New Guidelines on Treating Chronic Hepatitis B and C in
New Guidelines on Treating Chronic Hepatitis B and C in
A final statement was released in March from the First European Consensus Conference on the Treatment of Chronic Hepatitis B and C (HBV and HCV) in HIV-Coinfected Patients. The statement complements previous guidelines for treating HBV (Hepatology 2004; 39:857) and HCV (Hepatology 2002; 36(5B):S3 and 2004; 39:1147) monoinfection and for treating opportunistic infections (including viral hepatitis) in HIV-infected patients (ACC Feb 1 2005). The statement has been endorsed by several organizations, including the International AIDS Society and the European Association for the Study of the Liver.
The new European consensus statement highlights the following issues:
This European consensus statement adds to a growing number of guidelines on the management of viral hepatitis in HIV-coinfected patients. This expanding literature reflects an increasing recognition of the importance of this problem, as well as rapid advances in options for managing viral hepatitis. These guidelines should help improve the clinical care of patients with HIV. All HIV-infected patients should be tested for viral hepatitis, and those with coinfection should undergo further evaluation and therapy if indicated. As global efforts to treat HIV expand, screening for viral hepatitis will be particularly important in previously underserved areas where we know less about the prevalence of coinfection.
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A final statement was released in March from the First European Consensus Conference on the Treatment of Chronic Hepatitis B and C (HBV and HCV) in HIV-Coinfected Patients. The statement complements previous guidelines for treating HBV (Hepatology 2004; 39:857) and HCV (Hepatology 2002; 36(5B):S3 and 2004; 39:1147) monoinfection and for treating opportunistic infections (including viral hepatitis) in HIV-infected patients (ACC Feb 1 2005). The statement has been endorsed by several organizations, including the International AIDS Society and the European Association for the Study of the Liver.
The new European consensus statement highlights the following issues:
Coinfection of HIV and viral hepatitis is common in Europe (as in the U.S.): 40% of HIV-infected patients are estimated to have chronic HCV and 8% to have chronic HBV. All HIV-infected subjects should be screened for HCV antibody and HBV markers.
Although sexual transmission of HCV is rare, the guidelines note recent reports of probable sexual transmission between men who have sex with men (12th Retrovirus Conference, Boston, Feb 2005, Abstracts 122 and 943). This is an important trend to monitor, given recent reports that the prevalence of unsafe sexual practices may be increasing.
Only a small proportion of HIV-infected subjects in Europe (as in the U.S.) receive treatment for viral hepatitis coinfection. The evaluation and treatment of coinfection are becoming more important as HIV-infected patients live longer.
The recommended treatment for HCV in HIV-coinfected subjects is pegylated interferon-α and ribavirin. According to the consensus statement, 48 weeks of therapy is recommended for all HCV genotypes. Close monitoring and management of adverse events are key components of successful treatment.
Controversy continues as to whether HIV-infected subjects with isolated anti-HBc should receive HBV vaccine. If isolated anti-HBc is a marker for resolved HBV infection in which anti-HBs levels have declined below detection, then immunization with one dose of HBV vaccine might elicit an immune response; however, results from a recent study suggest that such an anamnestic response occurs in only a minority of HIV-infected subjects with isolated anti-HBc (ACC May 11 2005).
Testing for HBV DNA in subjects with isolated anti-HBc may reveal the presence of occult HBV infection in some individuals. Although the clinical relevance of occult infection is unclear, HBV may reactivate in the setting of progressive immunodeficiency or initiation of cancer chemotherapy.
The optimal outcome of treatment for HBV is clearance of HBsAg with durable anti-HBe seroconversion. However, this occurs in the minority of subjects with HBV infection.
For HIV/HBV-coinfected patients who do not need antiretroviral therapy, treatment options for HBV include interferon-α or the nucleoside analogue entecavir (recently approved by the U.S. FDA). These drugs do not induce HIV-drug resistance.
For HIV/HBV-coinfected subjects who require antiretroviral therapy and have a high HBV-DNA level, the statement recommends using two drugs with dual anti-HIV/HBV activity — such as tenofovir with either 3TC or FTC — plus a third antiretroviral medication.
The consensus statement concludes with a list of important unanswered questions regarding the management of viral hepatitis in HIV-coinfected patients. Clearly, despite rapid progress in this area, many fundamental issues remain unresolved.
This European consensus statement adds to a growing number of guidelines on the management of viral hepatitis in HIV-coinfected patients. This expanding literature reflects an increasing recognition of the importance of this problem, as well as rapid advances in options for managing viral hepatitis. These guidelines should help improve the clinical care of patients with HIV. All HIV-infected patients should be tested for viral hepatitis, and those with coinfection should undergo further evaluation and therapy if indicated. As global efforts to treat HIV expand, screening for viral hepatitis will be particularly important in previously underserved areas where we know less about the prevalence of coinfection.
Click here for AIDS Clinical Care subscription information.
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