antibodies to hepatitis B surface antigen in HIV-1 infected homosexual men |journal=AIDS |volume=2 |issue=5 |pages=400–1 |year=1988 |month=October |pmid=3146272 |doi= |url= |accessdate=2012-03-29}}</ref>
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| HIV also hastens the progression of HBV related liver disease. [[Cirrhosis]] is more common despite lower ALT levels than in HBV mono-infection and is also more common with lower [[CD4]] counts.<ref name="pmid10094979">{{cite journal |author=Colin JF, Cazals-Hatem D, Loriot MA, Martinot-Peignoux M, Pham BN, Auperin A, Degott C, Benhamou JP, Erlinger S, Valla D, Marcellin P |title=Influence of human immunodeficiency virus infection on chronic hepatitis B in homosexual men |journal=Hepatology |volume=29 |issue=4 |pages=1306–10|year=1999 |month=April |pmid=10094979 |doi=10.1002/hep.510290447 |url=http://dx.doi.org/10.1002/hep.510290447|accessdate=2012-03-29}}</ref><ref name="pmid12454838">{{cite journal |author=Di Martino V, Thevenot T, Colin JF, Boyer N, Martinot M, Degos F, Coulaud JP, Vilde JL, Vachon F, Degott C, Valla D, Marcellin P |title=Influence of HIV infection on the response to interferon therapy and the long-term outcome of chronic hepatitis B |journal=Gastroenterology |volume=123 |issue=6 |pages=1812–22 |year=2002 |month=December |pmid=12454838 |doi=10.1053/gast.2002.37061 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016508502004535 |accessdate=2012-03-29}}</ref>
| | ==[[HIV coinfection with hepatitis b differential diagnosis|Differentiating HIV coinfection with hepatitis b from other Diseases]]== |
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| ===Complications=== | | ==[[HIV coinfection with hepatitis b epidemiology and demographics|Epidemiology and Demographics]]== |
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| Following initiation of [[antiretroviral therapy]] (ART), [[immune reconstitution inflammatory syndrome]] (IRIS) may occur which can lead to worsening liver disease including [[Cirrhosis#Decompensated cirrhosis|hepatic decompensation]]. In addition, after discontinuation of an ART regimen containing anti-HBV agents, reactivation of hepatitis B can occur.
| | ==[[HIV coinfection with hepatitis b risk factors|Risk Factors]]== |
| ALT elevations occurred in 29% of 147 patients within 6 months of withdrawal.<ref name="pmid18795964">{{cite journal |author=Bellini C, Keiser O, Chave JP, Evison J, Fehr J, Kaiser L, Weber R, Vernazza P, Bernasconi E, Telenti A, Cavassini M |title=Liver enzyme elevation after lamivudine withdrawal in HIV-hepatitis B virus co-infected patients: the Swiss HIV Cohort Study |journal=HIV Med. |volume=10 |issue=1 |pages=12–8 |year=2009 |month=January |pmid=18795964 |doi=10.1111/j.1468-1293.2008.00646.x |url=http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=1464-2662&date=2009&volume=10&issue=1&spage=12 |accessdate=2012-03-29}}</ref> If reactivation occurs, resuming an agent that is active against HBV is required.
