Monitoring the HIV-infected patient with chronic hepatitis B virus infection
- Kenneth E Sherman, MD, PhD
Kenneth E Sherman, MD, PhD
- Professor of Medicine
- University of Cincinnati College of Medicine
The era of potent antiretroviral therapy (ART) has led to declining rates of opportunistic infections and a new focus on other leading causes of morbidity, such as end-stage liver disease (ESLD) secondary to chronic hepatitis B virus (HBV) infection . The treatment and prevention of hepatitis B has taken on great significance in light of the negative impact HIV has on the natural history of chronic hepatitis B infection. ART is indicated in all patients with HBV coinfection; two of the three HIV agents (tenofovir, emtricitabine, and lamivudine) should have dual activity against HIV and HBV .
However, treatment of HBV in the HIV-infected patient can be complicated by drug-induced hepatotoxicity, immune constitution syndromes, and toxicity related to medications. Furthermore, regardless of whether the patient is treated or not, surveillance for development of hepatocellular carcinoma is required.
Monitoring of the patient with HIV/HBV coinfection, regardless of whether the patient is taking antiviral therapy, will be discussed here. The epidemiology, clinical manifestations, diagnosis, management and prevention of HBV infection are discussed separately. (See "Epidemiology, clinical manifestations, and diagnosis of hepatitis B in the HIV-infected patient" and "Pretreatment evaluation of chronic hepatitis B virus infection in the HIV-infected patient" and "Treatment of chronic hepatitis B in the HIV-infected patient" and "Prevention of hepatitis B virus infection in the HIV-infected adult".)
PATIENT MONITORING DURING HBV THERAPY
HBV DNA and aminotransferase monitoring — Laboratory monitoring during hepatitis B virus (HBV) therapy includes serial aminotransferases and assessment of viral suppression. Some experts recommend monitoring HBV DNA and aminotransferases every three months .
Frequent monitoring of HBV DNA (ie, every three months) facilitates early detection of the emergence of drug resistance, which can lead to hepatic flares. In patients on stable regimens and high predicted levels of adherence, monitoring at six-month intervals may be sufficient. (See 'HBV drug resistance testing' below.)
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- PATIENT MONITORING DURING HBV THERAPY
- HBV DNA and aminotransferase monitoring
- Importance of HBeAg status
- Importance of HBV DNA suppression
- Importance of loss of hepatitis B surface antigen
- SCREENING FOR HEPATOCELLULAR CARCINOMA
- MONITORING IN HIV-INFECTED PATIENTS WITH HBV AND HCV
- ABNORMALITIES OF AMINOTRANSFERASES
- Chronic hepatitis B virus infection
- Immune reconstitution inflammatory syndrome
- Drug induced liver injury
- Emergence of HBV drug resistance
- HBV DRUG RESISTANCE TESTING
- MONITORING FOR DRUG SIDE EFFECTS
- DURATION OF HBV THERAPY
- Patients on antiretroviral therapy
- Patients who are not on antiretroviral therapy
- SUMMARY AND RECOMMENDATIONS