Management of Hepatitis B in HIV-Infected and other Immunosuppressed Patients

In the presence of an immmunosuppressed state, patients with chronic hepatitis B may have an aggressive course leading to significant liver-related morbidity and mortality. The most prevalent acquired immunosuppressed state is infection with HIV. About 10% of the estimated 36 million people with HIV worldwide are HBsAg positive, while up to two-thirds are anti-HBc positive suggestive of past exposure to HBV. Those co-infected with HIV and HBV have increased risk of development of chronic infection after acute HBV infection, persistence of HBeAg with high levels of HBV viraemia, and accelerated progression to cirrhosis. Therapy for HBV in co-infected patients should be carefully designed since some nucleos(t)ide analogues have activity against both HBV and HIV and incomplete viral suppression can lead to emergence of drug-resistant strains. Patients with chronic HBV infection receiving immunosuppression after organ transplantation also have rapid progression of liver disease that can be prevented by adequate suppression of viral replication with anti-HBV nucleos(t)ide analogues. Use of tumour necrosis factor-α inhibitors in chronic HBV patients with rheumatological diseases or inflammatory bowel disease has also been associated with HBV reactivation. The risk for reactivation should be widely recognized, and ideally all immunosuppressed patients should be screened for evidence of current HBV infection and considered for prophylaxis with anti-HBV nucleos(t)ide analogues.