Brief Report: Hepatitis B Infection or Reactivation After Switch to 2-Drug Antiretroviral Therapy: A Case Series, Literature Review, and Management Discussion

Abstract

Background: Two-drug antiretroviral therapy (ART) without hepatitis B virus (HBV) activity is prescribed for persons with HIV as simplified or salvage therapy. Although two-drug regimens are not recommended for persons with chronic HBV infection, guidelines do not address their use in those with HBV susceptibility and/or core antibody reactivity. We present a case series of individuals with HBV infection or reactivation following switch to two-drug, non-HBV-active ART. Setting: HIV primary care clinics of an academic medical center in New York, NY. Methods: Case surveillance was conducted to identify persons with HBV surface antigenemia and viremia following two-drug ART switch. Clinical characteristics and outcomes were ascertained through chart review. Results: Four individuals with HBV infection or reactivation after ART switch were identified. Two had HBV susceptibility, 1 had core antibody reactivity, and 1 had surface antigen reactivity preswitch. All eligible persons had received HBV vaccination: 2 with low-level antibody response and 1 with persistent nonresponse. Two presented with fulminant hepatitis, with 1 required liver transplantation. Conclusion: Two-drug ART switch may pose risk of HBV infection or reactivation. We propose careful patient selection and monitoring through the following: (1) assessment of HBV serologies before switch and periodically thereafter, (2) vaccination and confirmation of immunity before switch, (3) risk stratification and counseling about HBV reactivation for those with core antibody, (4) preemptive HBV DNA monitoring for those at the risk of reactivation, (5) continuation of HBV-active prophylaxis when above measures are not feasible, and (6) continuation of HBV-active therapy and surveillance for chronic HBV infection.

Hepatitis B Virus in People who Inject Drugs and Men who Have Sex With Men With HIV in India: A Cross-sectional Study

“…Unfortunately, we did not quantify HBV DNA in this study. Recently, there have been reports of PWH developing CHB following a change in ART to regimens that are not active against HBV, such as injectable cabotegravir and rilpivirine [ 7 , 8 , 25 ]. Because of this concern, PWH with anti-HBc are generally excluded from clinical trials of cabotegravir and rilpivirine, which restricts this potentially important therapeutic option from the many PWH in regions of the world where they might particularly benefit.…”

“…These individuals remain at risk for reactivation of HBV resulting in CHB, which is more likely to occur with immunosuppression from HIV. Further, PWH who have isolated core antibody reactivity are at risk for reactivation of HBV with nucelos(t)ide-sparing antiretroviral treatment (ART) regimens, limiting their ability to benefit from novel and emerging long-acting ART regimens [ 7–9 ]. Thus, accurate prevalence data of CHB and isolated core antibody reactivity in PWH are essential to the World Health Organization (WHO) goal of HBV elimination, especially in countries like India with a large burden of HIV and global HBV-related mortality.…”

Hepatitis B Virus Reactivation After Switch to Cabotegravir/Rilpivirine in Patient with Low Hepatitis B Surface Antibody

“…HBV reactivation has been reported in patients with low CD4 counts ( 12 , 13 ). Cases have also been reported of HBV DNA detection at very low levels with negative HBsAg after switching to ART regimens without anti-HBV drugs ( 14 ).…”

Chronic Hepatitis B Finite Treatment: Similar and Different Concerns With New Drug Classes

“…Human immunodeficiency virus (HIV)/HBV coinfection presents an unique issue in the assessment of finite therapy and functional cure as anti-HBV–containing antiretroviral therapy should not be stopped [ 2 ]. This is because of the risk of reactivation of CHB via covalently closed circular DNA (cccDNA), as noted with anti-CD20 therapy or after switching to non–HBV-containing antiretroviral therapy [ 2 , 30 ]. However, individuals with HIV/HBV coinfection should be included in studies of new HBV therapies to assess HBsAg loss.…”