| a) |
Cirrhotic patients should be referred for variceal assessment, have regular HCC monitoring and should be referred early for transplant assessment. Patients with liver cirrhosis and low CD4-counts require careful surveillance in the first months after starting HAART in order not to overlook immune-reconstitution syndrome and subsequent liver decompensation due to flares of liver enzymes. |
| b) |
See Figure 1 for assessment of HBV Rx indication. Some experts strongly believe that any HBV-infected patient requiring HAART should receive TDF + 3TC or FTC unless history of TDF intolerance, particularly in HIV/HBV co-infected patients with advanced liver fibrosis (F3/F4). |
| c) |
Antiretroviral naïve Asian, HBe-Ag+, HIV coinfected patients initiating HAART with TDF or TDF+FTC reached unexpected high rates of HBe (and even HBs) seroconversion, strengthening the rationale for early HAART. If a patient is unwilling to go on early HAART, adefovir and telbivudine may be used as an alternative to control HBV alone. A recent case report suggested possible anti-HIV activity of telbivudine. In-vitro data using an assay which was able to demonstrate anti-HIV-activity of entecavir however, failed to detect an influence of telbivudine on the replicative capacity of HIV-1. |
| d) |
Treatment length: 48 weeks for Peg-INF; recent data suggests that on-treatment quantification of HBsAg in patients with HBeAg-negative chronic hepatitis B treated with Peg-INF may help identify those likely to be cured by this therapy and optimize treatment strategies. The optimal treatment duration for nucleos(t)ide analogues with anti-HBV activity has not yet been determined and experts recommend life-long therapy if anti-HBV nucleos(t)ides are given as part of HAART. Patients not requiring HAART and on treatment with telbivudine +/- adefovir, or those on HAART where nucleoside back-bone needs changing, anti-HBV therapy may be stopped cautiously in HBeAg+ patients who have achieved HBe-seroconversion for at least six months or, after confirmed HBs-seroconversion in those who are HBeAg-. In patients with liver cirrhosis a stop of effective anti-HBV treatment is not recommend to avoid liver decompensation due to flares of liver enzymes. |
| e) |
In some cases of tenofovir intolerance (i.e. renal disease), entecavir + adefovir or tenofovir in doses adjusted to renal clearance in combination with effective HAART may be advisable. NRTI substitution should only be performed if feasible and appropriate from the perspective of maintaining HIV suppression. Caution is warranted to switch from a tenofovir based regimen to drugs with a lower genetic barrier, e.g. FTC/3TC, in particular in lamivudine pretreated cirrhotic patients as viral breakthrough due to archived YMDD mutations has been observed. This has also been described in individuals with previous 3TC HBV-resistance who have been switched from tenofovir to entecavir. |
