Initiating Treatment in Patients with Hepatitis B and HIV Coinfection

Author: Chloe L. Thio, MD H. Nina Kim, MD, MSc

Last updated: November 1, 2011

45-year-old man with HIV infection presents for a routine visit. He is antiretroviral-naïve and has chronic hepatitis B that was diagnosed 5 years ago at the same time he was diagnosed with HIV infection. He feels well and avoids alcohol. His CD4 cell count has been in the 400 to 500 cells/mm3 range for the past several years, but recent labs were as follows:

CD4 cell count: 345 cells/mm3
HIV RNA quantitation: 150,000 copies/ml
Alanine aminotransferase (ALT) 25 U/L (upper limit of normal = 30 U/L)
HBeAg: positive
HBeAb: negative
HBV DNA quantitation: 6.5 x 106 IU/ml
Albumin and INR: normal

Which of the following is the MOST APPROPRIATE statement regarding the management of this patient's hepatitis B infection?

A The patient should undergo a liver biopsy to determine if the HBV should be treated along with treatment for HIV infection.
B The patient should be started on a highly active antiretroviral therapy regimen that also will effectively treat hepatitis B.
C Antiretroviral therapy for HIV is indicated, but antiviral therapy for HBV is not indicated because of the normal ALT. The antiretroviral combination should exclude tenofovir, emtricitabine, and lamivudine, since each of these antiretroviral medications also has activity against HBV.
D Peginterferon alfa would be considered first-line therapy for this patient's HBV infection given his HBeAg positive status.