Mortality in relation to hepatitis B virus (HBV) infection status among HIV-HBV co-infected patients in sub-Saharan Africa after immediate initiation of antiretroviral therapy

Virological and serological outcomes in people with HIV-HBV coinfection who had discontinued tenofovir-containing antiretroviral therapy: Results from a prospective cohort study

Background and Aims

Given advances in antiretroviral therapy (ART), some people with HIV are transitioned to non-tenofovir-containing ART; the implications for people with HIV-hepatitis B virus (HBV) are unknown. We characterized HBV-related outcomes in people with HIV-HBV coinfection while not taking tenofovir-containing ART.

Methods

We analyzed participants from the French HIV-HBV Cohort Study in three treatment groups: (1) continuous tenofovir; (2) discontinued tenofovir; (3) never initiated tenofovir. We examined virological and clinical characteristics during follow-up. We assessed determinants of HBV DNA >2000 IU/mL and alanine aminotransferase (ALT) >2x upper limit of normal separately while participants were off tenofovir using univariable logistic regression with generalized estimating equations.

Results

Among 192 participants, 161 (83.9 %) were on continuous tenofovir, 22 (11.5 %) discontinued tenofovir, and 9 (4.7 %) never initiated tenofovir during a median follow-up of 14.5 years (IQR = 10.5-14.8). The median proportion of within-participant visits with undetectable HBV DNA was 96.0 % (IQR = 75.0-100) in the continuous group, 100 % (IQR = 84.0-100) in the discontinued tenofovir group (while off tenofovir), and 100 % (IQR = 95.2-100) in the never initiated tenofovir group. Determinants of HBV DNA >2000 IU/mL while people were off tenofovir were detectable HIV RNA (p = 0.041), lower CD4+ T-cell count (p = 0.027), HBeAg positive serology (p = 0.004) and positive hepatitis D serology (p = 0.001). ALT elevation was associated with positive hepatitis C antibody serology (p = 0.012).

Conclusions

This proof-of-concept study shows that selected people with HIV-HBV coinfection may not lose virologic control of HBV when off tenofovir. HBV virologic activity while off tenofovir may be more closely associated with uncontrolled HIV infection and positive HBeAg serology.

What does the scale-up of long-acting HIV pre-exposure prophylaxis mean for the global hepatitis B epidemic?

INTRODUCTION

The HIV and hepatitis B virus (HBV) epidemics are interconnected with shared routes of transmission and specific antiviral drugs that are effective against both viruses. Nearly, 300 million people around the world live with chronic HBV, many of whom are from priority populations who could benefit from HIV prevention services. Oral pre-exposure prophylaxis (PrEP) for HIV has implications in the prevention and treatment of HBV infection, but many people at increased risk of HIV acquisition may instead prefer long-acting formulations of PrEP, which are currently not active against HBV.

DISCUSSION

People at increased risk for HIV acquisition may also be at risk for or already be living with HBV infection. Oral PrEP with tenofovir is effective in preventing both HIV and HBV, and tenofovir is also the recommended treatment for chronic HBV infection. Although implementation of oral PrEP has been challenging in sub-Saharan Africa, investments in its scale-up could secondarily reduce the clinical impact of HBV. Long-acting PrEP, including injectable medicines and implantable rings, may overcome some of the implementation challenges associated with oral PrEP, such as daily pill burden, adherence challenges and stigma; however, current formulations of long-acting PrEP do not have activity against HBV replication. Ideally, PrEP programmes would offer both oral and long-acting formulations with HBV screening to optimize HIV prevention services and HBV prevention and care, when appropriate. People who are not immune to HBV would benefit from being vaccinated against HBV before initiating long-acting PrEP. People who remain non-immune to HBV despite vaccination may benefit from being offered oral, tenofovir-based PrEP given its potential for HBV PrEP. People using PrEP and living with HBV who are not linked to dedicated HBV care would also benefit from laboratory monitoring at PrEP sites to ensure safety when using and after stopping tenofovir. PrEP programmes are ideal venues to offer HBV screening, HBV vaccination for people who are non-immune and treatment with tenofovir-based PrEP for people with indications for HBV therapy.

CONCLUSIONS

Long-acting PrEP holds promise for reducing HIV incidence, but its implications for the HBV epidemic, particularly in sub-Saharan Africa, should not be overlooked.

Living with HIV and Getting Vaccinated: A Narrative Review

After 40 years of its appearance, human immunodeficiency virus (HIV) infection remains a leading public health challenge worldwide. Since the introduction of antiretroviral treatment (ART), HIV infection has become a chronic condition, and people living with HIV could have life expectancies close to those of the general population. People with HIV often have an increased risk of infection or experience more severe morbidity following exposure to vaccine-preventable diseases. Nowadays, several vaccines are available against bacteria and viruses. However, national and international vaccination guidelines for people with HIV are heterogeneous, and not every vaccine is included. For these reasons, we aimed to perform a narrative review about the vaccinations available for adults living with HIV, reporting the most updated studies performed for each vaccine among this population. We performed a comprehensive literature search through electronic databases (Pubmed-MEDLINE and Embase) and search engines (Google Scholar). We included English peer-reviewed publications (articles and reviews) on HIV and vaccination. Despite widespread use and guideline recommendations, few vaccine trials have been conducted in people with HIV. In addition, not all vaccines are recommended for people with HIV, especially for those with low CD4 cells count. Clinicians should carefully collect the history of vaccinations and patients' acceptance and preferences and regularly check the presence of antibodies for vaccine-preventable pathogens.

Risks and benefits of oral HIV pre-exposure prophylaxis for people with chronic hepatitis B

Individuals with chronic hepatitis B virus (HBV) infection who are at substantial risk of HIV acquisition benefit from pre-exposure prophylaxis (PrEP) with tenofovir-based antiviral therapy. Considering that tenofovir potently inhibits HBV, providing PrEP to individuals with HBV effectively results in treatment of their HBV infection. However, some clinicians might be hesitant to initiate PrEP in people with chronic HBV due to unknown risks of HBV reactivation, hepatitis, and acute liver failure during periods of antiviral cessation. Unfortunately, these knowledge gaps affect scale up of PrEP among people with chronic HBV. Emerging data regarding the risks and benefits of antiviral cessation in people with chronic HBV suggest that PrEP can be safely initiated despite the risks of non-adherence or discontinuation. People with chronic HBV who stop PrEP should be closely monitored for HBV reactivation and hepatitis flares after antiviral cessation.