HIV and hepatitis co-infection

BHIVA has specific guidelines for treating hepatitis B and C infection on their website. The main points made about HIV/hepatitis co-infection are that its presence:

• Increases the rate of progression to cirrhosis and liver cancer four- to fivefold over those with hepatitis alone.

• The risk of hepatotoxicity from ART is increased two- to threefold in the presence of chronic HBV or HBC, but that risk disappears when the hepatitis is successfully treated.

• Untreated co-infection carries a mortality rate ten times higher than those who have either infection alone.

• Appropriate ARV therapy seems to reduce the rate of progression to wards cirrhosis and/or death.

• When possible, avoid using nevirapine in those with active liver disease.

• With proper treatment, there is a possibility of curing HCV and suppressing HBV viral replication.

• When HAART is begun or changed, patients need to be carefully monitored for hepatotoxicity.

Antiretroviral therapy can reduce liver-related mortality when started at a CD4 count >200 cells/mm³ and initiating ART at 350 cells/mm³ is recommended. In specific situations (outlined in the BHIVA guidelines) ART may be started earlier.

Hepatitis B virus (HBV) treatment may be started with either specific HBV drugs (adefovir, pegylated interferon, telbivudine) or with ART-containing HBV-active drugs (lamivudine, emtricitabine, and tenofovir). Entecavir can only be used with ART because of its resistance pattern. All patients on triple ART who also have replicating HBV should be given tenofovir alone or tenofovir with lamivudine (3TC) or tenofovir with emtricitabine (FTC). If anti-HBV activity is ongoing when HIV resistance occurs, tenofovir and 3TC or FTC  would continue, but up to three other ARV drugs would need to be added.

ART should begin when CD4 cells are <350 cells/mm³ and be considered for anyone between 350 and 500 cells/mm³. Hepatitis C virus (HCV) can be treated with pegylated interferon and weight-based ribavirin. If patients with >350 cells/mm³ are not already on HCV therapy, it may be best to defer ART until any intended HCV therapy has been completed.

At this time, the guidelines recommend against using zidovudine, didanosine, stavudine, and abacavir with ribavirin or if HCV therapy is under consideration. To date, there have not been any identified raltegravir-related toxicities; however, some lipid increases have been seen with efavirenz use.