Prevention of hepatitis B virus infection in the HIV-infected adult
- 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
It is important to prevent hepatitis B virus (HBV) infection in HIV-infected individuals. HIV-infected patients are at high risk for acquiring HBV due to shared routes of transmission (eg, sexual transmission, injection drug use) . In addition, if acquired, HIV-infected individuals are less likely to develop a protective immune response with production of hepatitis B surface antibody during acute infection. Thus, such patients are at increased risk of developing chronic infection, cirrhosis, and end-stage liver disease compared with HIV-uninfected patients [2-4].
This topic will address how to prevent HBV in HIV-infected individuals. The epidemiology, clinical manifestations, evaluation, and treatment of HBV in HIV-infected patients are discussed elsewhere. (See "Treatment of chronic hepatitis B in the HIV-infected patient" and "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 "Monitoring the HIV-infected patient with chronic hepatitis B virus infection".)
HIV-infected patients should be vaccinated against HBV if they do not have evidence of protective immunity. Individuals are most likely to develop a protective serologic response if their CD4 count is >350 cells/microL and their HIV viral load is undetectable [5-8]. (See 'Whom to vaccinate' below and 'Dose and schedule of vaccination' below and 'Response to vaccination' below.)
Serologic testing should be performed one month after vaccination to confirm that the patient is immune. Repeat vaccination may be needed for some individuals. (See 'Assessing vaccine response' below and 'Anti-HBs ≤10 milli-international units/mL after initial series' below.)
Although vaccination is the best way to prevent HBV infection, additional prevention interventions may be needed, especially during the course of vaccination and for those who do not respond to the vaccine. These include behavioral interventions to decrease high-risk behaviors and possibly hepatitis B immune globulin if an exposure occurs. Antiretroviral agents used to treat HIV (eg, tenofovir, lamivudine, emtricitabine) may also provide protection against HBV infection. (See 'Avoiding HBV exposure' below and 'Post-exposure prophylaxis' below and 'The role of antiretroviral therapy' below.)
- Kellerman SE, Hanson DL, McNaghten AD, Fleming PL. Prevalence of chronic hepatitis B and incidence of acute hepatitis B infection in human immunodeficiency virus-infected subjects. J Infect Dis 2003; 188:571.
- Hadler SC, Judson FN, O'Malley PM, et al. Outcome of hepatitis B virus infection in homosexual men and its relation to prior human immunodeficiency virus infection. J Infect Dis 1991; 163:454.
- Walter SR, Thein HH, Amin J, et al. Trends in mortality after diagnosis of hepatitis B or C infection: 1992-2006. J Hepatol 2011; 54:879.
- Thio CL, Seaberg EC, Skolasky R Jr, et al. HIV-1, hepatitis B virus, and risk of liver-related mortality in the Multicenter Cohort Study (MACS). Lancet 2002; 360:1921.
- Chang JJ, Wightman F, Bartholomeusz A, et al. Reduced hepatitis B virus (HBV)-specific CD4+ T-cell responses in human immunodeficiency virus type 1-HBV-coinfected individuals receiving HBV-active antiretroviral therapy. J Virol 2005; 79:3038.
- Launay O, van der Vliet D, Rosenberg AR, et al. Safety and immunogenicity of 4 intramuscular double doses and 4 intradermal low doses vs standard hepatitis B vaccine regimen in adults with HIV-1: a randomized controlled trial. JAMA 2011; 305:1432.
- Okwen MP, Reid S, Njei B, Mbuagbaw L. Hepatitis B vaccination for reducing morbidity and mortality in persons with HIV infection. Cochrane Database Syst Rev 2014; :CD009886.
- González R, Castro P, García F, et al. Effects of highly active antiretroviral therapy on vaccine-induced humoral immunity in HIV-infected adults. HIV Med 2010; 11:535.
- Brook G. Prevention of viral hepatitis in HIV co-infection. J Hepatol 2006; 44:S104.
- Rockstroh JK, Bhagani S, Benhamou Y, et al. European AIDS Clinical Society (EACS) guidelines for the clinical management and treatment of chronic hepatitis B and C coinfection in HIV-infected adults. HIV Med 2008; 9:82.
- Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. http://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf (Accessed on September 06, 2016).
- Rabeneck L, Risser JM, Murray NG, et al. Failure of providers to vaccinate HIV-infected men against hepatitis B: a missed opportunity. Am J Gastroenterol 1993; 88:2015.
- Fonseca MO, Pang LW, de Paula Cavalheiro N, et al. Randomized trial of recombinant hepatitis B vaccine in HIV-infected adult patients comparing a standard dose to a double dose. Vaccine 2005; 23:2902.
- Ni JD, Xiong YZ, Wang XJ, Xiu LC. Does increased hepatitis B vaccination dose lead to a better immune response in HIV-infected patients than standard dose vaccination: a meta-analysis? Int J STD AIDS 2013; 24:117.
- Mitwalli A. Responsiveness to hepatitis B vaccine in immunocompromised patients by doubling the dose scheduling. Nephron 1996; 73:417.
- de Graeff PA, Dankert J, de Zeeuw D, et al. Immune response to two different hepatitis B vaccines in haemodialysis patients: a 2-year follow-up. Nephron 1985; 40:155.
- Chaiklang K, Wipasa J, Chaiwarith R, et al. Comparison of immunogenicity and safety of four doses and four double doses vs. standard doses of hepatitis B vaccination in HIV-infected adults: a randomized, controlled trial. PLoS One 2013; 8:e80409.
