Hepatitis B Virus Infection Flashcards
What is the average incubation period for HBV infection?
90 days (range 60–150 days)
What percentage of adults with HBV infection spontaneously recover and develop protective antibodies?
Many adults
What is the leading cause of chronic liver disease worldwide?
Chronic hepatitis B
What percentage of people with HIV have evidence of chronic HBV infection globally?
Approximately 8%
What are the primary transmission routes for HBV in higher-prevalence regions?
Perinatal and early-childhood exposures
In low-prevalence regions, what are the main modes of HBV transmission?
Sexual contact and injection drug use
How many genotypes of HBV have been identified?
Ten genotypes (A–J)
What is the prevalence of HDV coinfection in people with chronic HBV infection?
Approximately 5%
What symptoms may manifest in acute HBV infection?
Right upper quadrant abdominal pain, nausea, vomiting, fever, arthralgias, jaundice
What percentage of people with chronic HBV infection will develop cirrhosis, HCC, or liver failure?
Between 15% and 40%
What is the recommended initial testing for chronic HBV infection?
Triple screening panel: HBsAg, anti-HBc total, anti-HBs
What defines chronic HBV infection?
Persistent HBsAg detected on two occasions at least 6 months apart
What indicates ‘active’ HBV disease?
Presence of serum HBV DNA and persistent or fluctuating ALT elevations
What is the significance of isolated anti-HBc in low-prevalence countries?
May indicate past HBV infection with loss of anti-HBs
What is the recommended frequency of HCC surveillance for people with cirrhosis?
Every 6 months
What vaccination is recommended for family members and sexual contacts of people with chronic HBV infection?
Hepatitis B (HepB) vaccine
Which adult single-antigen HepB vaccines are available in the United States?
- Engerix-B
- Recombivax HB
- Heplisav-B
What is the preferred vaccine for previously unvaccinated patients?
Heplisav-B given at 0 and 4 weeks
What defines a positive response to HepB vaccination?
Anti-HBs ≥10 mIU/mL
What is the recommended action if anti-HBs levels fall below 10 mIU/mL?
Booster dose of HepB vaccine
What should be done for individuals with isolated anti-HBc?
Vaccinated with one standard dose of HepB vaccine
What is the role of HBV-active ART in relation to acute HBV infection?
Decreases risk for acute HBV infection
What is the anti-HBs response rate for individuals with >100 mIU/mL after a booster dose?
> 18 months maintained anti-HBs response
Compared to only 23% of those with titers of 10 to 100 mIU/mL.
What should be done if anti-HBs quantitative titers are not available?
Complete the HepB vaccine series followed by qualitative anti-HBs testing
(BII)
Does HBV-active ART eliminate the risk of HBV infection?
No, it decreases the risk but does not eliminate it
Therefore, HepB vaccine is recommended even if on HBV-active ART (AIII).
What was the HBV incidence rate for MSM not on HBV-active ART?
23.8 per 1,000 person-years
Compared to 2.6 per 1,000 PYs for those on HBV-active ART with HIV RNA <400 copies/mL.
What was the hazard ratio for new HBV infection in those receiving HBV-active ART?
0.11 (95% CI 0.03–0.39)
Indicates a substantially reduced risk.
What is the recommended vaccination for all people with HIV?
Hepatitis A vaccination
Including pregnant individuals who are HAV total (IgG plus IgM) antibody negative (AIII).
What should be assessed at least 1 month after hepatitis A vaccination?
Antibody response
If total HAV antibody (anti-HAV) is negative, revaccination is needed when CD4 count >200 cells/mm3 (BIII).
What is the indication for therapy in all people with HIV/HBV coinfection?
All should be treated with an ART regimen that includes drugs active against both HIV and HBV infections
Regardless of CD4 count and HBV DNA level (AII).
What is the preferred therapy for patients with CrCl ≥60 mL/min?
ART regimen should include two drugs active against HBV, preferably with TAF or TDF
TAF (10 or 25 mg) plus FTC 200 mg or TDF 300 mg plus FTC 200 mg or 3TC 300 mg PO once daily (AII).
What should be done for patients with CrCl <30 mL/min who are not receiving hemodialysis?
Renally dosed entecavir or ART with renally dose-adjusted TDF and FTC or 3TC
(AIII).
What is the monitoring frequency for HBV DNA during therapy?
Every 6 months
(AII).
What should be monitored yearly in patients on HBV treatment?
HBsAg
(AIII).