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| HIV-HBV coinfected men are greater than 17 times more likely to die of liver related causes compared to those mono-infected with HBV.<ref name="pmid12493258">{{cite journal |author=Thio CL, Seaberg EC, Skolasky R, Phair J, Visscher B, Muñoz A, Thomas DL |title=HIV-1, hepatitis B virus, and risk of liver-related mortality in the Multicenter Cohort Study (MACS) |journal=Lancet |volume=360 |issue=9349 |pages=1921–6 |year=2002 |month=December |pmid=12493258 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S0140673602119131 |accessdate=2012-03-29}}</ref> For individuals on ART, coinfection with chronic hepatitis B increases the risk of [[hepatotoxicity]] from ART three-fold to five-fold.<ref name="pmid12626885">{{cite journal |author=Puoti M, Torti C, Ripamonti D, Castelli F, Zaltron S, Zanini B, Spinetti A, Putzolu V, Casari S, Tomasoni L, Quiros-Roldan E, Favret M, Berchich L, Grigolato P, Callea F, Carosi G |title=Severe hepatotoxicity during combination antiretroviral treatment: incidence, liver histology, and outcome |journal=J. Acquir. Immune Defic. Syndr. |volume=32 |issue=3 |pages=259–67 |year=2003 |month=March |pmid=12626885 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1525-4135&volume=32&issue=3&spage=259 |accessdate=2012-03-29}}</ref><ref name="pmid10632283">{{cite journal |author=Sulkowski MS, Thomas DL, Chaisson RE, Moore RD |title=Hepatotoxicity associated with antiretroviral therapy in adults infected with human immunodeficiency virus and the role of hepatitis C or B virus infection |journal=JAMA |volume=283 |issue=1 |pages=74–80 |year=2000 |month=January |pmid=10632283 |doi= |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=10632283 |accessdate=2012-03-29}}</ref><ref name="pmid14628283">{{cite journal |author=Livry C, Binquet C, Sgro C, Froidure M, Duong M, Buisson M, Grappin M, Quantin C, Portier H, Chavanet P, Piroth L |title=Acute liver enzyme elevations in HIV-1-infected patients |journal=HIV Clin Trials |volume=4 |issue=6 |pages=400–10 |year=2003 |pmid=14628283 |doi= |url=http://thomasland.metapress.com/openurl.asp?genre=article&issn=1528-4336&volume=4&issue=6&spage=400 |accessdate=2012-03-29}}</ref>
| | ==[[HIV coinfection with hepatitis b screening|Screening]]== |
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| It is unclear at present if the risk of [[hepatocellular carcinoma]] (HCC) is increased, but there is some evidence that HIV infected individuals with lower CD4 counts are at greater risk of developing HCC.<ref name="pmid18832877">{{cite journal |author=Clifford GM, Rickenbach M, Polesel J, Dal Maso L, Steffen I, Ledergerber B, Rauch A, Probst-Hensch NM, Bouchardy C, Levi F, Franceschi S |title=Influence of HIV-related immunodeficiency on the risk of hepatocellular carcinoma |journal=AIDS |volume=22 |issue=16 |pages=2135–41 |year=2008 |month=October |pmid=18832877 |doi=10.1097/QAD.0b013e32831103ad |url= |accessdate=2012-03-29}}</ref>
| | ==[[HIV coinfection with hepatitis b natural history, complications and prognosis|Natural History, Complications and Prognosis]]== |
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| ==Diagnosis== | | ==Diagnosis== |
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| Accurate assessment of HBV infection in HIV co-infected individuals is necessary in order to base therapeutic decisions. <ref name="pmid19399813">{{cite journal |author=Thio CL |title=Hepatitis B and human immunodeficiency virus coinfection |journal=Hepatology |volume=49 |issue=5 Suppl |pages=S138–45 |year=2009 |month=May|pmid=19399813 |doi=10.1002/hep.22883 |url=http://dx.doi.org/10.1002/hep.22883 |accessdate=2012-03-29}}</ref>
| | [[HIV coinfection with hepatitis b history and symptoms|History and Symptoms]] | [[HIV coinfection with hepatitis b physical examination|Physical Examination]] | [[HIV coinfection with hepatitis b laboratory findings|Laboratory Findings]] | [[HIV coinfection with hepatitis b other diagnostic studies|Other Diagnostic Studies]] |
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| WHO advocates HBsAg testing especially in areas of high HBV prevalence; but additional testing for HBV markers such as HBeAg and HBV DNA and to assess stage of liver disease (e.g. [[Liver function tests|liver enzymes]], liver [[biopsy]]) may not be widely available in many resource limited countries.
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| Liver biopsy remains the '''gold standard''' for assessing disease severity in HIV-HBV coinfection. Non-invasive markers are also available but none have been widely studied in co-infected patients.
