HBV- HIV co-infection

cases
Case-1
A 39-year-old woman with HIV infection come to start antiretroviral
therapy. He also told to has chronic hepatitis B virus (HBV) infection.
- He has no other medical problems and is taking no medications. You
are planning on promptly starting HIV antiretroviral therapy for this
man.
How do you work him up ?
• baseline labs show a CD4 count of 488 cells/mm3,
• HIV RNA 68,400 copies/mL
• HBeAg +,
• HBV DNA level of 18,800,000 IU/mL.
• Plt- 101K/ml
• Alt-100Iu/ml
• Alb-3mg/dl
• AFP-5
• Abdominal US- coarse liver
• EGD- no varices
How do you treat this pt? which regimen?
• A. Dolutegravir plus tenofovir alafenamide-emtricitabine
• B. Dolutegravir-abacavir-lamivudine
• C. Raltegravir plus abacavir-lamivudine
• D. Entecavir plus tenofovir DF-emtricitabine
• E. Darunavir plus ritonavir plus abacavir-lamivudine
How do you follow this pt?
• Look for Decompensation
• HCC surveillance
Case-2
• A 43-year-old woman has HIV and hepatitis C virus (HCV) coinfection.
• She is seen in clinic to start treatment.
• What lab investigation do you order?
• Laboratory studies are obtained prior to starting treatment for HCV
and they show:
She has never received treatment for HIV, HCV, or HBV

• HIV RNA level of 2,460 copies/mL

• CD4 count of 884 cells/mm3
• Positive HBsAg and negative anti-HBS
• HCV RNA 1.1 million IU/mL
• HCV genotype- 4
• Alanine aminotransferase level of 56 U/L.
• CBC- in NR except - plt -90K
• Cr- 0.9
• Abdominal us- cirrhosis no ascites
• How do you approach ? Which one to treat 1st ? What regimen to use ?
• EGD-no varices
• plan was to defer antiretroviral therapy for HIV and promptly start
HCV treatment with a 24 -week course of ledipasvir-sofosbuvir.
• On follow up -4wks
• Alt- 300iu/ml

• How to explain the elevated ALT elvation of the pt.

• DDX-
• Reactivation of HBV
• DILI
• Alcoholic hepatitis
• HBeAg- seroconvertion
How to proceed in this pt?
1. do you do HB-VL?
2. Do you hold the DAA?
3. DO you start with ART? Which regimens?
Take home
There is increased risk of HBV reactivation and hepatic flare during HCV
therapy when oral direct-acting antiviral agents are used for HCV
treatment.