Immunological response to hepatitis B vaccination in patients with AIDS and virological response to highly active antiretroviral therapy

Insights into induction of the immune response by the hepatitis B vaccine

After more than four decades of hepatitis B virus (HBV) vaccine implementation, its safety and efficacy in preventing HBV infection have been proven and several milestones have been achieved. Most countries have included HBV immunization schedules in their health policies and progress has been made regarding universalization of the first HBV vaccine dose at birth. All of these actions have significantly contributed to reducing both the incidence of HBV infection and its related complications. However, there are still many drawbacks to overcome. The main concerns are the deficient coverage rate of the dose at birth and the large adult population that has not been reached timely by universal immunization. Additionally, the current most widely used second-generation vaccines do not induce protective immunity in 5% to 10% of the population, particularly in people over 40-years-old, obese (body mass index > 25 kg/m²), heavy smokers, and patients undergoing dialysis or infection with human immunodeficiency virus. Recently developed and approved novel vaccine formulations using more potent adjuvants or multiple antigens have shown better performance, particularly in difficult settings. These advances re-launch the expectations of achieving the World Health Organization’s objective of completing hepatitis control by 2030.

Immune Response to Hepatitis B Virus Vaccine Among People Living With HIV: A Meta-Analysis

Background

There is conflicting evidence about whether a double dose of the hepatitis B virus (HBV) vaccine induces better immunity than the standard-dose vaccine for people living with HIV (PLWH). This study provides a meta-analysis that summarizes the efficacy of HBV vaccine regimens among HIV-infected patients, clarifying the role of particular factors such as dose and frequency of vaccination in vaccine responsiveness and highlighting the need for evidence-based practice to assess HBV vaccination among PLWH.

Methods

Randomized clinical trials (RCTs) and prospective studies reporting vaccination response rates among PLWH were found through a search of PubMed, Cochrane, and the Web of Science. The key outcome was vaccine response. A random-effects model was used to estimate the pooled response rate. Subgroup analysis was conducted to evaluate key factors and explore sources of heterogeneity. Possible biases were assessed using quality and publication bias assessment.

Results

Eligible studies included controlled trials that examined the effects of 17 interventional studies with 1,821 participants. Among PLWH who received the HBV vaccine, the pooled response rate of HBV vaccination was 71.5% (95% CI 64.0%-77.9%, p < 0.001). Compared with the standard dose (65.5%, 95% CI 53.1%-76.1%), the double dose (75.2%, 95% CI 66.2%-82.5%) was associated with a better response rate [Q(1) = 19.617, p < 0.001]. When stratified by schedule, the four-dose schedule (89.7%, 95% CI 83.1%-93.9%) had a higher response rate than the three-dose schedule (63.3%, 95% CI 56.6%-69.4%) and the difference was significant [Q(1) = 88.305, p < 0.001]. PLWH with higher CD4⁺ T-cell counts (>500 cells/mm³) at the time of vaccination had better response rates [Q(1) = 88.305, p < 0.001].

Conclusions

In this meta-analysis, the double dose of the HBV vaccine and multiple injections were associated with better immune responses than the standard HBV vaccine regimen in PLWH. Higher seroconversion rates were observed in PLWH with high CD4⁺ T-cell levels, indicating that individuals infected with HIV should receive the HBV vaccine as soon as possible after diagnosis.

Systematic Review Registration

https://www.crd.york.ac.uk/PROSPERO/.

Undetectable Anti-HBs Antibodies: Need of a Booster Dose for HIV-1-Infected Individuals

HBV vaccination effectively prevents HBV transmission and the development of liver cancer. Disease progression and liver-related complications are more common in HIV-1/HBV co-infected than HBV mono-infected individuals. A considerable body of literature, which will be reviewed here, indicates that response to HBV vaccine is suboptimal in HIV-1-infected individuals and that the poor maintenance of protective immunity to HBV vaccines in these individuals is an important medical issue. Several factors affect HBV vaccine response during HIV-1 infection including CD4+ T cell counts, B cell response, vaccine formulation, schedules, and timing of antiretroviral therapy (ART). The initial response to HBV vaccination also plays a critical role in the sustainability of antibody responses in both HIV-1-infected and uninfected vaccinees. Thus, regular follow-up for antibody titer and a booster dose is warranted to prevent HBV transmission in HIV-1 infected people.

Brief Report: Heplisav-B Seroprotection in People With HIV: A Single-Center Experience

BACKGROUND

Heplisav-B, a hepatitis B virus (HBV) vaccine with an immunostimulatory adjuvant, was FDA approved in 2017 for adults ≥18 years. In randomized controlled trials, Heplisav-B demonstrated seroprotection rates (SPR) of 90%-95% versus 65%-80% for Engerix-B. No studies have included people with HIV (PWH), and the SPR and its predictors in this population are unknown.

