Hepatitis B Coinfection in Hiv-Positive Patients Starting Antiretroviral Therapy

Evidence is limited to support decisions on treatment and monitoring requirements in the management of hepatitis B virus (HBV) and HIV coinfected patients. The antiretroviral drugs lamivudine (3TC), emtricitabine (FTC) and tenofovir (TDF) are also active against HBV. To assess the evidence for using TDF with 3TC/FTC to suppress HBV viral replication in coinfected patients we performed a systematic review and meta-analysis of HBV viral suppression from published and unpublished reports. We then carried out a substudy of the DART trial (a randomised controlled trial of HIV treatment strategy in Africa) to examine HBV epidemiology, viral suppression and associations between HBV coinfection and liver status, immunosuppression (CD4 cell count) and death. The meta-analysis found: the proportion of coinfected patients with suppressed HBV replication after one year of TDF treatment was 57.4%, rising to 85.6% at three years; that prior or concomitant 3TC exposure had no effect; but that little data was available beyond three years follow-up. 55.2% of the DART population had evidence of HBV exposure and 9.3% had current infection (detectable HBsAg). HBeAg status and HBV viral load (HBV VL), but not exposure or current infection, were associated with immunosuppression. After 48 weeks, HBV suppression was achieved in 81 (56.6%) of 143 with detectable HBV DNA at baseline. Suppression was associated with baseline HBeAg status and HBV VL but not TDF/3TC versus 3TC alone. Suppression once achieved was durable regardless of which treatment was given. If not suppressed at 48 weeks, most treated with both 3TC and TDF suppressed by the end of follow-up, but not those treated with 3TC alone. Coinfection was associated with an increased risk of exacerbations of liver inflammation, HIV progression and death, but deaths were not usually liver-related. These studies have implications for the management of HBV coinfection in resourcepoor settings.