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| Hoffman and Thio provided management recommendations for use in areas with limited resources. They recommend that [[HBsAg]] and liver enzymes be tested before ART, with liver enzymes being repeated once or twice during the first 3 months after commencing ART. Detection of HBV DNA is helpful but may not be available. [[Hepatitis B natural history#Chronic infection|Chronic HBV]] carriers with [[Hepatitis B laboratory tests#Lab Tests|HBeAg]] positivity may benefit from starting [[Hepatitis B medical therapy|anti-HBV therapy]] early. <ref name="pmid17521593">{{cite journal|author=Hoffmann CJ, Thio CL |title=Clinical implications of HIV and hepatitis B co-infection in Asia and Africa |journal=Lancet Infect Dis |volume=7 |issue=6 |pages=402–9 |year=2007 |month=June |pmid=17521593 |doi=10.1016/S1473-3099(07)70135-4|url=http://linkinghub.elsevier.com/retrieve/pii/S1473-3099(07)70135-4 |accessdate=2012-03-29}}</ref>
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| ==Screening==
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| For HIV infected individuals with chronic HBV, additional screening for coinfection with HCV is recommended; [[hepatocellular carcinoma]] screening with [[alpha fetoprotein]] and imaging of liver every 6 months is being suggested by some but the cost benefit of one or both tests as well as the frequency of monitoring in various health economies remain to be assessed. <ref name="pmid19399813">{{cite journal |author=Thio CL |title=Hepatitis B and human immunodeficiency virus coinfection|journal=Hepatology |volume=49 |issue=5 Suppl |pages=S138–45 |year=2009 |month=May|pmid=19399813 |doi=10.1002/hep.22883|url=http://dx.doi.org/10.1002/hep.22883 |accessdate=2012-03-29}}</ref>
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| ==Treatment== | | ==Treatment== |
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| Treatment is most beneficial for those in the immunoactive phase of chronic hepatitis B (characterized by liver enzyme elevations, fluctuating [[Hepatitis B pathophysiology#Structure|HBV DNA]] levels and pronounced hepatic necro-inflammation) <ref name="pmid17521593">{{cite journal |author=Hoffmann CJ, Thio CL |title=Clinical implications of HIV and hepatitis B co-infection in Asia and Africa |journal=Lancet Infect Dis |volume=7 |issue=6 |pages=402–9 |year=2007 |month=June|pmid=17521593 |doi=10.1016/S1473-3099(07)70135-4|url=http://linkinghub.elsevier.com/retrieve/pii/S1473-3099(07)70135-4 |accessdate=2012-03-29}}</ref>
| | [[HIV coinfection with hepatitis b medical therapy|Medical Therapy]] | [[HIV coinfection with hepatitis b prevention|Prevention]] | [[HIV coinfection with hepatitis b cost-effectiveness of therapy|Cost-Effectiveness of Therapy]] | [[HIV coinfection with hepatitis b future or investigational therapies|Future or Investigational Therapies]] |
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| Patient characteristics that favour treatment success are <ref name="pmid15718833">{{cite journal |author=Soriano V, Puoti M, Bonacini M, Brook G, Cargnel A, Rockstroh J, Thio C, Benhamou Y |title=Care of patients with chronic hepatitis B and HIV co-infection: recommendations from an HIV-HBV International Panel |journal=AIDS |volume=19 |issue=3 |pages=221–40 |year=2005 |month=February |pmid=15718833 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=0269-9370&volume=19&issue=3&spage=221 |accessdate=2012-03-30}}</ref>
| | ==Case Studies== |
| *Low HBV DNA levels.
| | [[HIV coinfection with hepatitis b case study one|Case #1]] |
| *HBeAg positivity.
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| *Evidence of liver inflammation based on liver biopsy findings.
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| *Liver enzyme elevations.