SETTING

Quaternary care center HIV clinic.

METHODS

This retrospective cohort study evaluated PWH aged ≥18 years without current HBV seroprotection (anti-HBV surface antibody level [anti-HBs] <10 mIU/mL) who were administered Heplisav-B. Patients without post-immunization titers were excluded. The primary outcome was the SPR, the proportion of participants with HBV seroprotection at any point after the first vaccination.

RESULTS

Among 64 PWH included, median time to anti-HBs measurement after vaccination was 13 weeks. The median age was 58 years, 81% were men, and 95% had a viral load <200. The SPR was 81% in the entire cohort (and 86% in those without significant non-HIV immunosuppression), 79% in those with no prior HBV vaccination and no anti-HBc positivity, and 84% in those with prior vaccine nonresponse. Lower current and nadir CD4+ counts were associated with progressively lower seroprotection.

CONCLUSION

In the first single-center retrospective study of Heplisav-B in PWH, the SPR compared favorably with the SPR seen among PWH from prior HBV vaccines across key subgroups. Given these findings, Heplisav-B should be considered for expanded use for HBV vaccination in PWH. Further research on the effectiveness of a repeat vaccination series or higher dosing in nonresponders is needed.

The role of hepatitis B vaccine challenge dose in patients with underlying health conditions

We have evaluated the immunological response to Hepatitis B virus (HBV) booster vaccine dose in 129 adults with underlying diseases in comparison with 694 subjects at occupational risk of infection, who have previously completed the primary series and resulted with anti-HBs <10 mIU/mL. After booster dose, 60.5% of the patients with underlying diseases and 14.8% of the subjects at occupational risk resulted seronegative. By comparing two groups, rate of subjects with anamnestic response was higher in at occupational risk group respect to that at risk for medical conditions (OR: 5.99 [95%IC, 3.81-9.41], p < .001). This difference was associated to gender (males/females: OR: 0.619 [95%IC, 0.421-0.910], p = .015) and age (better response for younger people, p = .011).

Higher rate of long-term serologic response of four double doses vs. standard doses of hepatitis B vaccination in HIV-infected adults: 4-year follow-up of a randomised controlled trial

BACKGROUND

We previously reported that four doses or four double doses of hepatitis B vaccination regimens could not significantly increase a response rate compared with standard doses. However, the antibody levels were higher in the four doses and four double doses groups. This study followed those patients for at least 3 years and aimed to evaluate the immunogenicity of the three vaccination regimens.

METHODS

HIV-infected adults who had CD4+ cell counts > 200 cells/mm³, undetectable plasma HIV-1 RNA, and negative for all hepatitis B virus markers were randomly assigned to receive one of three recombinant vaccines (Hepavax-Gene^® Berna, Korea) regimens: 20 μg IM at months 0, 1, and 6 (standard doses group, n = 44), 20 μg IM at months 0, 1, 2, 6 (four doses group, n = 44), or 40 μg IM at months 0, 1, 2, and 6 (four double doses group, n = 44) between February 2011 and May 4, 2012. Of 132 participants, 126 were evaluated from August 2015 to January 2016; 42 in the standard doses, 43 in the four doses, and 41 in the four double doses groups.

RESULTS

At a median duration of 49.7 months (range 46.7-53.7) after completion of the primary vaccination schedule, the percentages of responders with anti-HBs ≥ 10 mIU/mL were 57.1% (95% CI 41.5-72.8%) in the standard doses group; 76.7% (95% CI 63.6-89.9%) in the four doses group (P = 0.067 vs. the standard doses group); and 80.5% (95% CI 67.8-93.2%) in the four double doses group (P = 0.033 vs. the standard doses group). Factors associated with a responder were the vaccination schedule (either four doses or four double doses groups) and a younger age.

CONCLUSIONS

Despite the highly effectiveness of the standard hepatitis B vaccination regimen at 6 months after completion, the long-term immunogenicity was lower than the four double doses regimen among HIV-infected adults with CD4+ cell counts > 200 cells/mm³ and undetectable plasma HIV-1 RNA. The standard vaccination regimen may not be the best strategy to provide long-term immune response against hepatitis B virus among HIV-infected individuals. Trial registration NCT1289106, NCT02713620.

