Less than 10% of HIV-positive people are adequately vaccinated against hepatitis B virus (HBV) despite being more vulnerable, according to research presented at this year’s Conference on Retroviruses and Opportunistic Infections (CROI 2022). At the same time, another study published in Clinical Infectious Diseases found that people living with both HIV and HBV received better care than people with hepatitis B alone.

Over years or decades, chronic hepatitis B can lead to severe liver disease, including cirrhosis, liver cancer and the need for a liver transplant. Between 5% and 10% of people living with HIV in the United States also have chronic hepatitis B, according to federal HIV treatment guidelines. People with HIV and HBV coinfection are at increased risk for liver complications compared to those with either virus alone.

Most people with hepatitis B recover without treatment, gain immunity and do not get it again. But around 5% of those who acquired HBV as adults develop chronic infection, a figure that is higher for people living with HIV. Certain antiretroviral medications used to treat HIV are also active against HBV: lamivudine (Epivir), emtricitabine (Emtriva), tenofovir disoproxil fumarate (Viread) and tenofovir alafenamide (Vemlidy). These drugs are components of several combination pills used for HIV treatment or pre-exposure prophylaxis (PrEP).

HBV Vaccination 

Hepatitis B can be prevented with a vaccine, which is routinely given to children soon after birth. For adults, the Centers for Disease Control and Prevention now recommends HBV vaccination for everyone under 60, all people living with HIV and people 60 and older with risk factors. These include being a man who has sex with men, having multiple sex partners, injecting drugs and traveling to countries where HBV is prevalent. The vaccine series involves three doses given over six months.

Mamta Jain, MD, of the University of Texas Southwestern Medical Center, and colleagues analyzed hepatitis B incidence among more than 30,000 HIV-positive people in Dallas and Houston. Most (72%) were men, a majority (57%) were Black and more than half lacked health insurance. At baseline, only 12% had an undetectable viral load, and a third had a CD4 count below 200.

Focusing on a subset of around 12,000 people who did not previously have hepatitis B, the researchers found that those who were not vaccinated against HBV, those who had hepatitis C and those with cancers other than hepatocellular carcinoma (the most common type of liver cancer) were at higher risk for new HBV infection. Taking medications active against both HIV and HBV did not have a protective effect.

Jain’s team also looked at vaccination rates in a subset of over 6,500 people without prior evidence of hepatitis B. Despite high vulnerability, only 9% received three doses of the HBV vaccine within 12 months. Women, white people and those with other medical conditions were more likely to be fully vaccinated.

However, the vaccine did not provide perfect protection. Only about half of those who received all three doses and were tested for HBV antibodies had built up immunity. Latino people and those with a CD4 count below 200 were less likely to respond well to the vaccine.

The researchers suggested that additional support and simpler, more effective HBV vaccines with a shorter course may be needed to improve outcomes.

Hepatitis B Care 

If people living with HIV do contract HBV, there is evidence that they might receive more attentive care than those with hepatitis B alone, according to a related study by Tzu-Hao Lee, MD, of Baylor College of Medicine, and colleagues.

Lee and his team looked at patient care for more than 8,000 U.S. veterans with hepatitis B who received care at multiple Veterans Health Administration sites, of whom 1,021 were also HIV-positive.

The differences in hepatitis B care were striking. They found that 97% of people living with both HIV and HBV received antiviral treatment that adhered to guidelines, compared with just 71% of those with only HBV. Patients with both viruses were also more likely to be screened for hepatitis A (69% versus 55%). However, both groups were about equally likely to be screened for hepatitis C (100%) and to undergo biannual monitoring for liver cancer (55%).

Lee and colleagues suggested that the reason for improved care for the HIV-positive group may be that they are more likely to receive care from infectious disease specialists. Patients without specialty care were less likely to receive antiviral treatment or liver cancer monitoring, while those seen by both infectious disease specialists and gastroenterologists were most likely to receive the recommended care.

“The quality of HBV-related care is likely to improve further by expanding access to specialty care and investigating and addressing patient- and system-related barriers to care,” Lee told Healio.com.

Click here to read the CROI abstract on HBV vaccination for people with HIV.

Click here to read the Clinical Infectious Diseases abstract.

Click here for more news from CROI 2022.

For more news about viral hepatitis, visit POZ’s sister publication HepMag.com.