HIV Hepatitis B and C Coinfection
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Direct answer
HIV hepatitis B and C coinfection means chronic infection with HIV together with hepatitis B virus or hepatitis C virus, and HIV speeds progression to fibrosis, cirrhosis and liver failure. In hepatitis B, the tenofovir-containing ART backbone treats both viruses and must not be stopped abruptly. In hepatitis C, direct-acting antivirals cure most patients but must be checked for interactions with the ART regimen.
What you must remember
- Liver progression: HIV accelerates fibrosis in both viral hepatitides, so cirrhosis and liver-related death occur earlier than in monoinfected patients.
- HBV backbone: Tenofovir disoproxil or tenofovir alafenamide, with emtricitabine or lamivudine, is active against both HIV and hepatitis B.
- Entecavir: Active against hepatitis B but with no meaningful anti-HIV effect, so it cannot replace tenofovir in the ART regimen.
- Stopping tenofovir: Abrupt withdrawal can trigger a severe hepatitis B flare, so ALT and HBV DNA are monitored closely if the backbone is changed.
- HCV treatment: Direct-acting antivirals achieve high cure rates in coinfection, and ritonavir- or cobicistat-boosted ART must be checked for interactions first.
- Serology: HBsAg, anti-HBs and anti-HBc in every HIV patient, with HBV DNA when needed, and HCV antibody confirmed by HCV RNA for active infection.
- Vaccination: Non-immune HIV patients are offered hepatitis B vaccine, often with a higher-dose or extended schedule, because HIV blunts the response.
Where the exam tries to catch you
Most errors come from treating the two viruses separately, or from changing the ART without thinking about the hepatitis.
- Trap: Using entecavir alone as HIV-HBV treatment. Correct: Entecavir treats hepatitis B but lacks anti-HIV activity, so an active ART backbone is still required.
- Trap: Stopping tenofovir for renal or bone concern without replacing hepatitis B cover. Correct: Switching to tenofovir alafenamide is preferred over stopping, and any change must keep an active hepatitis B drug to avoid a flare.
- Trap: Prescribing a direct-acting antiviral without checking the boosted ART. Correct: Ritonavir and cobicistat can alter DAA levels, so the interaction check is mandatory before the combination starts.
- Trap: Treating HIV-HCV coinfection as slow-moving because the patient feels well. Correct: HIV accelerates fibrosis, so early DAA treatment is prioritised in coinfected patients.
Frequently asked questions
Which ART drugs are active against both HIV and hepatitis B?
Tenofovir disoproxil fumarate and tenofovir alafenamide, combined with emtricitabine or lamivudine, are active against both HIV and hepatitis B. Entecavir is active against hepatitis B but has no meaningful effect on HIV, so it cannot replace the tenofovir backbone.
Why must tenofovir not be stopped suddenly in HIV hepatitis B coinfection?
Abrupt withdrawal of tenofovir in HIV hepatitis B coinfection can cause a severe hepatitis B flare with liver decompensation. Any change to the regimen must keep an active hepatitis B drug, with ALT and HBV DNA monitored during the transition.
Are direct-acting antivirals safe with ritonavir-boosted antiretroviral therapy?
Direct-acting antivirals for hepatitis C need an interaction check with ritonavir- or cobicistat-boosted ART, because the booster can alter their levels. The specific pairing should be checked against an interaction reference before the first dose.
Does HIV change the natural course of hepatitis C?
HIV accelerates liver fibrosis in hepatitis C, so cirrhosis develops earlier and liver-related mortality is higher than in hepatitis C monoinfection. This is why early direct-acting antiviral treatment is prioritised in HIV-HCV coinfection.