Hepatitis B Virus Vaccination in HIV: Immunogenicity and Persistence of Seroprotection up to 7 Years Following a Primary Immunization Course

Vaccination against hepatitis B virus (HBV) is recommended in people living with HIV (PLHIV), although immune response rates are lower than in healthy individuals. We aimed at assessing response rates and predictors as well as persistence of seroprotection in a cohort of PLHIV with no serological evidence of current or previous HBV infection. PLHIV followed at our site were retrospectively included if they started a primary HBV vaccination course (20 mcg three-dose schedule, alone or combined with inactivated hepatitis A virus) between 2007 and 2012. Serological response was defined as hepatitis B surface antibodies (HBsAb) ≥10 IU/liter 4 to 24 weeks after the third vaccine dose. Among 134 patients included, 119 completed the primary HBV vaccination schedule. Of them, 68% developed serological response. HIV viral suppression was associated with HBsAb ≥10 IU/liter [_adjustedOR (odds ratio) 0.52, 95% confidence interval (CI) 0.33-0.82, p = .005], whereas CD4-T cell count was not (_adjustedOR 1.001, 95% CI 1.001-1.003, p = .1). HBsAb titer declined over time, since 69.3% and 26.9% of vaccinees had HBsAb ≥10 IU/liter 36 and 84 months after the third HBV vaccine dose. Time-updated CD4-T cell count was associated with persistence of seroprotection [_adjustedHR (hazard ratio) 1.17, 95% CI 1.06-1.30, p = .003], independently from quantitative HBV surface antigen titer achieved at the end of the primary vaccination schedule (HR 1.02, 95% CI 0.96-1.08, p = .64). The longer the time interval from vaccination, the higher the risk of loss of seroprotection. Repeating HBsAb titer 5 years after a successful HBV vaccination may be used to guide booster vaccination, as the majority of subjects may no longer have seroprotective HbsAb titers.

Assessment of the HBV vaccine response in a group of HIV-infected children in Morocco

BACKGROUND

Since its development in the early 1980s, Hepatitis B virus (HBV) vaccine has been proven to be highly protective. However, its immunogenicity may be ineffective among HIV-infected children. In Morocco, HBV vaccine was introduced in 1999, and since then all infants, including vertically HIV-infected infants, have been following the vaccination schedule, implemented by the Moroccan ministry of health. An assessment of the immunization of these children is important to optimize efforts aimed at tackling Hepatitis B coinfection, within the country.

METHODS

Forty-nine HIV-infected children (HIV group) and 112 HIV uninfected children (control group) were enrolled in this study. Samples were tested by Elisa (Monolisa Anti-HBs, Biorad) to quantify the anti-HBs antibodies. The % of lymphocyte subsets i.e. CD4+ T cells, CD8+ T cells, B cells, and NK, was determined by flow cytometry, using CellQuest Pro software (Becton-Dickinson), and for HIV group, HIV viral load was measured by real time PCR assay (Abbott). All variables were statistically compared in the two groups.

RESULTS

The median age was 51 ± 35 months for the HIV group and 50 ± 36 months (p > 0.05) for the control group. Female represented 63% and 41% (p = 0.01), among the HIV group and the control group, respectively. Among HIV-infected children, 71.4% (35/49) were under HAART therapy at the enrollment in the study. Seroprotection titer i.e. anti-HBs ≥10mUI/ml among control group was 76% (85/112), and only 29% (14/49) among the perinatally HIV-infected children (p < 0.0001). Lower % of CD4 + T cells was observed in HIV-infected children with a poor anti-HBs response.

CONCLUSION

In this studied group, we have shown that despite the vaccination of HIV-children with HBV vaccine, 71% did not show any seroprotective response. These findings support the need for monitoring HBV vaccine response among HIV-infected children in Morocco, in order to revaccinate non-immunized children.

Vaccinations for the HIV-Infected Adult: A Review of the Current Recommendations, Part I

Vaccination is a critical component for ensuring the health of those living with the human immunodeficiency virus (HIV) by protection against vaccine-preventable diseases. Since HIV-infected persons may have reduced immune responses and shorter durations of protection post-vaccination, HIV-specific guidelines have been published by global and national advisory organizations to address these potential concerns. This article provides a comprehensive review of the current guidelines and evidence-based data for vaccinating HIV-infected adults, including guidance on modified vaccine dosing and testing strategies, as well as safety considerations, to enhance protection among this vulnerable population. In the current article, part I of the two-part series, inactivated vaccines with broad indications as well as vaccines for specific risk and age groups will be discussed.

CD4/CD8 ratio as a predictor of the response to HBV vaccination in HIV-positive patients: A prospective cohort study

BACKGROUND

Hepatitis B virus (HBV) and human immunodeficiency virus (HIV) share transmission mechanisms and thus coinfection is frequent. Active immunization against HBV is essential in HIV patients. Reports using standard and reinforced HBV vaccination schedules vary widely in seroconversion rates depending on the characteristics of the included patients. Regional data concerning HBV vaccination in HIV patients are scarce. We aim to determine the serological response to HBV vaccination using standard schedule in HIV-positive patients and to evaluate characteristics that predict seroconversion.

