Hepatitis B and HIV co-infection

People with HIV infection have a higher prevalence of chronic hepatitis B than the general population. HIV and hepatitis B virus (HIV–HBV) co-infection is associated with more rapid progression of liver fibrosis, and higher rates of complications such as hepatocellular carcinoma and liver failure. Liver disease is a significant cause of morbidity and mortality in patients with HIV–HBV co-infection, even in those whose HIV infection is well controlled on antiretroviral therapy. Management of co-infection can be complicated by immune reconstitution inflammatory syndrome (IRIS) and hepatotoxicity from antiretroviral drugs.

Patients with HIV–HBV co-infection should be managed by a clinician experienced in both of these conditions.

All patients with HIV–HBV co-infection should receive antiretroviral therapy. Standard antiretroviral therapy can be used to treat HIV–HBV co-infection, provided the regimen includes tenofovir alafenamide or a tenofovir disoproxil salt; both these forms of tenofovir are active against both HIV and hepatitis B¹. If tenofovir cannot be included in the antiretroviral regimen and the patient requires treatment for hepatitis B, then entecavir should be added to the HIV treatment regimen. Seek expert advice in this situation.

An acute flare of hepatitis B can occur if antiretroviral drugs active against hepatitis B virus are stopped—seek expert advice before stopping or changing therapy.

Patients with HIV–HBV co-infection who for any reason are not receiving antiretroviral therapy should not be treated with tenofovir or entecavir monotherapy for hepatitis B, because this can result in drug-resistant HIV.

Seek expert advice for patients with drug-resistant strains of HIV or hepatitis B.

All patients considering using pre-exposure prophylaxis (PrEP) for HIV prevention should be tested for hepatitis B. A person with chronic hepatitis B who is considering or taking regular PrEP should be assessed by a clinician experienced in the management of hepatitis B. On-demand PrEP is contraindicated. Stopping PrEP in a patient with chronic hepatitis B needs to be managed carefully because reactivation of hepatitis B can occur. For more information, see Pre-exposure prophylaxis (PrEP) against HIV.