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Brief Report: Hepatitis B Infection or Reactivation After Switch to 2-Drug Antiretroviral Therapy: A Case Series, Literature Review, and Management Discussion
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Vasishta, Shilpa MDa; Dieterich, Douglas MDb; Mullen, Michael MDa; Aberg, Judith MDa AIDS Journal of Acquired Immune Deficiency Syndromes Oct 1 2023
Despite the frequency of liver-related complications in HIV-HBV coinfection, studies demonstrate that HIV clinicians may not monitor for HBV complications as frequently as guidelines recommend.
Among PWH worldwide, up to 20% have HBV coinfection, whereas many more have prior infection (ie, HBcAb) or risk of exposure.
Among PWH with chronic HBV infection, lifelong HBV treatment is indicated, either with TAF/TDF and 3TC/FTC, or with ETV and a complete HIV regimen.
HBV infection or reactivation may confer significant morbidity and mortality and constitute a preventable complication for PWH on stable HBV-active ART. As NRTI-sparing options continue to expand, we encourage increased scrutiny during ART switches to mitigate HBV-associated complications.

Two-drug antiretroviral therapy (ART) without hepatitis B virus (HBV) activity is prescribed for persons with HIV as simplified or salvage therapy. Although two-drug regimens are not recommended for persons with chronic HBV infection, guidelines do not address their use in those with HBV susceptibility and/or core antibody reactivity. We present a case series of individuals with HBV infection or reactivation following switch to two-drug, non-HBV-active ART.
HIV primary care clinics of an academic medical center in New York, NY.
Case surveillance was conducted to identify persons with HBV surface antigenemia and viremia following two-drug ART switch. Clinical characteristics and outcomes were ascertained through chart review.
Four individuals with HBV infection or reactivation after ART switch were identified. Two had HBV susceptibility, 1 had core antibody reactivity, and 1 had surface antigen reactivity preswitch. All eligible persons had received HBV vaccination: 2 with low-level antibody response and 1 with persistent nonresponse. Two presented with fulminant hepatitis, with 1 required liver transplantation.
Two-drug ART switch may pose risk of HBV infection or reactivation. We propose careful patient selection and monitoring through the following: (1) assessment of HBV serologies before switch and periodically thereafter, (2) vaccination and confirmation of immunity before switch, (3) risk stratification and counseling about HBV reactivation for those with core antibody, (4) preemptive HBV DNA monitoring for those at the risk of reactivation, (5) continuation of HBV-active prophylaxis when above measures are not feasible, and (6) continuation of HBV-active therapy and surveillance for chronic HBV infection.


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