Antiretroviral Guidelines

US DHHS Guidelines with Australian commentary

Hepatitis B Virus/HIV Coinfection

Last Updated: October 17, 2017; Last Reviewed: October 17, 2017

Panel's Recommendations Regarding Hepatitis B Virus/ HIV Coinfection

Panel’s Recommendations

  • Before initiation of antiretroviral therapy (ART), all patients who test positive for hepatitis B surface antigen (HBsAg) should be tested for hepatitis B virus (HBV) DNA using a quantitative assay to determine the level of HBV replication (AIII).
  • Because emtricitabine (FTC), lamivudine (3TC), tenofovir disoproxil fumarate (TDF), and tenofovir alafenamide (TAF) have activity against both HIV and HBV, an ART regimen for patients with both HIV and HBV should be include (TAF or TDF) plus (3TC or FTC) as the nucleoside reverse transcriptase inhibitor (NRTI) backbone of a fully suppressive antiretroviral (ARV) regimen (AI).
  • If TDF or TAF cannot safely be used, the alternative recommended HBV therapy is entecavir in addition to a fully suppressive ARV regimen (BI). Entecavir has activity against HIV; its use for HBV treatment without ART in patients with dual infection may result in the selection of the M184V mutation that confers HIV resistance to 3TC and FTC. Therefore, entecavir must be used in addition to a fully suppressive ARV regimen when given to patients with HBV/HIV-coinfection (AII). Peginterferon alfa monotherapy may also be considered in certain patients (CII).
  • Other HBV treatment regimens, including adefovir alone or in combination with 3TC or FTC and telbivudine, are not recommended for patients with HBV/HIV coinfection (CII).
  • Discontinuation of agents with anti-HBV activity may cause serious hepatocellular damage resulting from reactivation of HBV; patients should be advised against stopping these medications and be carefully monitored during interruptions in HBV treatment (AII).
  • If ART needs to be modified due to HIV virologic failure and the patient has adequate HBV suppression, the ARV drugs active against HBV should be continued for HBV treatment in combination with other suitable ARV agents to achieve HIV suppression (AIII).
  • HBV reactivation has been observed in persons with HBV infection during interferon-free HCV treatment. For that reason, all patients initiating HCV therapy should be tested for HBV. Persons with HCV/HIV coinfection and active HBV infection (determined by a positive HBsAg test) should receive ART that includes two agents with anti-HBV activity prior to initiating HCV therapy (AIII).
Rating of Recommendations:  A = Strong; B = Moderate; C = Optional
Rating of Evidence:  I = Data from randomized controlled trials; II = Data from well-designed nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion