Pretreatment evaluation of chronic hepatitis B virus infection in the HIV-infected patient
- Kenneth E Sherman, MD, PhD
Kenneth E Sherman, MD, PhD
- Professor of Medicine
- University of Cincinnati College of Medicine
- Chloe L Thio, MD
Chloe L Thio, MD
- Professor of Medicine
- Johns Hopkins University
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 secondary to chronic hepatitis B virus (HBV) infection .
HIV treatment guidelines generally recommend treatment for HBV among all HIV-infected patients, regardless of the CD4 cell count [2-5]. Among HIV/HBV coinfected patients, ART should include agents with dual activity against HIV and HBV.
The pretreatment evaluation of HBV in the HIV-infected patient will be reviewed here. The epidemiology, clinical manifestations, diagnosis, treatment, and prevention of HBV infection among HIV-infected patients are discussed separately. (See "Epidemiology, clinical manifestations, and diagnosis of hepatitis B 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".)
APPROACH TO EVALUATION
Most HIV-infected patients with chronic HBV will be treated for their HIV and HBV, regardless of the stage of liver disease or their level of immunosuppression (ie, CD4 cell count). (See "Treatment of chronic hepatitis B in the HIV-infected patient", section on 'Deciding whom to treat'.)
The pretreatment evaluation of such patients includes obtaining baseline markers of disease activity (used to monitor the response to therapy), information to determine which antiviral agents to use for HBV treatment, and information to assess for other causes of liver injury and complications of advanced liver disease (eg, varices, hepatocellular carcinoma).
- Weber R, Sabin CA, Friis-Møller N, et al. Liver-related deaths in persons infected with the human immunodeficiency virus: the D:A:D study. Arch Intern Med 2006; 166:1632.
- Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. Department of Health and Human Services. Available at http://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf (Accessed on May 01, 2014).
- Günthard HF, Aberg JA, Eron JJ, et al. Antiretroviral treatment of adult HIV infection: 2014 recommendations of the International Antiviral Society-USA Panel. JAMA 2014; 312:410.
- European guidelines for treatment of HIV-infected adults. http://www.eacsociety.org/guidelines/eacs-guidelines/eacs-guidelines.html (Accessed on January 14, 2015).
- World Health Organization. Guidelines for the prevention, care and treatment of persons living with chronic hepatitis B http://apps.who.int/iris/bitstream/10665/154590/1/9789241549059_eng.pdf?ua=1 (Accessed on March 23, 2015).
- Stewart B, Jobarteh ML, Sarge-Njie R, et al. Emergence of HBV resistance to lamivudine (3TC) in HIV/HBV co-infected patients in The Gambia, West Africa. BMC Res Notes 2011; 4:561.
- Chon YE, Choi EH, Song KJ, et al. Performance of transient elastography for the staging of liver fibrosis in patients with chronic hepatitis B: a meta-analysis. PLoS One 2012; 7:e44930.
- Nakchbandi IA. Osteoporosis and fractures in liver disease: relevance, pathogenesis and therapeutic implications. World J Gastroenterol 2014; 20:9427.
- APPROACH TO EVALUATION
- BASELINE MARKERS OF DISEASE ACTIVITY
- Aminotransferase levels
- HBV DNA
- Hepatitis B e antigen (HBeAg) and hepatitis B e antibody (anti-HBe)
- INFORMATION NEEDED FOR DRUG SELECTION
- Kidney function
- Treatment history
- HBV resistance testing in some patients
- Hepatitis D antibody
- EVALUATION FOR OTHER CAUSES OF LIVER DISEASE
- Hepatitis C
- Hepatic steatosis
- Hepatotoxic medications
- SCREENING AND PREVENTION
- Stage of liver disease
- Hepatocellular carcinoma screening
- Hepatitis A screening
- Bone density screening
- SUMMARY AND RECOMMENDATIONS