The U.S. Department of Health and Human Services has updated its Guidelines for the Use of Antiretroviral Agents in Adults and Adolescents With HIV with revisions to the section on hepatitis B virus (HBV). HIV and HBV share some of the same transmission routes, and around 8% of people with HIV worldwide also have chronic hepatitis B.

HBV Vaccination

The updated guidelines recommend two doses of Heplisav-B as the preferred hepatitis B vaccine regimen for people living with HIV, including those who have never been vaccinated and those who did not respond well to prior vaccination. A three-dose series of Engerix-B, Recombivax HB or Twinrix (a combination hepatitis A and B vaccine) may be used if Heplisav-B is unavailable. The PreHevbrio vaccine was removed from the guidelines as it will no longer be available in the United States

Studies have shown that Heplisav-B—a recombinant hepatitis B surface antigen vaccine with a toll-like receptor 9 agonist adjuvant to boost immune response—is more effective for HIV-positive people than Engerix-B or Recombivax HB.

Hepatitis B surface antibodies should be measured four weeks after completion of the vaccine series to assess response. People who do not respond to two doses of Heplisav-B may receive a third dose, though data on this approach are lacking.

Hepatitis B Treatment

People with HIV/HBV coinfection are advised to include two drugs in their antiretroviral regimen that have dual activity against both viruses, namely tenofovir disoproxil fumarate (a component of Truvada and several single tablet regimens) or tenofovir alafenamide (a component of Descovy and coformulations including Biktarvy) plus lamivudine or emtricitabine. Tenofovir alafenamide is preferred for those with impaired kidney function.

However, use of nucleoside/nucleotide-sparing antiretroviral regimens is increasingly common. The revised guidelines recommend that for people without a known history of hepatitis B, hepatitis B surface antigen (HBsAg) and HBV surface (anti-HBs) and core (anti-HBc) antibodies should be checked before starting or switching to a nucleoside/nucleotide-sparing regimen to ensure they do not have unrecognized HBV infection.

People with chronic HBV infection (HBsAg positive) who opt for a nucleoside/nucleotide-sparing HIV regimen should also receive hepatitis B treatment in addition, that is tenofovir disoproxil fumarate (sold alone as Viread), tenofovir alafenamide (sold alone as Vemlidy) or entecavir (Baraclude).

Switching to the dolutegravir/lamivudine combination pill (Dovato) without additional hepatitis B treatment should be avoided, as lamivudine alone is not considered adequate to control HBV. Added hepatitis B treatment is also needed for people who switch to long-acting injectable cabotegravir and rilpivirine (Cabenuva), as neither drug is active against HHBV.

People who test positive for isolated HBV core antibodies (without HBsAg or surface antibodies) could potentially carry the virus, but results are considered indeterminate. Some experts recommend against switching to a nucleoside/nucleotide-sparing regimen without additional hepatitis B meds, “but this could be considered if the benefits outweigh the risk of potential HBV reactivation.”

People who test positive for both HBV core and surface antigens and negative for HBsAg have immunity against hepatitis B after recovering from prior infection. Those with isolated HBV surface antibodies are immune thanks to vaccination. Both groups can switch to a nucleoside/nucleotide-sparing HIV regimen without additional hepatitis B therapy.

Pegylated interferon has historically been used alone or with antivirals to treat hepatitis B, but it can cause difficult side effects and seldom leads to a cure. In the latest guidelines, the authors have changed pegylated interferon monotherapy to an alternative treatment that “should only be used in rare cases with consultation of an expert.”

See the full Hepatitis B Virus section of the guidelines for more detailed information, including treatment of hepatitis B and C coinfection.