Less than 10% of HIV-positive people are properly vaccinated against hepatitis B virus (HBV), although they are more vulnerable, according to a study presented at this year’s Conference on Retroviruses and Opportunistic Infections (CROI 2022) . Meanwhile, another study published in Clinical Infectious Diseases found that people living with both HIV and HBV received better care than people with only hepatitis B.
Over years or decades, chronic hepatitis B can lead to serious 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 co-infected with HIV and HBV are at increased risk of liver complications compared to those with either virus alone.
Most people with hepatitis B recover without treatment, build immunity, and don’t get it again. But about 5% of those who contracted HBV as adults develop chronic infection, a figure that is higher among people living with HIV. Some antiretroviral drugs 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).
Vaccination against HBV
Hepatitis B can be prevented with a vaccine, which is routinely given to children shortly after birth. For adults, the Centers for Disease Control and Prevention now recommends vaccination against HBV for all people under 60, all people living with HIV and people 60 and over 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 common. The vaccine series consists of three doses given over six months.
Mamta Jain, MD, of the University of Texas Southwestern Medical Center, and colleagues analyzed the incidence of hepatitis B in more than 30,000 HIV-positive people in Dallas and Houston. Most (72%) were male, a majority (57%) were black, and more than half had no 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 about 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 who had cancers other than hepatocellular carcinoma (the most common type of liver cancer) had a higher risk of new HBV infection. Taking drugs active against HIV and HBV did not have a protective effect.
Jain’s team also looked at vaccination rates in a subset of more than 6,500 people with no prior evidence of hepatitis B. Despite high vulnerability, only 9% received three doses of the HBV vaccine in 12 month. Women, whites, and people with other health 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 developed immunity. Latinos and those with CD4 counts below 200 were less likely to respond well to the vaccine.
The researchers suggested that additional support and simpler, more effective HBV vaccines with shorter treatment may be needed to improve outcomes.
Hepatitis B care
If people living with HIV contract HBV, there is evidence that they may receive more attentive care than those with hepatitis B alone, according to a related study led by Tzu-Hao Lee, MD, of Baylor College of Medicine. , and his colleagues.
Lee and his team examined the patient care of more than 8,000 US veterans with hepatitis B who received care at multiple Veterans Health Administration sites, 1,021 of whom were also HIV-positive.
The differences in the management of hepatitis B were striking. They found that 97% of people living with both HIV and HBV received antiviral treatment according to guidelines, compared to only 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 semi-annual follow-up for liver cancer (55%).
Lee and his colleagues suggested that the reason for the improved care for the HIV-positive group may be that they are more likely to receive care from infectious disease specialists. Patients without specialist care were less likely to receive antiviral treatment or follow-up for liver cancer, while those seen by both infectious disease specialists and gastroenterologists were most likely to receive recommended care.
“The quality of HBV-related care has the potential to improve further by expanding access to specialist care and by studying and removing barriers to patient- and system-related care,” Lee told Healio.com.
Click here to read the CROI summary on HBV vaccination for people living with HIV.
Click here to read the summary of clinical infectious diseases.
Click here for more CROI 2022 news.
For more information on viral hepatitis, visit POZ’s sister publication HepMag.com.