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| It is unknown, if this applies to HIV coinfected individuals who have higher HBV DNA and lower liver enzyme elevations but more cirrhosis, and therefore the optimum time to commence treatment in HIV-HBV coinfected individuals is unclear at present.
| | ==Related Chapters== |
| | * [[Coinfection]] |
| | * [[AIDS]] |
| | * [[HIV disease]] |
| | * [[Hepatitis C with HIV coinfection]] |
| | * [[Tuberculosis and HIV coinfection]] |
| | * [[HIV and tuberculosis coinfection : drug interaction]] |
| | * [[HIV and pregnancy]] |
| | * [[Hepatitis]] |
| | * [[Jaundice]] |
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| The treatment and management of coinfected individuals requires modification in resource poor countries due to limited availability of some HBV tests as well as therapeutic agents for treatment of HIV and HBV. [[Lamivudine|3TC]] is widely available and [[tenofovir]] and [[adefovir]] have limited availability.
| | [[Category:Gastroenterology]] |
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| ===Current Regimen===
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| There are several agents presently used for the treatment of HBV and HIV coinfection including [[Antiretroviral drug#Classes of antiretroviral drugs|interferon]] and [[Antiretroviral drug#Classes of antiretroviral drugs|nucleoside]] or [[Antiretroviral drug#Classes of antiretroviral drugs|nucleotide analogs]].<ref name="pmid16556638">{{cite journal |author=Soriano V, Barreiro P, Nuñez M |title=Management of chronic hepatitis B and C in HIV-coinfected patients |journal=J. Antimicrob. Chemother. |volume=57 |issue=5 |pages=815–8 |year=2006 |month=May |pmid=16556638 |doi=10.1093/jac/dkl068 |url=http://jac.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=16556638 |accessdate=2012-03-30}}</ref> Decisions regarding when to initiate anti-HBV therapy require assessment of HIV status prior to initiation of treatment as several of these agents ([[tenofovir]], [[lamivudine]], [[emtricitabine]], [[adefovir]] and [[entecavir]]) have activity against both HIV and HBV.
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| [[Telbivudine]], a newer agent used to treat HBV, has not been shown to have activity against HIV.
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| Treatment decisions should be based on a combination of these factors:<ref name="pmid17521593">{{cite journal |author=Hoffmann CJ, Thio CL |title=Clinical implications of HIV and hepatitis B co-infection in Asia and Africa |journal=Lancet Infect Dis |volume=7 |issue=6 |pages=402–9 |year=2007 |month=June |pmid=17521593 |doi=10.1016/S1473-3099(07)70135-4 |url=http://linkinghub.elsevier.com/retrieve/pii/S1473-3099(07)70135-4 |accessdate=2012-03-29}}</ref>
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| # Which virus needs treatment.
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| # The type of antiviral agents used in the concurrent anti-HIV regimen.
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| # The presence of 3TC-resistant HBV.
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| # The potential effect of drug resistance on the long term management of HIV and HBV infection.
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| '''If ART is to be initiated''', then first line therapy should include [[Tenofovir|TDF]] and [[Lamivudine|3TC]]/[[Emtricitabine|FTC]] as the [[Reverse transcriptase inhibitor#Nucleoside analog reverse transcriptase inhibitors (NARTIs or NRTIs)|nucleoside]] backbone.
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| Current WHO criteria for commencing ART in HIV infected individuals are based on a combination of WHO Clinical Stage and CD4 count.
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| '''Lamivudine/emtricitabine (3TC/FTC)'''
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| Dore et al demonstrated the efficacy of 3TC in persons co infected with HIV and hepatitis B virus in the CAESAR study, a randomized placebo-controlled trial assessing the addition of 3TC or 3TC (150 mg 2x/day) plus [[loviride]] (100 mg 3x/day) to [[zidovudine]]-containing background antiretroviral treatment.<ref name="pmid10438346">{{cite journal |author=Dore GJ, Cooper DA, Barrett C, Goh LE, Thakrar B, Atkins M |title=Dual efficacy of lamivudine treatment in human immunodeficiency virus/hepatitis B virus-coinfected persons in a randomized, controlled study (CAESAR). The CAESAR Coordinating Committee |journal=J. Infect. Dis. |volume=180 |issue=3 |pages=607–13 |year=1999 |month=September |pmid=10438346 |doi=10.1086/314942 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=10438346 |accessdate=2012-03-30}}</ref> Baseline HBsAg was positive in 122 (6.8%) of 1790 subjects. At weeks 12 and 52, median log10 HBV DNA change was -2.0 and -2.7, respectively, in the [[lamivudine]] arms, compared with no reduction among placebo recipients (P<.001).