MATERIALS AND METHODS

We performed a single centre prospective study of HBV vaccination with standard schedule in HIV-positive patients. Adults with negative markers of HBV infection were included between November 2012 and December 2014. Anti-HBs titres were measured 4-8 weeks after completion of vaccination schedule. Clinical, laboratory values and HIV characteristics were analyzed to determine their association with seroconversion and adherence to the HBV vaccination schedule.

RESULTS

The study included 245 HIV-positive patients, 68.9% were male and the mean age was 42.1 years. A total of 80.7% of the patients had undetectable HIV viral loads, 86.1% had CD4 counts >200, and 94.7% were on HAART. The response to vaccination was positive in 62% (95% CI, 56-68%) and mean anti-HBs titres of 646 IU/ml. 85.5% of the responders had anti-HBs titres >100 IU/ml. An age less than 45 years, no tobacco use and a CD4/CD8 ratio >0.4 were associated with seroconversion in multivariate analysis. The seroconversion rates were 86% in the subgroup of patients who met these criteria. A total of 97.9% of the study population completed the vaccination schedule.

CONCLUSION

The CD4/CD8 ratio was the primary factor associated with positive serological conversion in the multivariate analysis. The seroconversion rates were higher in a selected group of patients who were particularly suitable for the use of the standard HBV vaccination schedule.

Prevention of hepatitis B virus infection: from the past to the future

About 3-5 % of the world's population is chronically infected by hepatitis B virus (HBV) and is at risk of developing liver cirrhosis or hepatocellular carcinoma. The risk of dying prematurely because of chronic HBV infection is higher in younger people. The current strategies to prevent HBV infection involve immunization (active and/or passive) and antiviral chemoprophylaxis. The vaccines available for active immunization, containing hepatitis B surface antigen, are safe and confer long-term immunity in most healthy subjects. Since the vaccination is unsatisfactory in some patients, e.g., those with chronic kidney disease, human immunodeficiency virus infection, type I diabetes mellitus, and celiac disease, new strategies of vaccination are required. The neonatal, infant, and adolescent routine program vaccination in about 180 countries has greatly decreased the disease burden. Passive immunization with specific HBV immunoglobulins is recommended after single acute exposure, in infants born to infected mothers, and in HBV-infected patients undergoing liver transplantation combined with nucleoside/nucleotide analogues (chemoprophylaxis). Chemoprophylaxis is also indicated in HBV carrier candidates for immunosuppressive treatment and in patients with occult B infection undergoing immunosuppressive therapy or hematopoietic stem cell transplantation. Since HBV is not eradicable by an immune response or by antiviral drugs developed so far, the only preventive strategy remains global neonatal vaccination in all countries, firstly in HBV-endemic countries.

Vaccination coverage and immunity against hepatitis B among HIV-infected patients in South Brazil

Evidence-based strategies to improve the hepatitis B virus (HBV) vaccination coverage rates might help to reduce the burden caused by co-infection with HBV and human immunodeficiency virus (HIV). In this study, the aim was to evaluate the vaccination coverage and immunity against HBV among HIV-infected individuals in South Brazil, and identify factors that are associated with compliance patterns and antibody reactivity. Three hundred HIV-infected men and women were included in this survey. The patients answered a standardized questionnaire, and vaccination cards were checked in order to assess hepatitis B vaccine status. A blood sample was collected for quantitative determination of antibody to hepatitis B virus surface antigen (anti-HBs). Participants were also evaluated for their CD4 cell count and HIV viral load. The overall vaccination coverage of HBV vaccination found in this study (57.4%) was lower than that was previously reported in South Brazil. Anti-HBs levels >10 IU/L were observed in 47.0% of the studied population. A significant inequality in the coverage rates and antibody reactivity was found in favor of patients with better economic status. In conclusion, the results indicate the need for improvement in the HBV vaccination coverage among HIV carriers, in particular focusing on low-income individuals.

Potent antiviral therapy improves survival in acute on chronic liver failure due to hepatitis B virus reactivation

Acute on chronic liver failure (ACLF) is a disease entity with a high mortality rate. The acute event arises from drugs and toxins, viral infections, bacterial sepsis, interventions (both surgical and non-surgical) and vascular events on top of a known or occult chronic liver disease. ACLF secondary to reactivation of chronic hepatitis B virus is a distinct condition; the high mortality of which can be managed in the wake of new potent antiviral therapy. For example, lamivudine and entecavir use has shown definite short-term survival benefits, even though drug resistance is a concern in the former. The renoprotective effects of telbivudine have been shown in a few studies to be useful in the presence of renal dysfunction. Monotherapy with newer agents such as tenofovir and a combination of nucleos(t)ides is promising for improving survival in this special group of liver disease patients. This review describes the current status of potent antiviral therapy in patient with acute on chronic liver failure due to reactivation of chronic hepatitis B, thereby providing an algorithm in management of such patients.

Hepatitis B virus coinfection in human immunodeficiency virus-infected patients: A review

Hepatitis B virus (HBV) infection is a leading cause of chronic hepatitis, liver cirrhosis, and hepatocellular carcinoma worldwide. Due to the shared modes of transmission, coinfection with HBV and human immunodeficiency virus (HIV) is not uncommon. It is estimated that 10% of HIV-infected patients worldwide are coinfected with HBV. In areas where an HBV vaccination program is implemented, the HBV seroprevalence has declined significantly. In HIV/HBV-coinfected patients, HBV coinfection accelerates immunologic and clinical progression of HIV infection and increases the risk of hepatotoxicity when combination antiretroviral therapy (cART) is initiated, while HIV infection increases the risk of hepatitis events, cirrhosis, and end-stage liver disease related to chronic HBV infection. With the advances in antiviral therapy, concurrent, successful long-term suppression of HIV and HBV replication can be achieved in the cART era. To reduce the disease burden of HBV infection among HIV-infected patients, adoption of safe sex practices, avoidance of sharing needles and diluent, HBV vaccination and use of cART containing tenofovir disoproxil fumarate plus emtricitabine or lamivudine are the most effective approaches. However, due to HIV-related immunosuppression, using increased doses of HBV vaccine and novel approaches to HBV vaccination are needed to improve the immunogenicity of HBV vaccine among HIV-infected patients.

Hepatitis B vaccination for reducing morbidity and mortality in persons with HIV infection

BACKGROUND

Hepatitis B vaccine has been recommended for use in people living with HIV (PLHIV) mostly because of the similarities in routes of infection and their prevalence in the same geographic areas. PLHIV may not develop sero-protection after receiving standard hepatitis B vaccine due to their compromised immune status.

OBJECTIVES

To evaluate the efficacy of hepatitis B virus vaccine in PLHIV compared to placebo or no vaccine.

SEARCH METHODS

We searched 6 English language databases in July 2012, and updated the search in June 2013 and August 2014. We searched the grey literature, conference proceedings, specialised web sites, and contacted experts in the field.

SELECTION CRITERIA

Randomised controlled trials of hepatitis B vaccine compared to placebo or no vaccine, evaluating relevant outcomes of efficacy and safety.

DATA COLLECTION AND ANALYSIS

Two review authors independently sought and extracted data on study design, participants, hepatitis B infection, hepatitis B related morbidity and mortality, anti-HBs immunogenicity and adverse effects related to vaccines from published articles or through correspondence with authors. Data were analysed qualitatively.

MAIN RESULTS

One double-blind randomised controlled trial with 26 participants who were on antiretroviral therapy (ART), comparing hepatitis B vaccine to placebo conducted in Spain met our eligibility criteria and was included in this review. The study ran for three years and participants were followed up on a monthly basis. The study reported adequate humoral response to vaccine at 12 months and no local or systematic side effects in both intervention and control groups. This humoral response was lost when the participants stopped taking ART. The sample size of the study was small and the study was conducted in a high income setting unlike the areas of highest burden of hepatitis B and HIV co-infections.

AUTHORS' CONCLUSIONS

The evidence from this study is insufficient to support any recommendations regarding the use of hepatitis B vaccine in PLHIV. Neither does this evidence demonstrate that hepatitis B vaccine is unsafe in PLHIV. Further randomised controlled trials in high prevalence areas are required to generate evidence on the long term efficacy and safety of hepatitis B vaccine in PLHIV with and without ART. Different regimens and routes of administration should also be explored.

Fibronectin predicts the outcome of acute-on-chronic hepatitis B liver failure

BACKGROUND

Acute-on-chronic hepatitis B liver failure (ACHBLF) is a serious condition with varied etiologies and manifestations, and is associated with a high mortality rate. Fibronectin is involved in a number of biological processes, including cellular adhesion, motility, differentiation, apoptosis, hemostasis, wound healing and ischemic injury. Serum fibronectin concentrations may provide prognostic information in ACHBLF; however, as a prognostic marker of mortality in patients with ACHBLF, it needs further validation.

METHODS

The aim of this study was to examine whether admission levels of fibronectin in ACHBLF patients are correlated with outcomes. In this prospective study, 78 ACHBLF patients were compared to 70 matched healthy controls. Fibronectin levels were determined using a commercial enzyme-linked immunosorbent assay kit to determine the prognostic value of fibronectin levels on admission.

