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New York State Updated HBV Guidelines in HIV+
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What's New and Key Recommendations - August 2013 Update
The Office of the Medical Director, New York State Department of Health AIDS Institute, is pleased to announce that the Medical Care Criteria Committee, under the leadership of Judith Aberg, MD, and Samuel Merrick, MD, has updated the guidelines for the manag
ement of Hepatitis B Virus in HIV-infected patients.
RECOMMENDATION:
Clinicians should assess for the risk of hepatocellular carcinoma in HIV-infected patients with chronic HBV according to standard guidelines (see Table 5).
"......surveillance has to be based on ultrasound examination. The recommended screening interval is 6 months. Diagnosis of
HCC should be based on imaging techniques and/or biopsy.......Serum α-fetoprotein screening is no longer recommended as part of surveillance for HCC among patients at high risk. (AI).......Patients with cirrhosis are at HIGH RISK for HCC & should receive screening every 6 months. Patients at High Risk for Hepatocellular Carcinoma*:
· Asian men over 40 years and Asian women over 50 years of age64
· Black patients over 20 years of age64
· Patients over 40 years of age with persistent or intermittent serum ALT elevation and/or HBV DNA level >2000 IU/mL64,65
· Patients with cirrhosis64,65 including those awaiting transplantation65
· Patients with a family history of HCC64,65
· Patients with chronic HCV infection and advanced liver fibrosis65
Hepatocellular carcinoma (HCC) is a major cause of death in patients with chronic HBV infection, and all HIV-infected patients should be assessed for the risk of HCC. However, determining an individual's risk can be challenging. According to guidelines from the American Association for the Study of Liver Diseases (AASLD)64 and the European Association for the Study of the Liver (EASL),65 the patient populations listed in Table 5Table 5 are at high risk for HCC.
What's New and Key Recommendations - August 2013 Update
HBV Vaccination in HIV-Infected Patients (see Section IV)
· Administer the HBV vaccination series to HIV-infected patients who are susceptible to HBV infection (see Figure 3)
· Alternative vaccination strategies may be considered for primary HBV vaccination, such as a three- or four-injection double-dose vaccination series or an accelerated HBV vaccination schedule of 0, 1, and 3 weeks. Do not administer the accelerated HBV vaccination schedule to patients with CD4 counts <500 cells/mm3.
· Test for anti-HBs 1 to 2 months after administration of the last dose of the vaccination series
· Re-vaccinate with a double-dose vaccination series when HIV-infected patients do not respond to the primary HBV vaccination series (hepatitis B surface antibody <10 IU/L)
Treatment of HBV Infection in the Setting of HIV (see Section VII)
· Strongly encourage HIV-infected patients with chronic HBV infection to initiate treatment for both viruses
· Initiate treatment with an ART regimen that contains two agents that are also active against the patient's HBV strain, including tenofovir plus either lamivudine or emtricitabine
· Consult with a provider experienced in the treatment of hepatitis and HIV to determine an alternative anti-HBV regimen if first-line anti-HBV treatment with tenofovir plus lamivudine or emtricitabine cannot be prescribed because of HBV resistance to any of these agents or the presence of renal insufficiency or fulminant hepatic disease
· Avoid discontinuation of either HBV or HIV treatment whenever possible and monitor serum ALT levels closely if discontinuation of anti-HBV therapy is unavoidable
Monitoring HIV-Infected Patients with Chronic HBV Infection (see Section VIII)
· Monitor HIV/HBV co-infected patients according to the considerations listed in Table 4
· Assess for the risk of hepatocellular carcinoma (HCC) in HIV-infected patients with chronic HBV infection according to standard guidelines (see Table 5)
· Perform surveillance for HCC among patients at high risk every 6 to 12 months according to standard guidelines (see Section VIII. B. Patients at Risk for Hepatocellular Carcinoma)
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