Low Prevalence of Hepatitis B Vaccination Among Patients Receiving Medical Care for HIV Infection in the United States, 2009 to 2012

Immunological and Clinical Responses to Vaccinations among Adults Living with HIV

People living with human immunodeficiency virus (HIV) are at higher risk of morbidity and mortality due to vaccine-preventable diseases. At the same time, they are less likely to respond to vaccinations, and might have a higher rate of vaccine adverse event and faster waning of protective effect. International and national guidelines emphasize the importance of vaccinating people living with HIV against respiratory system disease pathogens including seasonal influenza, Streptococcus pneumoniae, and COVID-19, as well as against sexually transmitted infections, i.e., Hepatitis A and B (HAV, HBV) and human papillomavirus (HPV). This narrative review aims to provide a comprehensive examination of the current knowledge regarding the immune and clinical responses elicited by vaccinations in the older adult population living with HIV.

Comparison of hepatitis B and SARS-CoV2 vaccination rates in people who attended Drugs and Addiction Centres

Background and aims

Persons with substance use disorder are at increased risk for hepatitis B virus (HBV) infection. Although most of them are attached to social health centers, the vaccination rate in this group is low. In this context, we designed a study to evaluate the prevalence of users of drug addiction centers (DAC) not immunized against hepatitis B and to compare the rate of vaccination against hepatitis B with the rate of immunization against SARS-Cov-2 in 2 years of follow-up.

Design

Retrospective study that included individuals attended at DAC. Patients were screened at baseline (June 2020-January 2021) for HBV immunization. Individuals with HBsAb < 10 IU/mL were recommended to receive hepatitis B vaccine, during follow-up (January 2021-October 2022). At the end of follow-up, the HBV vaccination rate among candidates was determined and compared with the vaccination rate against SARS-Cov-2 in this population in the same period.

Findings

A total of 325 subjects were surveyed and tested. At baseline, the 65% (211/325) of were candidates to initiate vaccination and were advisor to HBV vaccination. During the follow-up 15 individuals received at least one dose of HBV vaccine, supposing a vaccination rate of 7.2%. In the same period, 186 individuals received at least one dose against SARS-Cov-2, representing a vaccination rate of 83%. The comparison between vaccination rates reached statistically significant (p < 0.001).

Conclusion

Our study manifests a low rate of immunization against HBV in DAC users, despite a high level of immunization for SARS-Cov-2 during the same period in the same population. Consequently, the lack of immunization against HVB in this population might be related with health policy issue more than to individuals linked to care and awareness. A similar approach for vaccination intended for SARS-CoV2 should be applied in high-risk population to warrant the success of immunization program against other preventable diseases such as HBV.

Risk of hepatocellular carcinoma in people with HIV in the United States, 2001-2019

BACKGROUND

People with HIV have higher risk of hepatocellular carcinoma than the general population, partly because of higher prevalence of coinfection with hepatitis B virus (HBV) or hepatitis C virus (HCV).

METHODS

We calculated standardized incidence ratios for hepatocellular carcinoma in people with HIV by comparing rates from people with HIV in the HIV/AIDS Cancer Match Study, a population-based HIV and cancer registry linkage, to those in the general population. We used multivariable Poisson regression to estimate adjusted incidence rate ratios among people with HIV and linked the Texas HIV registry with medical claims data to estimate adjusted odds ratios (AORs) of HBV and HCV in hepatocellular carcinoma patients with logistic regression.

RESULTS

Compared with the general population, hepatocellular carcinoma rates in people with HIV were elevated 2.79-fold (n = 1736; 95% confidence interval [CI] = 2.66 to 2.92). Hepatocellular carcinoma rates decreased statistically significantly from 2001-2004 to 2015-2019 (P < .001). Compared with men who have sex with men, hepatocellular carcinoma risk was elevated 4.28-fold among men who injected drugs (95% CI = 3.72 to 4.93) and 1.83-fold among women who injected drugs (95% CI = 1.49 to 2.26). In Texas, 146 hepatocellular carcinoma cases among people with HIV were linked to claims data: 25% HBV positive, 59% HCV positive, and 13% coinfected with HBV and HCV. Compared with men who had sex with men, people who inject drugs had 82% decreased odds of HBV (AOR = 0.18, 95% CI = 0.05 to 0.63) and 2 times the odds of HCV (AOR = 20.4, 95% CI = 3.32 to 125.3).