RESULTS

The median (range) fibronectin level at admission for ACHBLF patients was significantly reduced compared with that of healthy controls (142 [62-275] mg/l vs 265 [190-346] mg/l, respectively; p<0.001). Fibronectin levels were significantly higher in surviving patients than in those who died (155 [70-275] mg/l vs 119 [62-235] mg/l; p=0.020). Receiver operating characteristic curve analysis showed that a cut-off level of 135 mg/l was the best prognostic indicator, yielding positive and negative predictive values of 60% (18/30) and 71% (30/42), respectively.

CONCLUSIONS

Our results suggested that decreased serum fibronectin levels in patients with ACHBLF were correlated to hepatic injury and inflammation. However, because of the lack of specificity, the use of fibronectin as an independent prognostic indicator is limited.

Hepatitis B vaccine by intradermal route in non responder patients: An update

Vaccination is the main prophylactic measure to reduce the mortality caused by hepatitis B virus (HBV) infection in healthy subjects since the immune response to hepatitis B recombinant vaccination occurs in over 90% of general population. Individuals who develop an anti-HBs titer less than 10 mIU/mL after primary vaccination cycle are defined “no responders”. Many factors could cause a non response to the HBV vaccination, such as administration of the vaccine in buttocks, impaired vaccine storage conditions, drug abuse, smoking, infections and obesity. Moreover there are some diseases, like chronic kidney disease, human immunodeficiency virus infection, chronic liver disease, celiac disease, thalassaemia, type I diabetes mellitus, down’s syndrome and other forms of mental retardation that are characterized by a poorer response to HBV vaccination than healthy subjects. To date it is still unclear how to treat this group of patients at high risk of hepatitis B infection. Recent studies seem to indicate that the administration of HBV recombinant vaccine by the intradermal route is very effective and could represent a more useful strategy than intramuscular route. This review focuses on the use of anti hepatitis B vaccine by intradermal route as alternative to conventional intramuscular vaccine in all non responder patients. A comprehensive review of the literature using PubMed database, with appropriate terms, was undertaken for articles in English published since 1983. The literature search was undertaken in September 2013.

Rapid loss of vaccine-acquired hepatitis B surface antibody after three doses of hepatitis B vaccination in HIV-infected persons

HIV-infected individuals have poor responses to hepatitis B vaccine and may have decreased durability of post-vaccination immunity. Retrospective chart review was conducted for HIV-1 positive individuals aged ≥18 years who received hepatitis B vaccine at an urban HIV clinic. A total of 309 patients completed three doses and 178 had post-vaccine serology testing after the third dose. In multivariate analysis, time between the third dose and the first post-vaccine serology testing at 180-359 days (OR = 0.077, p = 0.049) and at ≥360 days (OR = 0.065, p = 0.019) were associated with poor vaccine responses. A significant decrease in seropositivity appeared as early as 180 days after the third vaccine dose, suggesting a rapid loss of vaccine-acquired hepatitis B surface antibody in HIV-infected persons. Our findings suggest that hepatitis B surface antibody should be tested at 6 to 12 months after completing primary vaccine series in order to detect early secondary vaccine failure.

Comparison of immunogenicity and safety of four doses and four double doses vs. standard doses of hepatitis B vaccination in HIV-infected adults: a randomized, controlled trial

BACKGROUND

HBV vaccination is recommended in HIV-infected adults with CD4+ cell count >200/mm(3) although the efficacy is only 33.3% -65%. We conducted a randomized, controlled trial to evaluate the efficacy and safety of three regimens of HBV vaccination at Chiang Mai University Hospital, Thailand.

METHODS

From February 4, 2011 to May 4, 2012, 132 HIV-infected adults with CD4+ cell counts >200 cells/mm(3), undetectable plasma HIV-1 RNA, and negative for all HBV markers were randomly assigned to receive one of three recombinant vaccine (Hepavax-Gene(®) Berna, Korea) regimens: 20 μg IM at months 0, 1, and 6 (Standard doses group, n=44), 20 μg IM at months 0, 1, 2, 6 (four doses group, n=44), or 40 μg IM at months 0, 1, 2, and 6 (four double doses group, n=44). The primary outcomes were to compare the immunogenicity and safety between the four-doses groups with the Standard doses group.

RESULTS

At months 7 and 12, the percentages of responders (anti-HBs ≥ 10 mIU/mL) were 88.6% and 70.4% in the Standard doses group, 93.2% and 86.4% in the four doses group, (P=0.713 and 0.119), and 95.4% and 88.6% in the four double doses group, (P=0.434 and 0.062), respectively. Factors associated with a high titer level (anti-HBs ≥ 100 mIU/mL) were vaccination schedule and younger age. The most common adverse event was pain at the injection site (42.4%); this was significantly more frequent in the four double doses group compared to the Standard doses group. No serious adverse events were observed.

