HIV-HBV co-infection screening and monitoring guidelines: ACTHIV 2023, Jessie Torgersen
Screening and managing HIV-hepatitis B virus (HBV) co-infection is important due to increased risks in patients, therefore it is important to ensure standard practices involve comprehensive assessment, including serological testing and liver function evaluation, and healthcare professionals follow guidelines for regular monitoring to assess disease progression and treatment response. In this interview, we speak with Dr Jessie Torgersen (University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA) to explore the importance of implementing these strategies for patients with HIV-HBV co-infection.
The presentation ‘Hepatitis B Treatment Among Persons with HIV‘ was presented at ACTHIV 2023, 4-6 May 2023, Phoenix, AZ, USA
Questions:
- What are the key implications of screening strategies and patient management among patients with HBV who are living with HIV? (0:21)
- When evaluating individuals with co-infection of HBV and HIV, what are the recommended best practices for conducting an assessment? (1:19)
- What are the current guidelines or recommendations for monitoring disease progression and treatment response in these individuals? (3:09)
Disclosures: Jessie Torgersen has nothing to disclose in relation to this video interview.
Support: Interview and filming supported by Touch Medical Media Ltd. Interview conducted by Katey Gabrysch.
Filmed in coverage of the American Conference for the Treatment of HIV™ (ACTHIV™)
My name is Jessie Torgersen. I’m an Infectious Disease Physician at the University of Pennsylvania, Perelman School of Medicine in Philadelphia, Pennsylvania, USA.
What are the key implications of screening strategies and patient management among patients with HBV who are living with HIV?
It is important to remember that every person living with HIV should also be screened for hepatitis B, and this is completed with a triple lab panel including both hepatitis B, surface antigen, core antibody, and surface antibody.
And this initial three panel of labs allows the provider to identify those who are in need of hepatitis B vaccination. So those are who are not immune. And then as well as those who may have chronic hepatitis B. Because among those with chronic hepatitis B and HIV, it is important to initiate an antiretroviral regimen that includes a hepatitis B active agents. And so this is generally limited to a tenofovir containing regimen, so either tenofovir disoproxil fumarate, tenofovir alafenamide, usually in combination with either emtricitabine or lamivudine.
When evaluating individuals with co-infection of HBV and HIV, what are the recommended best practices for conducting an assessment?
For the initial evaluation of someone coming in with hepatitis B and HIV, it is important to get a full initial panel to stage the hepatitis B infection. And so this can include hepatitis B DNA levels, hepatitis B, E antigen and E antibody, as well as a complete assessment for any liver inflammation, or hepatic synthetic dysfunction, which can generally be accomplished with a comprehensive metabolic panel, complete blood counts, and evaluation for coagulopathy with an INR or international normalized ratio.
Additionally, it’s important to evaluate for additional hepatitis viruses, specifically hepatitis D or delta co infection with hepatitis B. Hepatitis C, as well as hepatitis A. Now for hepatitis delta and hepatitis c, treatments strategies may differ ever so slightly. But for hepatitis a, it’s important since that is a vaccine preventable infection. You can definitely identify those who would benefit from hepatitis A vaccine.
For that initial evaluation is also important to assess any evidence of advanced hepatic fibrosis. And so a simple assay is using the Fibrosis-4 Index, a widely available can be calculated with liver aminotransferase levels, platelet levels and the patient’s age.
But if that’s additionally available, things like transient elastography are great to get a sense what degree of hepatic fibrosis there is, is ultimately you’ll really want to identify patients who have cirrhosis who are also living with hep b and and HIV co infection as those patients may need additional evaluation down the road.
What are the current guidelines or recommendations for monitoring disease progression and treatment response in these individuals?
For following up patients once they start on hep B, active antiretroviral regimen, it is important to monitor for response to that antiviral therapy specifically identifying an appropriate decline in hepatitis B viral load and ultimate suppression of hepatitis b viremia. It’s important to note that hep B viremia does not follow the same dynamics as HIV viremia where we can often see a complete suppression of HIV me within a month or so of initiating antiretroviral therapy, hepatitis b may take several months if not up to a year to really see a complete suppression.
And in our patients living with HIV and hep B co-infection, we can actually see that sometimes upwards of 50% will not be fully suppressed find that about 48 week mark or nearly a year. And while it’s not necessarily due to failure of therapy, there may be some additional components or characteristics either high viral load to start, lower CD four, that may impair that complete hepatitis B suppression within that time frame So it’s important to continue that therapy. And among those who may still have quite high hepatitis B viremia after a year of therapy, Some experts may consider adding on an additional agent, such as entecavir, depending on some of those additional factors specific to the patient, but that’s not across the board. So at least keeping with that tenofovir backbone therapy, lamivudine or emtricitabine as co formulated combination, and monitoring to evaluate for that suppression is key.
With regards to additional follow-up and generally labs at least every six months to assess for that control of hepatitis B of viremia, as well as any evidence of hepatitis or, liver hepatic inflammation with those a liver aminotransferases is as important. Patients may also need evaluation on somewhat of an annual basis for the surface antigen, E antigen, E antibody to see if you do find any seroconversion or functional cure with loss of surface antigen while rare and occurring, you know, single digit percentages anywhere one to to five percent, one to eight percent depending on which reference you review. Usual annual assessments of those the surface antigen, E antigen, E antibody are important to evaluate for that seroconversion.
