Hepatitis B infection or reactivation after switch to two-drug antiretroviral therapy: A case series, literature review, and management discussion.

Abstract

Two-drug antiretroviral therapy (ART) without hepatitis B virus (HBV) activity is prescribed for persons with HIV as simplified or salvage therapy. While two-drug regimens are not recommended for persons with chronic HBV infection, guidelines do not address 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. HIV primary care clinics of an academic medical center in New York, NY. 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. Four individuals with HBV infection or reactivation after ART switch were identified. Two had HBV susceptibility, one had core antibody reactivity, and one had surface antigen reactivity pre-switch. All eligible persons had received HBV vaccination, two with low-level antibody response and one with persistent nonresponse. Two presented with fulminant hepatitis, one requiring liver transplantation. 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 risk of reactivation, 5) Continuation of HBV-active prophylaxis when above measures are not feasible, 6) Continuation of HBV-active therapy and surveillance for chronic HBV infection.