CONCLUSIONS

In Northern Thailand, the standard three-doses HBV vaccination in HIV-infected adults with CD4+ cell counts >200 cells/mm(3) and undetectable plasma HIV-1 RNA is highly effective. Although regimens of four injections of either standard or double doses could not significantly increase the response rate, these regimens may induce higher levels of antibody to the virus.

TRIAL REGISTRATION INFORMATION

ClinicalTrials.gov; NCT1289106; http://clinicaltrials.gov/ct2/show/NCT01289106.

Strategies to increase responsiveness to hepatitis B vaccination in adults with HIV-1

HIV and hepatitis B virus co-infection leads to substantially increased morbidity and mortality compared with either infection alone. Immunisation with hepatitis B virus vaccine is the most effective way to prevent the infection in people with HIV; however, these patients have decreased vaccine responses and a short duration of protection compared with immunocompetent individuals. Control of HIV replication with highly active antiretroviral therapy and increased CD4 cell counts are associated with improved immune responses to hepatitis B vaccination. New vaccination strategies, such as increased vaccine dose, use of the intradermal route, and addition of adjuvants, could improve response rates in adults with HIV.

Psychological comorbidities in Chinese patients with acute-on-chronic liver failure

OBJECTIVES

Patients with acute-on-chronic liver failure (ACLF) experience long-term chronic liver diseases plus an acute liver function decompensation. This study aimed to determine whether psychological symptoms in patients with hepatitis B virus (HBV)-related ACLF differ from those with other chronic liver diseases and to identify which factors could predict psychological impairment in liver patients.

METHODS

This was a paired case-control study. A total of 120 inpatients, including 40 cases for HBV-related ACLF, 40 paired controls for HBV-related cirrhosis and 40 paired controls for chronic hepatitis B (CHB), as well as 40 paired healthy controls were studied.

RESULTS

A high proportion of patients with HBV-related ACLF were classified as Child's stage C. The prevalence of depression in patients with HBV-related ACLF was significantly higher than in CHB patients and healthy controls, but was equivalent to patients with HBV-related cirrhosis. Patients with HBV-related ACLF had significantly higher level of self-esteem than those with HBV-related cirrhosis. However, there was no significant difference among the three liver patient groups and healthy controls in anxiety and suicide intent. Lower education level, anxiety, poor sleep quality and greater severity of disease were associated with elevated depression.

CONCLUSIONS

Patients with HBV-related ACLF and cirrhosis are at higher risk of depression. It appears that severity of liver disease measured by Child-Pugh class, rather than additional acute liver function decompensation, significantly predicted depression among liver patients.

Hepatitis B vaccination in HIV-infected youth: a randomized trial of three regimens

BACKGROUND

HIV-infected youth are at risk of hepatitis B infection and should be vaccinated. Previous reports suggest reduced response to standard hepatitis B vaccine regimens.

METHODS

HIV-infected youth, aged 12 to younger than 25 years, were randomly assigned to one of three treatment arms: Arm 1: Engerix B, 20 μg HBsAg; Arm 2: Engerix B (GlaxoSmithKline, Rixensart, Belgium), 40 μg; and Arm 3: Twinrix (GlaxoSmithKline, Rixensart, Belgium), 20 μg HBsAg combined with 720 ELU hepatitis A antigen. Vaccines were administered at Weeks 0, 4, and 24.

RESULTS

Characteristics of evaluable patients (n = 336) at entry were similar in the study arms. At enrollment, median CD4+ T-cell count was 460 cells/mm3 (interquartile range, 305-668); 13% were less than 200 cells/mm3. Among Engerix B, 20-μg recipients, 60.4% responded to vaccine (HBsAb 10 IU/mL or greater at Week 28). Improved vaccine response was seen in recipients of Engerix B, 40 μg (73.2% versus Arm 1, P = 0.04) and Twinrix (75.4% versus Arm 1, P = 0.02). In multivariate analysis, only baseline CD4+ T-cell count and study arm were independent predictors of vaccine response.

CONCLUSIONS

In HIV-infected youth, a three-dose vaccination regimen with Engerix B, 40 μg, or Twinrix and higher baseline CD4+ T-cell counts were independently associated with improved vaccine response.

European guideline for the management of hepatitis B and C virus infections, 2010

These are the guidelines on hepatitis B and C management for IUSTI/WHO in Europe, 2010. They describe the epidemiology, diagnosis, clinical features, treatment and prevention of hepatitis B and C with particular reference to sexual health clinical practice.

