Challenges in Providing Treatment and Care for Viral Hepatitis among Individuals Co-Infected with HIV in Resource-Limited Settings

Table 2

Summary of diagnostic criteria and treatment currently in use as well as its perspectives in management.

Stage of disease	Diagnostic criteria	Current treatment practices	Perspectives in management
Chronic hepatitis B coinfection	(i) HBsAg+ >6 mos; (ii) Serum HBV DNA >2,000 IU/mL (10^4 copies/mL); (iii) Persistent or intermittent ALT/AST elevation; (iv) Liver biopsy (done in some) showing chronic hepatitis with moderate or severe necroinflammation	Tenofovir plus lamivudine or tenofovir plus emtricitabine	(i) HBV-DNA assessment for treatment outcome; (ii) Add adefovir or entecavir if no virologic suppression or suspected resistance; (iii) Close monitoring of cirrhosis and hepatocellular carcinoma; (iv) Hepatitis B vaccination for susceptible partner
Inactive HBsAg carrier state among PLWHA	(i) HBsAg+ >6 mos; (ii) HBeAg−, anti-HBe+; (iii) Serum HBV DNA <2,000 IU/mL (10^4 copies/mL); (iv) Persistently normal ALT/AST levels; (v) Liver biopsy (unfortunately not done in clinical practice as recommended) confirms absence of significant hepatitis	Due to limited options of antiretroviral regimen, lamivudine is used as part of HAART in majority of cases that need HIV treatment	(i) Misleading term/new term “chronic low replicative hepatitis B” can be used; (ii) Lamivudine/emtricitabine preserved for combination treatment for HBV infection if indicated; (iii) Need to closely F/U: LFT. α-FP and ultrasound regularly at least q 6–12 mos for cirrhotic patients; (iv) Hepatitis B vaccination for susceptible partner
Occult hepatitis B coinfection or isolated core antibody	(i) Presence of anti-HBc +/− anti-HBs; (ii) HBsAg−; (iii) Undetectable serum HBV DNA (very low levels may be detected by sensitive PCR assays) or serum HBV DNA <2,000 IU/mL (10^4 copies/mL); (iv) Normal ALT levels	Due to limited options of antiretroviral regimen, lamivudine is used as part of HAART in majority of cases that need HIV treatment	(i) Lamivudine/emtricitabine preserved for combination treatment for future HBV infection if occult infection suspected; (ii) LFT q 6 mos if ALT/AST elevated, further assessment for HBe Ag and HBV-DNA; (iii) Hepatitis B vaccination for susceptible partner; (iv) It is not clear whether Hepatitis B revaccination is needed or not
Chronic hepatitis C coinfection	(i) Anti-HCV+ and HCV-RNA+; (ii) Normal ALT levels or ALT elevation; (iii) Liver biopsy showing fibrosis (or Fibroscan >7.5 kPa)	No treatment in most cases; For those who can afford treatment: PegIFNα2a or 2b plus ribavirin 800 mg/D, duration of treatment guided by genotype: 3,6 for 24 wks; 1 for 48 wks	(i) Selected cases with good prognostic factors can access treatment comprising PegIFN plus RBV; (ii) Genotyping and HCV-RNA for assessing EVR, RVR, and SVR; (iii) Lower dose of PegIFN; (iv) Shorter treatment duration; (v) Need F/U: LFT, α-FP and ultrasound q 6–12 mos for cirrhotic patients; (vi) Close monitoring of cirrhosis and HCC; (vii) Harm reduction to reduce transmission