CONCLUSIONS

During 2001-2019, hepatocellular carcinoma risk declined among people with HIV, though rates remain statistically significantly elevated compared with the general population, particularly among people who inject drugs. Prevention and treatment of HBV/HCV are needed to reduce hepatocellular carcinoma risk among people with HIV.

Strategies for Hepatitis B Virus Prevention in People Living with HIV

PURPOSE OF REVIEW

Coinfection with HIV and hepatitis B virus (HBV) is common owing to shared routes of transmission, and persons with HIV-HBV coinfection experience an accelerated progression of liver disease. Despite the widespread availability of HBV vaccination, rates of seroprotection in people living with HIV (PLWH) have historically been low. In this article, we review strategies in HBV prevention among PLWH, focusing specifically on updates in HBV vaccination and chemoprophylaxis.

RECENT FINDINGS

Vaccination remains the hallmark of HBV prevention, and recent studies suggest that a double dose of HBV vaccine and Heplisav-B can improve rates of seroprotection among PLWH. The use of tenofovir-containing antiretroviral therapy (ART) has similarly been shown to provide some HBV protection in PLWH; however, this protection can be lost when switching to newer tenofovir-sparing regimens, including long-acting injectables. All HBV-susceptible persons with HIV should be vaccinated against HBV, regardless of ART regimen and CD4 count.

Delays in Hepatitis B Immunization Series Completion in People With Human Immunodeficiency Virus

Background

Studies have demonstrated low hepatitis B virus (HBV) vaccine series completion among persons with human immunodeficiency virus (HIV).

Methods

We conducted a retrospective record review of persons entering HIV care at 2 clinics in Houston, Texas, between 2010 and 2018. Kaplan-Meier curves summarized time to receipt of HBV vaccines for those eligible for vaccination. We estimated the proportions of patients who had received 1, 2, or 3 HBV vaccine doses at 12 and 24 months after entry to care. A Prentice Williams and Peterson total time model was used to evaluate associations between patient characteristics and time to vaccination.

Results

Of the 5357 patients who entered care, 2718 were eligible for HBV vaccination. After 2 years of follow-up, 51.2% of those eligible had received 1 HBV vaccine, 43.2% had received 2, and 28.4% received 3 vaccines. With adjustment for significant cofactors, patients whose CD4 cell count was ≥200/μL (adjusted hazard ratio [aHR], 1.43 [95% confidence interval (CI), 1.29-1.59]) and transgender patients (1.49 [1.08-2.04]) received any given vaccine dose sooner than those with CD4 cell counts <200/μL or cisgender patients, respectively. Compared with non-Hispanic whites, Hispanic patients were vaccinated sooner (aHR, 1.28 [95% CI, 1.07-1.53]). Those with an active substance use history had a significantly longer time to vaccination than those with no substance use history (aHR, 0.73 [95% CI, .62-.85]).

Conclusions

Strategies are needed to increase HBV vaccine completion rates in our study population, particularly among those with CD4 cell counts <200/μL or with a substance use disorder.

Persistent low prevalence of hepatitis B vaccination among people with HIV: Time for a change?

Hepatitis B virus (HBV) infection is one of the leading causes of hepatocellular carcinoma and mortality among people living with HIV (PLWH). HBV vaccination provides protection from infection; however, vaccination rates are low. We conducted a retrospective analysis at three HIV centres in Texas to determine the proportion of PLWH who received the recommended 3 doses of hepatitis B vaccine within 1 year. Factors associated with vaccination completion were explored. In our sample of three sites in a state with high HIV transmission and high rates of liver disease from 2011 to 2021, showed low rates of hepatitis B vaccination. Among eligible PLWH, only 9% completed the 3-dose hepatitis B vaccine series in 1 year. There is an urgent need to improve HBV vaccination to reach 2030 target for hepatitis B elimination.

Who Is at Risk for New Hepatitis B Infections Among People With HIV?

Hepatitis B virus (HBV) increases morbidity and mortality among people with HIV (PWH). We retrospectively analyzed HBV incidence among 5785 PWH. Fourteen had newly positive hepatitis B s antigen (mean 5.2 person-years of follow-up, 46.4/100 000 infections/year). These data show gaps in HBV vaccination and in the preventative efficacy of HBV-specific antiretroviral therapy.

Burden of vaccine-preventable diseases among at-risk adult populations in the US

Life-course immunization holds significant benefit for population health by reducing the burden of vaccine-preventable diseases (VPD) through vaccinating individuals at different stages and circumstances in life. The study aimed to determine the epidemiologic, clinical, economic, and societal burden of VPDs among at-risk adult subpopulations in the United States. A systematic literature review was conducted for articles published between January 2010 and June 2020, which identified 72 publications. There was heterogeneity in available epidemiology data, with the prevalence of VPDs ranging from 1.1% to 68.7%. Where the disease burden was described, outcomes were typically worse among high-risk subpopulations than in the general population. Several VPDs, including herpes zoster, meningococcal, and pneumococcal infections were associated with increased costs. This review suggests that subpopulations may not frequently interact with the healthcare system, or their risk factors may not be recognized by healthcare providers, and therefore individuals may not be appropriately targeted for vaccination.

Vaccine uptake and barriers to vaccination among at-risk adult populations in the US

To reduce morbidity and mortality associated with vaccine-preventable diseases (VPD), it is imperative that vaccination programs are implemented and prioritized throughout all stages of life across all populations. This study aimed to determine vaccine uptake and barriers to vaccination against VPDs among at-risk adult populations in the United States. We conducted a systematic literature review for articles published between January 2010 and June 2020 and identified 153 publications. The review identified 17 at-risk populations. Vaccine uptake was suboptimal among many populations, with factors including age, gender, and disease severity, associated with uptake. This review identified several barriers that impact vaccine uptake among at-risk populations, with concerns over safety, vaccine costs, lack of insurance, and lack of provider recommendation commonly reported across populations. Embracing a national life-course immunization framework that integrates developing policies, guidelines, and education would be a step to addressing these barriers.

Comparative Efficacy of a High-Dose vs Standard-Dose Hepatitis B Revaccination Schedule Among Patients With HIV: A Randomized Clinical Trial

IMPORTANCE

Active immunization for hepatitis B virus (HBV) infection is recommended in patients living with HIV. Limited evidence is available about the most appropriate regimen of HBV vaccination among those who have not responded to an initial schedule.

OBJECTIVE

To determine the efficacy of a high-dose schedule compared with a standard dose of HBV vaccination.

DESIGN, SETTING, AND PARTICIPANTS

This double-masked, parallel-group, randomized controlled trial included patients living with HIV at a single outpatient HIV and hepatology clinic in Chile for whom previous HBV vaccination had failed. Patients with hepatitis B surface antibody (anti-HBs) titers less than 10 IU/L after an initial HBV vaccination regimen were included. Consecutive patients were recruited between December 2013 and March 2018. Data were analyzed in June 2018 using intention-to-treat analysis.

INTERVENTION

The high-dose HBV vaccination group consisted of 3 doses of 40 μg recombinant hepatitis B vaccine at 0, 1, and 2 months. The standard-dose group received 3 doses 20 μg each at 0, 1, and 2 months.

MAIN OUTCOMES AND MEASURES

Primary outcome was the serologic response to HBV vaccination (anti-HBs greater than 10 IU/L) 4 to 8 weeks after completion of the schedule. Secondary outcomes were anti-HBs greater than 100 IU/L and seroprotective anti-HBs at 1 year follow up.

RESULTS

A total of 107 patients underwent randomization (55 to the standard-dose group, 52 to the high-dose group); 81 (75.7%) were men, and the mean (SD) patient age was 47.0 (13.3) years. Nearly all patients were receiving antiretroviral therapy (105 patients [98%]) and 92 patients (86%) had an undetectable HIV viral load. Mean (SD) CD4 count was 418 (205) cells/mm3. There were no differences in baseline characteristics between groups. Serological response in the high-dose group was found in 36 of 50 patients (72%; 95% CI, 56.9%-82.9%) compared with 28 of 55 patients in the standard-dose group (51%; 95% CI, 37.1%-64.6%) (odds ratio, 2.48; 95% CI, 1.02-6.10; P = .03). Mean (SD) anti-HB levels were 398.0 (433.4) IU/L in the high-dose group and 158.5 (301.4) IU/L in the standard-dose group (P < .001). Of patients with a serological response in the high-dose group, 29 of 36 (80.6%) had anti-HBs titers greater than 100 IU/L compared with 14 of 28 responders (50.0%) in the standard-dose group (P = .02). At 1-year follow-up, 20 of 25 patients (80.0%) with a serological response in the high-dose group had protective anti-HBs vs 9 of 23 patients (39.1%) in the standard-dose group (P = .01).

CONCLUSIONS AND RELEVANCE

The results of this randomized clinical trial suggest that use of a high-dose regimen for HBV revaccination for patients with HIV achieves a higher and longer-lasting serological response as compared with a standard-dose regimen.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02003703.

Epidemiology estimates of hepatitis D in individuals co-infected with human immunodeficiency virus and hepatitis B virus, 2002-2018: A systematic review and meta-analysis

Hepatitis delta virus (HDV) is an obligate satellite of hepatitis B virus (HBV). HIV/HDV co-infection is associated with a high rate of hepatic decompensation events and death. We aimed to characterize the epidemiology of HDV infection in HIV/HBV co-infected individuals. We systematically searched PubMed, Embase, Cochrane Library, Web of Science, CINAHL and Scopus for studies published from 1 Jan 2002 to 7 May 2018 measuring prevalence of HDV among the HIV population. Pooled seroprevalence was calculated with the DerSimonian-Laird random-effects model. Our search returned 4624 records, 38 of which met the inclusion and exclusion criteria. These studies included data for 63 cohorts from 18 countries and regions. The overall HDV seroprevalence of HIV-infected individuals was 1.03% (95% CI 0.43-1.85) in 2002-2018 globally. Moreover, the estimated pooled HDV seroprevalence among the general population was 1.07% (95% CI 0.65-1.59) in 2002-2018, which was not significantly different from the HDV seroprevalence of individuals living with HIV (p = 0.951). The overall HDV seroprevalence of the HBsAg positive population was 12.15% (95% CI 10.22-14.20), p = 0.434 when compared with the corresponding data of HIV/HBV co-infected individuals. This meta-analysis suggested that there was no difference between the HDV seroprevalence in HIV-infected individuals and the general population.

Sociodemographic, HIV-Related Characteristics, and Health Care Factors as Predictors of Self-Reported Vaccination Coverage in a Nationwide Sample of People Aging with HIV in Germany

Preventing infectious diseases through vaccination becomes more significant among the growing population of people aging with HIV. Coverage rates for vaccinations and factors associated with vaccination utilization among this population in Germany are unknown. We assessed the coverage of eight recommended vaccinations in a certain time frame in our convenience sample of 903 people living with HIV aged 50 years and older. We analysed coverage rates and used bivariate and multiple linear regression analyses to identify factors associated with number of reported vaccinations. Coverage rates in our sample ranged between 51.0% for meningococcus disease and 84.6% for the triple vaccination against tetanus, diphtheria, and pertussis. All rates were higher compared to the German general population. Seven factors were related to the number of vaccinations in multiple regression analysis: sexual orientation, education, relationship status, CD4 count, time since last visit to HIV specialist, type of HIV specialist, and distance to HIV specialist. Vaccination coverage among people aging with HIV in Germany is high, but not optimal. To improve vaccination uptake, strengthened efforts need to be focused on female and heterosexual male patients, socioeconomically disadvantaged patients, and patients with barriers to access regular HIV care.

Trends in Prevalence of Protective Levels of Hepatitis B Surface Antibody Among Adults Aged 18-49 Years With Risk Factors for Hepatitis B Virus Infection-United States, 2003-2014

BACKGROUND

Hepatitis B virus (HBV) infection can be prevented through vaccination. However, previous data show that only about 24%-45% of US adults at high risk of HBV infection are protected. Our aims were to assess prevalence and trends in protective levels of hepatitis B surface antibody (anti-HBs) from 2003 to 2014 and explore factors associated with protection among adults at high risk.

METHODS

Data were taken from the 2003-2014 National Health and Nutrition Examination surveys. Our sample included adults aged 18-49 years who were tested for HBV and reported at least 1 of the following infection risks: history of sexually transmitted disease, sex with men (for men), infection with human immunodeficiency virus, and injection drug use. We calculated the prevalence of anti-HBs (≥10 mIU/mL), indicative of immunity from vaccination, among respondents for three 4-year time intervals (2003-2006, 2007-2010, and 2011-2014) and applied the Cochran-Mantel-Haenszel test to assess trends. Using multivariable logistic regression, we examined factors associated with positive anti-HBs serology.

RESULTS

The prevalence of positive anti-HBs serology was 23.4%. Prevalence increased from 2003-2006 (16.3%) to 2007-2010 (27.3%), but no change occurred from 2007-2010 (27.3%) to 2011-2014 (28.1%). Among factors predicting positive anti-HBs serology were young age and higher education.

CONCLUSIONS

By 2014, less than one-third of adults aged 18-49 years at risk of infection exhibited protective antibodies ≥10 mIU/mL. Because these adults account for a majority of unprotected adults, targeted intervention strategies are essential to achieve the hepatitis B elimination goal.

Occult hepatitis B virus infection in a Kenyan cohort of HIV infected anti-retroviral therapy naïve adults

BACKGROUND

Occult hepatitis B virus (HBV) infection (OBI) is a phase of HBV infection characterised by the presence of HBV DNA in the absence of detectable hepatitis B surface antigen (HBsAg). OBI is of concern in the HIV-infected due to high prevalence and risk of HBV reactivation. The prevalence and clinico-demographic characteristics of OBI in anti-retroviral therapy (ART) naïve HIV infected adults in Kenya is unknown.

METHODS

A cross sectional study carried was out at three sites in Kenya. HIV infected ART naïve adults were enrolled and demographic data collected. Blood samples were assayed for HBsAg, HBV DNA, alanine aminotransferase, aspartate aminotransferase, antibodies to hepatitis B surface antigen (anti-HBs) and hepatitis B core antigen (anti-HBc). Data on CD4 count, HIV viral load and platelet count were obtained from medical records.

RESULTS

Of 208 patients, 199 (95.7%) did not report HBV vaccination, 196 (94.2%) were HBsAg negative, 119 (57.2%) had no HBV markers, 58 (27.9%) had previous HBV infection (anti-HBc positive) and 11 (5.3%) had OBI. All 11 (100%) OBI patients were anti-HBc positive. OBI patients comprised 19.0% of HBsAg negative, anti-HBc positive patients. There was no difference in clinico-demographic characteristics between the overt HBV, OBI and HBV negative patients.

CONCLUSION

This was the first study on OBI in ART naïve HIV infected adults in Kenya. The lower OBI prevalence compared to other sub-Saharan African countries could be attributed to lower HBV exposure. Most patients were HBV unexposed and unimmunized, outlining the need to implement guideline recommended immunization strategies.

Chronic Hepatitis B and HIV Coinfection: A Continuing Challenge in the Era of Antiretroviral Therapy

PURPOSE OF REVIEW

The burden of chronic hepatitis B (HBV) remains disproportionately high among people living with HIV (PLWH) despite the advent of HBV vaccination and HBV-active antiretroviral therapy (ART). This review summarizes new insights and evolving issues in HIV-HBV coinfection.

RECENT FINDINGS

HBV-HIV coinfection is still a leading cause of cirrhosis, hepatocellular carcinoma (HCC) and liver-related mortality more than a decade after the approval of tenofovir. While tenofovir-based ART has been shown to improve rates of HBV virologic suppression and halt fibrosis progression, the long-term benefits on the prevention of end-stage liver disease or HCC in HIV-HBV coinfection have yet to be convincingly demonstrated in PLWH. Missed opportunities for HBV vaccination persist despite evidence of ongoing risk for HBV infection in this population.

SUMMARY

Even as we work towards HBV elimination and functional cure, ongoing efforts should focus on optimizing risk stratification as well as uptake of HBV-active antiviral therapy and HBV immunization in this priority population.

Assessing the cost-utility of preferentially administering Heplisav-B vaccine to certain populations

Vaccination is the primary strategy to prevent hepatitis B virus (HBV) infection in the United States. Prior to 2017, most standard hepatitis B vaccine schedules required 3 doses over 6 months. Heplisav-B, approved in 2017, is administered in 2 doses over a 1 month time period but has a higher per-dose cost ($115.75 per dose compared to $57.25 per Engerix-B dose, costs as of June 1, 2019). We aimed to assess the cost-utility of providing the two-dose Heplisav-B vaccine compared to a three-dose Engerix-B vaccine among adult populations currently recommended for vaccination against hepatitis B. We used a decision-tree model with microsimulation and a Markov disease progression process to assess the cost-utility separately for the following populations: adults with diabetes, obesity, chronic kidney disease, HIV; non-responders to previous hepatitis B vaccination; older adults; and persons who inject drugs (PWID). We modeled epidemiologic outcomes (incident HBV infections, sequelae and related deaths), costs (2019 USD) and benefits (quality-adjusted life years, QALYs) and compared them across strategies. Sensitivity analyses assessed the cost-utility at varying estimates of Heplisav-B efficacy. In the base case scenario for each population, vaccination with Heplisav-B resulted in fewer HBV infections (37.5-59.8% averted), sequelae, and HBV-related deaths (36.3-71.4% averted). Heplisav-B resulted in decreased costs and increased benefits compared to Engerix-B for all populations except non-responders. Incremental costs from the baseline strategy ranged from $4746.78 saved (PWID) to $14.15 added cost (non-responders). Incremental benefits per person ranged from 0.00005 QALYs (older adults) to 0.7 QALYs (PWID). For persons with HIV and PWID, Heplisav-B resulted in lower costs and increased benefits in all scenarios in which Heplisav-B series efficacy was at least 80%. Vaccination using Heplisav-B is a cost-saving strategy compared to Engerix-B for adults with diabetes, chronic kidney disease, obesity, and HIV; older adults; and PWID.

Predictors of vaccination rates in people living with HIV followed at a specialty care clinic

People Living with HIV (PLWH) remain disproportionately susceptible to vaccine-preventable illnesses due to increased morbidity and mortality from common pathogens, increased transmission related to epidemiologic factors, and decreased vaccination rates. We aimed to describe patient-specific predictive factors that may impact adherence to the CDC's recommended vaccination schedules in PLWH. We retrospectively evaluated adult PLWH in care at the University of Nebraska Medical Center's HIV clinic and collected information related to demographics, clinic visits, vaccination status, and measures of HIV disease control. Patients were categorized as "Adherent" if they had received all vaccinations for which they were eligible and were categorized as "Non-Adherent" if they were deficient or delayed in receiving one or more vaccinations. Participant characteristics were compared between groups by multivariable logistic regression to identify predictors associated with vaccine schedule non-adherence. We evaluated 502 PLWH who met our inclusion criteria; 206 of these (41%) had received all eligible vaccinations, while 296 (59%) were missing one or more vaccinations. The mean age of participants was 48 years old, 76% were male, and 53% were white. Our participants had a median of 2.83 clinic visits per year and missed 8.3% of scheduled clinic visits. Factors associated with non-adherence to vaccination schedules included a high frequency of missed clinic appointments (>10%), men who have sex with men, and a CD4 count <200 cells/mm³. Knowledge of variables associated with vaccination rates may be beneficial in identifying patients at-risk for under-vaccination and designing targeted education programs for providers and patients.

Chronic hepatitis B virus infection

Chronic hepatitis B virus infection is a global public health threat that causes considerable liver-related morbidity and mortality. It is acquired at birth or later via person-to-person transmission. Vaccination effectively prevents infection and chronic hepatitis B virus carriage. In chronically infected patients, an elevated serum hepatitis B virus DNA concentration is the main risk factor for disease progression, although there are other clinical and viral parameters that influence disease outcomes. In addition to liver biochemistry, virological markers, and abdominal ultrasonography, non-invasive assessment of liver fibrosis is emerging as an important assessment modality. Long-term nucleos(t)ide-analogue therapy is safe and well tolerated, achieves potent viral suppression, and reduces the incidence of liver-related complications. However, a need to optimise management remains. Promising novel therapies are at the developmental stage. With current vaccines, therapies, and an emphasis on improving linkage to care, WHO's goal of eliminating hepatitis B virus as a global health threat by 2030 is achievable.