Efficacy of double-dose hepatitis B rescue vaccination in HIV-infected patients

Impaired hepatitis B virus vaccine (HBVV) efficacy has been observed in HIV-infected patients. We assessed the immunogenicity of double-dose (DD) hepatitis B virus revaccination in patients who had failed to respond to standard vaccination. A retrospective chart review of 4,663 patients ensued in two urban HIV clinics between January 2004 and March 2009. Of 363 patients who received three standard doses (SDs) of HBVV, 126 (34.7%) responded with detectable hepatitis B surface antibody [(HBsAb) HBsAb titer of > or =10 mIU/ml] and 237 (65.3%) nonresponders (NRs) remained seronegative. Among NRs, 61 received three to eight additional SDs of HBVV; 29 received three double doses (DDs) of HBVV (40 microg/dose), spaced at monthly dosing intervals; and 11 received from one to five additional SD HBVV (who remained seronegative) and then received three DDs HBVV. Response rate was significantly higher among the 40 DD recipients than among the 61 who received only additional SD (34/40, 85%, vs. 36/61, 59%; p = 0.006). In the revaccinated NR group (61 SD + 40 DD), a logistic regression analysis found that use of highly active antiretroviral therapy (HAART) (OR, 10.166; CI, 1.359-76.026; p = 0.024), and CD4 cell counts > or =200 cells/mm(3) at the time of revaccination (OR, 9.233; CI, 1.393-61.207; p = 0.021) were associated with HBsAb response, as was DD HBV revaccination (OR, 4.177; CI, 1.282-13.614; p = 0.018). Rescue DD hepatitis B vaccination appears to improve the HBsAb response rate significantly in HIV-infected NR patients, especially after an adequate immune restoration with HAART. More prospective studies are needed to confirm these findings.

Hepatitis B vaccination in HIV-infected adults: current evidence, recommendations and practical considerations

Immunization with hepatitis B (HBV) vaccine is recommended for all HIV-infected individuals without immunity to HBV. This patient population, however, has relatively poor HBV vaccine responses. Factors associated with this impaired HBV vaccine response in HIV-infected individuals may include older age, uncontrolled HIV replication, and low nadir CD4 cell count. Postvaccination testing for HBV surface antibody is recommended and vaccine non-responders should undergo repeat immunization with a full series. The benefit of double dosage, the appropriate strategy for HIV-infected patients with isolated HBV core antibody and the timing and number of vaccinations in persons with advanced immunosuppression on highly active antiretroviral therapy remain controversial areas.

Hepatitis B vaccination: The key towards elimination and eradication of hepatitis B

Hepatitis B virus infection is a global health problem. Worldwide, about 360 million people are chronically infected with the virus. They continue to spread the virus to others and are themselves at risk of chronic liver diseases and hepatocellular carcinoma. The infection can now be treated by antivirals or interferons and the transmission route can be interrupted. Nevertheless, the most effective means is to immunize all susceptible individuals, especially young children, with safe and efficacious vaccines. The combined efforts of vaccination, effective treatment and interruption of transmission make elimination of the infection plausible and may eventually lead to eradication of the virus. Because hepatitis B vaccination has a key role in the control of hepatitis B, properties of this vaccine, its effectiveness in pre-exposure and post-exposure settings, duration of protection after vaccination and the need of booster doses are discussed. Mass hepatitis B vaccination in children decreases the carriage of the virus, and the diseases associated with acute and chronic infection, including hepatocellular carcinoma. Challenges that need to be solved to expand mass vaccination, and the strategies towards elimination and eventual eradication of hepatitis B in the world are also discussed.

Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL)

The Asian Pacific Association for the Study of the Liver (APASL) set up a working party on acute-on-chronic liver failure (ACLF) in 2004, with a mandate to develop consensus guidelines on various aspects of ACLF relevant to disease patterns and clinical practice in the Asia-Pacific region. Experts predominantly from the Asia-Pacific region constituted this working party and were requested to identify different issues of ACLF and develop the consensus guidelines. A 2-day meeting of the working party was held on January 22-23, 2008, at New Delhi, India, to discuss and finalize the consensus statements. Only those statements that were unanimously approved by the experts were accepted. These statements were circulated to all the experts and subsequently presented at the Annual Conference of the APASL at Seoul, Korea, in March 2008. The consensus statements along with relevant background information are presented in this review.

Bloodborne viral hepatitis infections among drug users: the role of vaccination

Drug use is a prevalent world-wide phenomenon and hepatitis virus infections are traditionally a major health problem among drug users (DUs). HBV and HCV, and to a lesser extent HAV, are easily transmitted through exposure to infected blood and body fluids. Viral hepatitis is not inevitable for DUs. Licensed vaccines are available for hepatitis A and hepatitis B. The purpose of this overview is to show some epidemiological data about HBV and the other blood-borne viral hepatitis among DUs and to summarize and discuss use of hepatitis vaccinations in this population. Successful vaccination campaigns among DUs are feasible and well described. We try to focus on the most significant results achieved in successful vaccination programs as reported in scientific literature. Vaccination campaigns among DUs represent a highly effective form of health education and they are cost-saving.