Hepatitis B is a viral infection that primarily affects the liver and is caused by the hepatitis B virus (HBV). It is a major global health concern, with an estimated 257 million people living with chronic hepatitis B worldwide.
Hepatitis B can have significant implications for individuals who are coinfected with other viral infections, such as human immunodeficiency virus (HIV) and hepatitis C virus (HCV). Understanding the interactions between hepatitis B and these coexisting viral infections is crucial for effective management and treatment.
In this article, we will delve into the intricacies of hepatitis B coinfection, its impact on HIV, HCV, and other viral infections, and explore potential treatment strategies.
Coinfection: Hepatitis B and HIV:
Hepatitis B and HIV coinfection are relatively common, especially in regions where both viruses are endemic. The two viruses share similar routes of transmission, making co-infection a significant concern.
Coinfection with HIV can have a profound impact on the natural course and clinical outcomes of hepatitis B, as well as HIV itself. Key points to consider include:
a. Disease Progression: Coinfection with HIV can have a profound impact on the natural course of hepatitis B. HIV-mediated immunosuppression weakens the immune response against HBV, leading to increased viral replication and liver inflammation.
As a result, individuals with HIV and hepatitis B coinfection are more likely to experience faster progression of liver fibrosis, higher rates of liver cirrhosis, and an increased risk of developing hepatocellular carcinoma (HCC), a type of liver cancer.
b. Antiretroviral Therapy (ART): The management of individuals with HIV and hepatitis B coinfection requires careful consideration due to potential drug interactions and hepatotoxicity. Some antiretroviral drugs used in ART regimens are effective against both HIV and HBV, providing dual benefits by suppressing both viruses.
These medications, such as tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF), have potent antiviral activity against both HIV and HBV. However, certain antiretroviral drugs may have limited activity against HBV or can cause HBV resistance, necessitating careful selection and monitoring of treatment regimens.
c. Immune Reconstitution: With the initiation of ART, individuals with HIV and hepatitis B coinfection may experience immune reconstitution inflammatory syndrome (IRIS), which is characterized by an exaggerated immune response against hepatitis B antigens.
IRIS can lead to an exacerbation of hepatitis B symptoms, liver inflammation, and liver enzyme elevation. Close monitoring of liver function, viral replication, and appropriate management strategies are necessary during this period to prevent further liver damage.
Coinfection: Hepatitis B and HCV:
Hepatitis C virus (HCV) coinfection in individuals with chronic hepatitis B is also a significant concern, particularly among people who inject drugs (PWID).
Coinfection with HCV and HBV can have a synergistic effect on liver disease progression and complications. Consider the following aspects:
a. Increased Liver Damage: Coinfection with HCV and HBV has a synergistic effect on liver disease progression.
The presence of both viruses leads to increased liver inflammation, more rapid fibrosis progression, and a higher risk of developing liver cirrhosis, liver failure, and HCC.
Coinfected individuals may experience more severe liver disease compared to those infected with either virus alone.
b. Treatment Challenges: The management of individuals with both chronic hepatitis B and HCV infections requires careful consideration due to the complexity of treating dual viral infections.
Antiviral therapies for hepatitis B and HCV must be selected based on their activity against both viruses, potential drug interactions, and the risk of cross-resistance.
Newer direct-acting antiviral (DAA) therapies for HCV have revolutionized the treatment landscape, offering high cure rates. However, selecting optimal regimens that address both HBV and HCV infections can be challenging and may require the expertise of a liver specialist.
c. Liver Transplantation: Coinfection with HBV and HCV can influence the eligibility and outcomes of liver transplantation.
The presence of both viruses increases the risk of graft failure and the likelihood of viral reactivation post-transplant.
Careful assessment of liver function, viral replication, and appropriate antiviral prophylaxis strategies are crucial for successful transplantation outcomes in coinfected individuals.
Coinfection: Hepatitis B and Other Viral Infections:
Apart from HIV and HCV, individuals with chronic hepatitis B may also experience coinfections with other viral pathogens, such as the hepatitis D virus (HDV) and the hepatitis E virus (HEV). Understanding these interactions is vital for comprehensive management. Key points include:
a. Hepatitis D Virus (HDV): HDV is a defective virus that requires the presence of HBV for replication. Coinfection with HDV and chronic hepatitis B can lead to more severe liver disease compared to HBV mono-infection.
HDV superinfection, where HDV infects an individual already infected with HBV, is particularly concerning. It can result in severe liver injury, accelerated fibrosis progression, and an increased risk of developing cirrhosis and HCC.
Treatment options for HDV are limited, and interferon-based therapies are currently the mainstay of treatment.
b. Hepatitis E Virus (HEV): HEV infection is primarily transmitted through contaminated food and water.
It usually causes acute hepatitis, but in individuals with chronic hepatitis B, coinfection with HEV can lead to more severe liver injury and complications.
HEV superinfection in pregnant women with chronic hepatitis B has been associated with an increased risk of fulminant hepatitis, leading to adverse maternal and fetal outcomes.
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Singh, K. P., Crane, M., Audsley, J., Avihingsanon, A., Sasadeusz, J., & Lewin, S. R. (2017). HIV-hepatitis B virus coinfection: epidemiology, pathogenesis, and treatment. AIDS (London, England), 31(15), 2035–2052. https://doi.org/10.1097/QAD.0000000000001574
Saravanan, S., Velu, V., Kumarasamy, N., Nandakumar, S., Murugavel, K. G., Balakrishnan, P., Suniti, S., & Thyagarajan, S. P. (2007). Coinfection of hepatitis B and hepatitis C virus in HIV-infected patients in south India. World journal of gastroenterology, 13(37), 5015–5020. https://doi.org/10.3748/wjg.v13.i37.5015
Co-infection of Hepatitis B and Hepatitis C among HIV-infected patients: A cross-sectional from tertiary care hospital of easternNepal