Education material on HIV/hepatis B coinfection

BORDERNETwork Training on

HIV and HBV Co-Infections Dr. med. Wolfgang Güthoff / Alexander Leffers, M.A. www.bordernet.eu www.aidshilfe-potsdam.de

This presentation arises from the BORDERNETwork project which has received funding from the European Union, in the framework of the Health Program, and cofunding of the Ministry of Environment, Health and Consumer Protection of the Federal State of Brandenburg. The sole responsibility of any use that may be made of the information lies with the authors (SPI, AIDS-Hilfe Potsdam e.V.)

Table of Contents

Epidemiology HIV/HBV co-infection

Diagnostic Treatment

HIV Infection and Chronic Hepatitis B Overlapping HBV and HIV Epidemics

35 Million Persons

HIV

Hepatitis B

350 Million Persons 3,5 Million Persons HIV/HBV co- infected

HIV Infection and Chronic Hepatitis B  HBV/HIV Co-infection prevalence depends on HBV epidemic  5 - 7% co-infections in low prevalence countries  10 - 20% co-infections in high prevalence countries

> 8 % High

 Despite ART - increasing risk of liver related death in this group

2 - 8 % Intermediate < 2 % Low

 the natural course of HBV - infection in HIV/HBV co-infected patients is different

Increased Liver Mortality in HIV /HBV Co-infected Patients  Increased rates of chronic hepatitis after infection  Higher levels of HBVDNA viraemia

 Faster progression to liver cirrhosis  Increased rate of liver cancer development

HIV / HBV Co-infection

There are two main reasons for considering HBV therapy as a priority in HBV/HIV co-infected patients:  Liver disease may progress more rapidly in those patients and could lead to serious liver disease complications such as cirrhosis and liver cancer at younger ages.  There is a higher risk of developing hepatotoxicity following the initiation of antiretroviral therapy in HIV patients co-infected with HBV than in patients infected with HIV alone.

HIV / HBV Co-infection

Because HIV infection can accelerate progression of liver disease, treatment of chronic hepatitis B is generally recommended in patients with:  HBV replication ( >2000 IU/ml )  Liver inflammation signs ( elevated ALAT )  Fibrosis ( liver biopsy Metavir 2, or high elastography )

HIV / HBV Co-infection Patients without ART indication:  use only substances without HIV activity (Peg Ifn, Adefovir, Telbivudine)  avoid Tenofovir, 3TC and FTC  avoid also Entecavir ( induction of HIV reverse transcriptase

mutation M184V is possible )

Treatment of Hepatitis B in co-infected patients without ART indication Treatment with pegylated interferon should be considered in special circumstances:  HIV treatment is not needed (high number of CD4 cells)  HBe Ag positive

 HBsAg genotype A  Elevated ALAT  Low level of HBVDNA ( poor data and no encouraging results )

Treatment of Hepatitis B in co-infected patients without ART indication Alternatively to peg. Interferon patients can be treated with HBV polymerase inhibitors:  Telbivudine  Adefovir  Telbivudine was preferred by most experts more than Adefovir (greater antiviral efficacy)

 But always check possibility of early HAART including Tenofovir + FTC or 3TC (it is preferred - EACS 2011)

Treatment Algorithm for HBV in HIV Co-infected Patients HIV/HBV coinfection

CD4 >500/µl or No indication of HAART

HBV Rx indicated (b)

a)

b)

Early HAART including TDF + FTC/3TC® PEG-INF if genotype A, high ALT, low HBV DNA

CD4 2000 IU/µl HBV DNA

Patients without HBV-associated 3TC resistance

Patients with HBVassociated 3TC resistance

HAART including TDF + 3TC or FTC

Substitute one NRTI with Tenofovir or add Tenofovir

Source: EACS 2011

300/µl

successful response in 80% of patients with CD4 > 500/µl

Rey D et al. Vaccine 18,116182000)