TREATMENT OF HIV AND HBV/HCV COINFECTED PATIENTS
HBV co-infection
All HIV infected patients should be screened for HBsAg and if possible anti-HBc antibodies
at baseline. History of Hepatitis B vaccination should also be elicited. HBV co-infected patient should have additional baseline workup, which
includes LFTs, PT, HBeAg and HBV-DNA (results should be expressed in international units/ml). Consider liver biopsy (if no contra-indications)
to measure stage of fibrosis and of necroinflammatory activity and to exclude other causes of chronic liver disease. Exclude co-infection
with Hepatitis C. Patients should be advised abstinence from alcohol.
Anti-HBV therapy in HIV/HBV co-infected patient
The ideal goal of treatment for HBV is to achieve HBsAg clearance with anti-HBs seroconversion. However, this can rarely be achieved in clinical practice.
A more realistic goal is to maximally suppress HBV DNA thus delaying progression of liver
disease.The optimal time for initiating anti-HBV therapy in co-infected patients has not been established but HBV-specific treatment should be
considered for all patients who are HBeAg positive, or are HBeAg negative but with an abnormal LFT (ALT > 1.5xupper limit of normal) and high HBV-DNA levels
(HBV DNA>20,000 IU/ml for HBeAg positive and >2000 IU/ml for HBeAg negative patients).80 A histological evidence of active and/or advanced
disease(Metavir>A2 and/or >F2) in patients with high HBV DNA levels is a strong
indication for treatment.80.Interferon alpha is the preferred option for HBeAg +ve patients and adefovir in HBeAg βve patients with an HBV-DNA >104copies/ml
in patients who donβt qualify for HIV treatment (herethe indication to initiate ART is a CD4<500/mm3).81,82
Early results suggest that adefovir does not select for resistance to HIV and therefore compromise future use
of tenofovir.83,84 PEG-INF 2a(180Β΅g once weekly) for treatment of HBV should be given for 48weeks, independently of HBeAg/anti HBe status. When using standard
INF, HBeAg-positive patients should be treated with 5-6 MU/day or 10MU three times weekly for 4-6 months. HBeAg-negative patient should receive 3-6 MU three
times weekly for atleast 12 months.80
When ART is indicated for HIV-HBV co-infected patients include lamivudine and/or tenofovir (agents also active
against HBV) as a part of ART. Withdrawal of lamivudine may result in an acute exacerbation of hepatitis that may be sufficient to precipitate liver
decompensation.22,85 Table 10 summarizes recommendations for management of HIV-HBV co-infection.