What therapy should be given if there is a switch to a nucleos(t)ide-sparing ARV regimen for patients with chronic HBV infection?
Anti-HBV therapy (TDF, TAF, or entecavir) must be given
(AIII).
What is a significant risk for people with HBV/HCV/HIV coinfection?
Accelerated liver fibrosis progression, high risk of HCC, and increased mortality
(AII).
What is the preferred dual-NRTI backbone for pregnant people with chronic HBV infection?
TAF or TDF with 3TC or FTC
(AIII).
What should infants born to HBsAg positive individuals receive within 12 hours of delivery?
HBIG and HepB vaccine (first dose)
Followed by second and third doses at 1–2 months and 6 months of age, respectively (AI).
What is the effect of switching from a TDF-based ART regimen to TAF/FTC/elvitegravir/cobicistat in HIV/HBV coinfected individuals?
Maintained or achieved HBV suppression, improved eGFR and bone turnover markers
eGFR refers to estimated glomerular filtration rate.
How did TAF 25 mg compare to TDF 300 mg in terms of HBV DNA levels after 48 weeks?
Non-inferior; 94% for TAF vs. 93% for TDF (P = 0.47)
This indicates similar efficacy in maintaining low HBV DNA levels.
What were the findings regarding bone mineral density in individuals receiving TAF compared to TDF?
TAF had significantly smaller mean percentage decreases in hip and spine bone mineral density at 48 weeks (P < 0.0001)
Indicates better bone health outcomes with TAF.
What was the result of the study comparing TAF/FTC/bictegravir (BIC) to TDF/FTC/DTG in HIV/HBV coinfected individuals?
TAF/FTC/BIC was superior in achieving HBV DNA <29 IU/ml at 48 weeks (63% vs. 43%, P = 0.002)
Similar results at 96 weeks (75% vs 70%, P = 0.64).
Why is chronic administration of 3TC or FTC as the only active drug against HBV not recommended?
High rate of selection of HBV drug-resistance mutations
This leads to treatment failure and complications.
What should people receiving ART do regarding HBV therapy?
Continue HBV therapy indefinitely
Relapses can occur, especially with lower CD4 counts.
What is the risk of HBV reactivation after discontinuation of nucleos(t)ide analog therapy?
Approximately 30%
This can lead to decompensation of liver disease and even death.
What should be monitored if anti-HBV therapy and ART are discontinued?
Serum transaminase levels and HBV DNA every 6 weeks for 3 months, then every 3 months
Essential for detecting reactivation.
What is the recommendation for people with HIV/HBV coinfection who will be treated for HCV infection?
Should be on HBV-active ART at the time of HCV treatment initiation
Prevents HBV reactivation during HCV treatment.
What tests should be conducted before switching to nucleos(t)ide-sparing regimens?
Check HBsAg, anti-HBc, and anti-HBs
Avoids reactivation of unrecognized chronic HBV infection.
Why should switching to DTG/3TC be avoided in people with chronic HBV infection?
3TC would be the only active drug against HBV
Increases risk of treatment failure.
What is the risk of HBV reactivation in individuals who are anti-HBc positive and HBsAg negative after switching to a nucleos(t)ide-sparing regimen?
1.6%
Higher risk in those with a remote positive HBsAg.
What is the recommendation for people with isolated anti-HBc positivity regarding nucleos(t)ide-sparing regimens?
Consider not switching due to small risk of reactivation
Benefits should outweigh the risk.
What is the recommended treatment for people with HIV who are not receiving HBV-active ART?
All people with HIV should receive ART; co-treatment for HIV/HBV is essential
Pegylated interferon (IFN)-α-2a should be used rarely with expert consultation.
What regimens are not recommended for HBV treatment in individuals with HIV?
TDF, TAF, entecavir, 3TC, and FTC alone without fully HIV-suppressive ART
Risk of developing HIV drug-resistance mutations.
How often should HBV DNA be monitored to evaluate response to therapy?
Every 6 months
Treatment responses are slower compared to HIV therapy.
What constitutes a virologic response in HBV therapy?
Undetectable HBV DNA (<10 IU/mL) by real-time PCR
Indicates effective suppression of the virus.
What is the significance of sustained loss of HBsAg?
Considered a complete response or functional cure
Uncommon in HBsAg-positive people without HIV.
What adverse effect is associated with TDF regarding renal health?
Renal toxicity, including increased serum creatinine or renal tubular dysfunction
More frequent in individuals with renal insufficiency.
What should be evaluated at baseline and every 6 months for patients on TDF?