- Tedaldi EM, Baker RK, Moorman AC, et al. Hepatitis A and B vaccination practices for ambulatory patients infected with HIV. Clin Infect Dis 2004; 38:1478.
- de Vries-Sluijs TE, Hansen BE, van Doornum GJ, et al. A randomized controlled study of accelerated versus standard hepatitis B vaccination in HIV-positive patients. J Infect Dis 2011; 203:984.
- Gandhi RT, Wurcel A, Lee H, et al. Response to hepatitis B vaccine in HIV-1-positive subjects who test positive for isolated antibody to hepatitis B core antigen: implications for hepatitis B vaccine strategies. J Infect Dis 2005; 191:1435.
- McIntyre A, Nimmo GR, Wood GM, et al. Isolated hepatitis B core antibody--can response to hepatitis B vaccine help elucidate the cause? Aust N Z J Med 1992; 22:19.
- Mast EE, Weinbaum CM, Fiore AE, et al. A comprehensive immunization strategy to eliminate transmission of hepatitis B virus infection in the United States: recommendations of the Advisory Committee on Immunization Practices (ACIP) Part II: immunization of adults. MMWR Recomm Rep 2006; 55:1.
- Tasker SA, Wallace MR. Vaccination in HIV-infected Patients. Curr Infect Dis Rep 2000; 2:245.
- Landrum ML, Hullsiek KH, Ganesan A, et al. Hepatitis B vaccination and risk of hepatitis B infection in HIV-infected individuals. AIDS 2010; 24:545.
- Overton ET, Sungkanuparph S, Powderly WG, et al. Undetectable plasma HIV RNA load predicts success after hepatitis B vaccination in HIV-infected persons. Clin Infect Dis 2005; 41:1045.
- Rey D, Krantz V, Partisani M, et al. Increasing the number of hepatitis B vaccine injections augments anti-HBs response rate in HIV-infected patients. Effects on HIV-1 viral load. Vaccine 2000; 18:1161.
- Shire NJ, Sherman KE. Management of hepatitis B virus in HIV-positive patients. Minerva Gastroenterol Dietol 2006; 52:67.
- Laurence JC. Hepatitis A and B immunizations of individuals infected with human immunodeficiency virus. Am J Med 2005; 118 Suppl 10A:75S.
- Irungu E, Mugo N, Ngure K, et al. Immune response to hepatitis B virus vaccination among HIV-1 infected and uninfected adults in Kenya. J Infect Dis 2013; 207:402.
- Chakvetadze C, Bani-Sadr F, Le Pendeven C, et al. Serologic response to hepatitis B vaccination in HIV-Infected patients with isolated positivity for antibodies to hepatitis B core antigen. Clin Infect Dis 2010; 50:1184.
- Centers for Disease Control. Hepatitis B FAQs for Health Professionals. http://www.cdc.gov/hepatitis/hbv/hbvfaq.htm#vaccFAQ (Accessed on July 08, 2015).
- Cooper CL, Davis HL, Angel JB, et al. CPG 7909 adjuvant improves hepatitis B virus vaccine seroprotection in antiretroviral-treated HIV-infected adults. AIDS 2005; 19:1473.
- Cooper CL, Angel JB, Seguin I, et al. CPG 7909 adjuvant plus hepatitis B virus vaccination in HIV-infected adults achieves long-term seroprotection for up to 5 years. Clin Infect Dis 2008; 46:1310.
- de Vries-Sluijs TE, Hansen BE, van Doornum GJ, et al. A prospective open study of the efficacy of high-dose recombinant hepatitis B rechallenge vaccination in HIV-infected patients. J Infect Dis 2008; 197:292.
- Bloom A, Jackson K, Kiviat A, et al. Repeat hepatitis B vaccination may lead to seroprotection in HIV-infected patients who do not respond to an initial series. J Acquir Immune Defic Syndr 2009; 50:110.
- Shafran SD, Mashinter LD, Lindemulder A, et al. Poor efficacy of intradermal administration of recombinant hepatitis B virus immunization in HIV-infected individuals who fail to respond to intramuscular administration of hepatitis B virus vaccine. HIV Med 2007; 8:295.
- Lopes VB, Hassing RJ, de Vries-Sluijs TE, et al. Long-term response rates of successful hepatitis B vaccination in HIV-infected patients. Vaccine 2013; 31:1040.
- Heuft MM, Houba SM, van den Berk GE, et al. Protective effect of hepatitis B virus-active antiretroviral therapy against primary hepatitis B virus infection. AIDS 2014; 28:999.
- Shilaih M, Marzel A, Scherrer AU, et al. Dually Active HIV/HBV Antiretrovirals as Protection Against Incident Hepatitis B Infections: Potential for Prophylaxis. J Infect Dis 2016; 214:599.
- SEROLOGIC SCREENING
- Whom to vaccinate
- Vaccine formulations
- Dose and schedule of vaccination
- - Initial series
- - Accelerated dosing schedule
- - Missed doses
- Patients with isolated anti-HB core antibody
- Safety and adverse events
- Response to vaccination
- - Assessing vaccine response
- - Likelihood of response
- Management based upon vaccine response
- - Anti-HBs >10 milli-international units/mL
- - Anti-HBs ≤10 milli-international units/mL after initial series
- - Anti-HBs ≤10 milli-international units/mL after repeat vaccination
- - Waning immunity
- AVOIDING HBV EXPOSURE
- POST-EXPOSURE PROPHYLAXIS
- THE ROLE OF ANTIRETROVIRAL THERAPY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS