Treatment of HIV/HBV Coinfection: Clinical and Virologic Issues

Chronic hepatitis B affects nearly 10% of HIV-infected patients. Thus, approximately four million peopleworldwide are HBV/HIV coinfected. Hepatitis B virus (HBV) infection is a dynamic disease and coinfectionwith HIV impacts directly on the outcome of HBV infection, considerably complicating its naturalhistory, diagnosis, and management. Hepatic necroinflammation is lower in HBV/HIV coinfection, yetliver damage, especially fibrosis, progresses at a faster rate than in HBV monoinfection. With improvedcontrol of HIV disease with HAART, liver disease has emerged as one of the leading causes of deathin patients with HIV. Anti-HBV therapy should be considered for all HIV/HBV-coinfected patients withevidence of liver disease, irrespective of the CD4 cell count. In coinfected patients not requiring HAART,HBV therapy should be based on agents with no HIV activity such as adefovir. In contrast, in patientswith CD4 counts less than 350 cells/μl, the use of agents with dual anti-HIV and anti-HBV activity shouldbe considered. Combination therapy should ideally be used to avoid or delay the development of antiviralresistance. Regular monitoring of patients is imperative to recognize reactivation and subsequentneed for treatment, and to identify drug resistance and viral breakthrough early. Similar close monitoringis required for patients presenting with advanced HIV infection and reduced functional hepaticreserve due to HBV-related cirrhosis. Effective antiviral treatment can precipitate immune reconstitutiondisease resulting in serious hepatic flare and precipitating liver decompensation. Clearly, more dataare needed to more effectively treat HIV/HBV coinfection.