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| A trend to lower ALT level, and delayed progression of HIV disease (relative hazard, 0.26; 95% confidence interval, 0.08-0.80) were also seen in the 3TC arms, compared with the placebo group. 3TC used as monotherapy however, results in the development of resistance at rates of 14-32% annually, exceeding 70% after 49 months of treatment and plateauing at > 90% in HIV-co-infected patients at 4-5 years.<ref name="pmid8929003">{{cite journal |author=Benhamou Y, Katlama C, Lunel F, Coutellier A, Dohin E, Hamm N, Tubiana R, Herson S, Poynard T, Opolon P |title=Effects of lamivudine on replication of hepatitis B virus in HIV-infected men |journal=Ann. Intern. Med. |volume=125 |issue=9 |pages=705–12 |year=1996 |month=November |pmid=8929003 |doi= |url= |accessdate=2012-03-30}}</ref><ref name="pmid16549970">{{cite journal |author=Matthews GV, Bartholomeusz A, Locarnini S, Ayres A, Sasaduesz J, Seaberg E, Cooper DA, Lewin S, Dore GJ, Thio CL |title=Characteristics of drug resistant HBV in an international collaborative study of HIV-HBV-infected individuals on extended lamivudine therapy |journal=AIDS |volume=20 |issue=6 |pages=863–70 |year=2006 |month=April |pmid=16549970 |doi=10.1097/01.aids.0000218550.85081.59 |url= |accessdate=2012-03-30}}</ref>
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| Since 3TC has been widely used as part of ARV regimens in co infected persons, with HBV Pol mutations observed in 94% of viremic patients who have been on treatment for at least four years.<ref name="pmid16549970">{{cite journal |author=Matthews GV, Bartholomeusz A, Locarnini S, Ayres A, Sasaduesz J, Seaberg E, Cooper DA, Lewin S, Dore GJ, Thio CL |title=Characteristics of drug resistant HBV in an international collaborative study of HIV-HBV-infected individuals on extended lamivudine therapy |journal=AIDS |volume=20 |issue=6 |pages=863–70 |year=2006 |month=April |pmid=16549970 |doi=10.1097/01.aids.0000218550.85081.59 |url= |accessdate=2012-03-30}}</ref>
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| FTC possesses similar characteristics to 3TC, although FTC has a longer half-life and is more potent in monotherapy in treatment naive patients.<ref name="pmid14639535">{{cite journal |author=Rousseau FS, Wakeford C, Mommeja-Marin H, Sanne I, Moxham C, Harris J, Hulett L, Wang LH, Quinn JB, Barry DW |title=Prospective randomized trial of emtricitabine versus lamivudine short-term monotherapy in human immunodeficiency virus-infected patients |journal=J. Infect. Dis. |volume=188 |issue=11 |pages=1652–8 |year=2003 |month=December |pmid=14639535 |doi=10.1086/379667 |url=http://www.jid.oxfordjournals.org/cgi/pmidlookup?view=long&pmid=14639535 |accessdate=2012-03-30}}</ref>
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| 3TC/FTC are interchangeable agents according to current treatment guidelines.
