Education material on HIV/hepatis B coinfection

Report
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 <500/µl or symptomatic HIV or
cirrhosis
No HBV Rx
indicated (b)
Lamivudine
experienced
Lamivudine naive
Monitor closely
Add or substitute
one NRTI with TDF
® as part of HAART
HAART including
TDF ® + 3TC or
FTC
Source: EACS 2011
HIV / HBV Coinfection - Treatment Algorithm
for HBV in Patients with ART
Indication for HIV treatment
>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
<2000 IU/µl HBV
DNA
Patients with
cirrhosis
HAART regimen of
choice (in case of
HBV polymerase
inhibitor maintain full
suppression)
HAART including
TDF + 3TC or FTC
In case of liver
decompensation
refer for evaluation
for LT
Treatment of HIV / HBV Co-infection
Gold standard: ART contains Tenofovir +Emtricitabine or Lamivudine
There is a problem in patients with virological failure to this first line ART:
 if these patients are switched from Tenofovir / Emtricitabine to another
drug, they will be vulnerable for hepatitis B liver inflammation flare
Possibility: Continue Tenofovir and add Zidovudine
HIV / HBV Co-infection - Conclusions
 Best solution: Early start of ART
 If ART is not indicated: Limited treatment options with only
Adefovir and Telbivudine
 (Alternative Interferon)
 Treatment of choice with patients on ART: Tenofovir
 3TC or FTC mono-therapy should never be considered
HIV / HBV Co-infection - Conclusions
Treatment of Hepatitis B follows the same rules as HIV:
 full suppression of viral replication to avoid the development of
drug resistance
 successful therapy leads to inhibition of inflammation activity
and reversion of fibrosis
 final goal: immune control of infection
HIV / HBV Co-infection
Don‘t forget:
HIV patients not infected with Hepatitis B should be
vaccinated against HBV
successful response in 33% of patients with CD4 > 300/µl
successful response in 80% of patients with CD4 > 500/µl
Rey D et al. Vaccine 18,116182000)

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