Electrolytes and serum creatinine levels
Essential for monitoring renal function.
What is the relationship between TDF and bone mineral density?
Associated with a decrease in BMD
TAF is associated with less decrease in BMD.
What is immune reconstitution inflammatory syndrome (IRIS)?
Reactivation of HBV-associated liver disease after return of immune competence
May cause hepatitis flare.
What should be monitored closely after ART initiation?
Serum ALT levels
Recommended testing at 6 and 12 weeks, then every 3 to 6 months.
What defines HBV treatment failure on nucleos(t)ide analogs?
Primary nonresponse after 3 months or increase in HBV DNA levels >1 log10 above nadir
Indicates either drug resistance or nonadherence.
What should be done if drug-resistant HBV is present?
Change in treatment is needed
Distinct resistance patterns exist for different anti-HBV drugs.
What is the rate of developing 3TC-resistance among people with HIV/HBV coinfection?
Approximately 20% per year
Indicates risks associated with monotherapy.
What is the recommendation if treatment failure occurs on entecavir?
TDF or TAF (with or without FTC) is recommended
Due to cross-resistance with L-nucleosides.
What should be done if treatment failure with TDF or TAF occurs?
Consider entecavir as an active alternative
Especially if higher doses can be used.
What is recommended for people with HBV infection who failed to respond to pegylated IFN-α?
Nucleos(t)ide analog therapy
Follow the previous recommendations (CIII)
What are the recommended treatments for people with HBV infection who experience treatment failure with TDF or TAF?
Entecavir may be an active alternative
Especially if higher doses can be used (CIII)
How quickly do HBV DNA levels typically drop among people receiving a high-potency drug like tenofovir?
Quickly, but may still be detectable for some years
Especially in those with very high pretherapy HBV DNA levels
What is the management recommendation for people with HIV/HBV coinfection and end-stage liver disease?
Manage as a person with HBV mono-infection
Including referral to a hepatologist (AIII)
Is IFN-α contraindicated for people with HIV/HBV coinfection in end-stage liver disease?
Yes, it is contraindicated
Nucleos(t)ide analogs are safe and efficacious (AI)
What dietary restriction is recommended for people with ascites?
Sodium restriction (<2 g/day)
Combined with a diuretic regimen of spironolactone and furosemide
What is the recommended prophylaxis for spontaneous bacterial peritonitis (SBP)?
Oral antibiotics such as ciprofloxacin or trimethoprim-sulfamethoxazole
Administered to those with ascites and specific conditions (AI)
How often should esophagogastroduodenoscopy (EGD) be performed on people with cirrhosis?
Every 1 year to 2 years
To identify substantial gastroesophageal varices
What is a primary prevention method for variceal hemorrhage?
Nonselective beta blockers
Such as nadolol or propranolol
What kind of diet is recommended for treating hepatic encephalopathy?
40-g protein diet
Along with nonabsorbable disaccharides or antibiotics
What imaging studies should be performed for people with HBV-related cirrhosis?
Alpha fetoprotein imaging studies every 6 months
To monitor for HCC risk (AI)
Are people with HIV/HBV coinfection candidates for liver transplantation?
Yes, if they have decompensated liver disease or early HCC
HIV infection is not a contraindication
What is the recommendation for HBV therapy after achieving response?
Continue HBV therapy with nucleos(t)ide analogs indefinitely
To prevent relapses, especially in those with lower CD4 counts (AIII)
What is the risk of HBV reactivation during immunosuppressive therapy?
Reactivation can occur in up to 18% of people
Especially with anti-cancer drugs and anti-CD20 antibodies
What testing should be done for people with HIV undergoing immunosuppressive therapy?
HBsAg, anti HBc, and anti-HBs testing
To assess HBV status
What is the preferred ART regimen for people who are HBsAg positive?
TDF or TAF plus 3TC or FTC
As part of their HIV regimen (AII)
What is the recommendation for pregnant people with HIV regarding HBV screening?
Screen for HBV infection during each pregnancy
Preferably in the first trimester (AI)
What vaccine should be offered to pregnant people who are HBsAg negative and anti-HBs negative?
Vaccination against HBV
Recommended (AII)
What is the recommended NRTI backbone for pregnant people with chronic HBV infection?
TAF or TDF in combination with 3TC or FTC
Preferred for those with HIV/HBV coinfection (AIII)
What is the recommendation for infants born to HBsAg positive mothers?
Receive HBIG and HepB vaccine within 12 hours of delivery
Followed by additional doses at specific intervals (AI)