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| ===Goals of treatment===
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| '''HIV:'''Treatment for HIV has resulted in a marked reduction in AIDS-related mortality. As a result, liver disease from HBV and HCV is now becoming a major cause of morbidity and mortality in HIV infected patients.<ref name="pmid10969344">{{cite journal |author=Puoti M, Spinetti A, Ghezzi A, Donato F, Zaltron S, Putzolu V, Quiros-Roldan E, Zanini B, Casari S, Carosi G |title=Mortality for liver disease in patients with HIV infection: a cohort study |journal=J. Acquir. Immune Defic. Syndr. |volume=24 |issue=3 |pages=211–7 |year=2000 |month=July |pmid=10969344 |doi= |url=http://meta.wkhealth.com/pt/pt-core/template-journal/lwwgateway/media/landingpage.htm?issn=1525-4135&volume=24&issue=3&spage=211 |accessdate=2012-03-29}}</ref> Therefore the goal of treatment is to optimize anti-HIV therapy in HIV/HBV co-infected patients to improve and/or preserve immune function and reduce HIV associated morbidity and mortality.
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| '''HBV:''' In mono-infected patients, HBV therapy can reduce the risk of developing complications of liver disease.<ref name="pmid8618580">{{cite journal |author=Niederau C, Heintges T, Lange S, Goldmann G, Niederau CM, Mohr L, Häussinger D |title=Long-term follow-up of HBeAg-positive patients treated with interferon alfa for chronic hepatitis B |journal=N. Engl. J. Med. |volume=334 |issue=22 |pages=1422–7 |year=1996 |month=May |pmid=8618580 |doi=10.1056/NEJM199605303342202 |url=http://dx.doi.org/10.1056/NEJM199605303342202 |accessdate=2012-03-30}}</ref> <ref name="pmid11481627">{{cite journal |author=Yao FY, Terrault NA, Freise C, Maslow L, Bass NM |title=Lamivudine treatment is beneficial in patients with severely decompensated cirrhosis and actively replicating hepatitis B infection awaiting liver transplantation: a comparative study using a matched, untreated cohort |journal=Hepatology |volume=34 |issue=2 |pages=411–6 |year=2001 |month=August |pmid=11481627 |doi=10.1053/jhep.2001.26512 |url=http://dx.doi.org/10.1053/jhep.2001.26512 |accessdate=2012-03-30}}</ref> Natural history studies of chronically infected individuals have linked the risk of progression to cirrhosis and HCC to ongoing HBV replication.<ref name="pmid16391218">{{cite journal |author=Chen CJ, Yang HI, Su J, Jen CL, You SL, Lu SN, Huang GT, Iloeje UH |title=Risk of hepatocellular carcinoma across a biological gradient of serum hepatitis B virus DNA level |journal=JAMA |volume=295 |issue=1 |pages=65–73 |year=2006 |month=January |pmid=16391218 |doi=10.1001/jama.295.1.65 |url=http://jama.ama-assn.org/cgi/pmidlookup?view=long&pmid=16391218 |accessdate=2012-03-30}}</ref><ref name="pmid16817842">{{cite journal |author=Chen G, Lin W, Shen F, Iloeje UH, London WT, Evans AA |title=Past HBV viral load as predictor of mortality and morbidity from HCC and chronic liver disease in a prospective study |journal=Am. J. Gastroenterol. |volume=101 |issue=8 |pages=1797–803 |year=2006 |month=August |pmid=16817842 |doi=10.1111/j.1572-0241.2006.00647.x |url=http://dx.doi.org/10.1111/j.1572-0241.2006.00647.x |accessdate=2012-03-30}}</ref><ref name="pmid16530509">{{cite journal |author=Iloeje UH, Yang HI, Su J, Jen CL, You SL, Chen CJ |title=Predicting cirrhosis risk based on the level of circulating hepatitis B viral load |journal=Gastroenterology |volume=130 |issue=3 |pages=678–86 |year=2006 |month=March |pmid=16530509 |doi=10.1053/j.gastro.2005.11.016 |url=http://linkinghub.elsevier.com/retrieve/pii/S0016-5085(05)02276-6 |accessdate=2012-03-30}}</ref> In addition,
