This document discusses HIV/HBV and HIV/HCV co-infections, providing perspectives from Thailand on optimal management. It outlines the natural history of HBV infection and conflicting results on whether telbivudine has activity against HIV. Guidelines are presented on determining active liver disease, treating HBV infection based on ART status, causes of transaminitis in coinfected patients, treating HCV infection, and contraindications for interferon and ribavirin use. Terminology for treatment response such as rapid virological response and sustained virological response is also defined.

1. HIV/HBV and HIV/HCV
Co-infections
Thailand Perspectives and
Optimal Management
Boonchai Kowadisaiburana
Bamrasnaradura Institute
25 August 2010

6. Natural history of HBV infection

9. Vincent Soriano, HIV and Viral Hepatitis Coinfection
2007

11. Conflicting results about
telbivudine
E Low, A Cox, M Atkins, and M Nelson. Telbivudine
Has Activity against HIV. 16th Conference on
Retroviruses and Opportunistic Infections (CROI 2009).
Montreal, Canada. February 8-11, 2009. Abstract 813a.
C Avila, S Karwowska, C Lai, and T Evans. Telbivudine
Has No in vitro Activity against Laboratory and Clinical
HIV-1, including 5 Clades and Drug-resistant Clinical
Isolates. 16th Conference on Retroviruses and
Opportunistic Infections (CROI 2009). Montreal, Canada.
February 8-11, 2009. Abstract 813b

12. Hepatology
2007;45(4)

13. Vincent Soriano, HIV and Viral Hepatitis Coinfection 2007

14. Frequency of 3TC resistance in a cohort of
HIV/HBV coinfectd patients

15. Vincent Soriano, HIV and Viral Hepatitis Coinfection 2007

17. How to know “active liver disease”
Transaminitis, ALT >/= 1.5 ULN
Liver biopsy
- invasive test, death = 1/10,000-1/12,000
- sample represents 1:50,000 of liver
- 10-20% observer variation
Noninvasive technique
- hepatic elastography ( FibroScan )
- serum fibromarkers

23. When to stop treatment
HBeAg-positive CHB
- HBeAg seroconversion and
- HBV-DNA < 400 copies/ml x 2 (0, 6 m)
and
- continue treatment more 6-12 m
HBeAg-negative CHB
- HBsAg clearance or
- undetectable HBV-DNA x 3 (0, 6, 12 m)

25. How to treat HBV infection (1)
ARV- naïve, HAART- not indicated, HBV- active
- avoid 3TC monotherapy
- use interferon or ADV?
- full HAART regimen (including TDF+3TC/FTC)
ARV- naïve, HAART- indicated, HBV- inactive
- TDF+3TC/FTC are NRTI backbone
- avoid TDF, 3TC, FTC monotherapy for HBV
infection

26. How to treat HBV infection (2)
ARV- naïve, HAART- indicated, HBV- active
- full HAART regimen (including TDF+3TC/FTC)
ARV- naïve, HAART- indicated, HBV-
active/cirrhosis
- use TDF+3TC/FTC first to reduce HBV-DNA ?
- if high HBV-DNA and low CD4 risk of severe
hepatitis related to IRS after HAART initiation

27. www.liversocietythailand.org

28. AIDS 2006,
20:1951-4

29. Causes of transminitis in
HIV/HBV coinfected patients
Discontinuation of anti-HBV drugs
Development of resistance to anti-HBV drugs
HBeAg or HBsAg seroconversion
HBV reactivation
Immune reconstitution syndrome
Delta superinfection
Hepatotoxicity from ARV

31. Clin Infect Dis 2004;38:128-
33

32. Vincent Soriano, HIV and Viral Hepatitis Coinfection 2007
AIDS 2007;21:1073-
89

38. How to treat HCV infection
Combination of PEG-IFN and RBV is the
treatment of choice
Anti-HCV treatment should be started before
CD4 < 350 and before ART is started
Aim of treatment is SVR
Any ART should be stabilized before anti-
HCV therapy is commenced
Duration of treatment for all genotypes
should be 48 weeks

39. Terminology for treatment
response
Rapid virological response ( RVR )
- HCV-RNA PCR at week 4
Early virological response ( EVR )
- HCV-RNA at week 12
- if PCR negative = complete EVR
- if HCV-RNA decrease > 2 log = partial EVR
End of treatment response ( ETR )
- HCV-RNA PCR at the end of treatment
Sustained virological response ( SVR )
- HCV-RNA PCR at week 24 after treatment

40. AIDS 2007;21:1073-89

41. Contraindication for use of PEG-
interferon and ribavirin
Absolute Relative contraindication
contraindication History of depression
Psychosis, severe Uncontrolled DM, HT
depression Retinopathy
Uncontrolled seizures Active autoimmune disease
Liver decompensation Symptomatic heart disease
Pregnancy Anemia
Renal failure Ischemic vascular disease
Severe heart disease

42. BHIVA guidelines 2010

47. http://www.who.int/hiv/pub/guidelines/artadultguidelines.pdf