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| treatment for HBV has been directed at reducing replicating virus. It has been demonstrated that the degree of HBV viral suppression achieved during treatment appears to be the most important determinant of treatment outcomes <ref name="pmid16461216">{{cite journal |author=Liaw YF |title=The current management of HBV drug resistance |journal=J. Clin. Virol. |volume=34 Suppl 1 |issue= |pages=S143–6 |year=2005 |month=December |pmid=16461216 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/S1386-6532(05)80025-3 |accessdate=2012-03-30}}</ref><ref name="pmid17310811">{{cite journal |author=Liaw YF |title=Hepatitis B virus replication and liver disease progression: the impact of antiviral therapy |journal=Antivir. Ther. (Lond.) |volume=11 |issue=6 |pages=669–79 |year=2006 |pmid=17310811 |doi= |url= |accessdate=2012-03-30}}</ref>, but HBV DNA levels as low as 2000 IU/mL is still associated with disease progression.<ref name="pmid15985007">{{cite journal |author=Yuan HJ, Yuen MF, Ka-Ho Wong D, Sablon E, Lai CL |title=The relationship between HBV-DNA levels and cirrhosis-related complications in Chinese with chronic hepatitis B |journal=J. Viral Hepat. |volume=12 |issue=4 |pages=373–9 |year=2005 |month=July |pmid=15985007 |doi=10.1111/j.1365-2893.2005.00603.x |url=http://onlinelibrary.wiley.com/resolve/openurl?genre=article&sid=nlm:pubmed&issn=1352-0504&date=2005&volume=12&issue=4&spage=373 |accessdate=2012-03-30}}</ref><ref name="pmid15871997">{{cite journal |author=Yuen MF, Yuan HJ, Wong DK, Yuen JC, Wong WM, Chan AO, Wong BC, Lai KC, Lai CL |title=Prognostic determinants for chronic hepatitis B in Asians: therapeutic implications |journal=Gut |volume=54 |issue=11 |pages=1610–4 |year=2005 |month=November |pmid=15871997 |pmc=1774768 |doi=10.1136/gut.2005.065136 |url=http://gut.bmj.com/cgi/pmidlookup?view=long&pmid=15871997 |accessdate=2012-03-30}}</ref> Recent recommendations have advocated for undetectable HBV DNA as the therapeutic goal with the overall goal of therapy being to reduce 5 progression to cirrhosis, liver failure, HCC and need for liver transplantation.<ref name="pmid17632041">{{cite journal |author=Keeffe EB, Zeuzem S, Koff RS, Dieterich DT, Esteban-Mur R, Gane EJ, Jacobson IM, Lim SG, Naoumov N, Marcellin P, Piratvisuth T, Zoulim F |title=Report of an international workshop: Roadmap for management of patients receiving oral therapy for chronic hepatitis B |journal=Clin. Gastroenterol. Hepatol. |volume=5 |issue=8 |pages=890–7 |year=2007 |month=August |pmid=17632041 |doi=10.1016/j.cgh.2007.05.004 |url=http://linkinghub.elsevier.com/retrieve/pii/S1542-3565(07)00526-5 |accessdate=2012-03-30}}</ref><ref name="pmid18845489">{{cite journal |author=Keeffe EB, Dieterich DT, Han SH, Jacobson IM, Martin P, Schiff ER, Tobias H |title=A treatment algorithm for the management of chronic hepatitis B virus infection in the United States: 2008 update |journal=Clin. Gastroenterol. Hepatol. |volume=6 |issue=12 |pages=1315–41; quiz 1286 |year=2008 |month=December |pmid=18845489 |doi=10.1016/j.cgh.2008.08.021 |url=http://linkinghub.elsevier.com/retrieve/pii/S1542-3565(08)00853-7 |accessdate=2012-03-30}}</ref>
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| ==Reference==
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| {{reflist|2}}
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| [[Category:Hepatitis|B]]
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| [[Category:Gastroenterology]]
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| [[Category:Infectious disease]]
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| [[Category:Disease]] | | [[Category:Disease]] |
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