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Hepatitis – Treatment Overview


For information on prevention of HBV or HCV infection in PLWHIV, and on the reduction of risk factors for fibrosis progression, refer to the page on risk factors and prevention

Antiretroviral therapy (ART) initiation in HBV/HCV-HIV co-infected patients

  • Early initiation of ART may be beneficial in HBV-HIV or HCV-HIV co-infection, as progression of hepatic fibrosis is reduced with changes associated with successful ART, such as immune reconstitution and suppression of HIV RNA 1,2
    • in patients with HCV-HIV co-infection, ART should be initiated if the CD4 cell count is <500 cells/µL
      • in patients with <350 CD4 cells/μL, ART should be initiated and CD4 cell levels should be allowed to rise before starting anti-HCV treatment
      • patients with a CD4 relative percentage >25% are more likely to achieve sustained virological response (SVR) than patients with a lower CD4 percentage.1 Access ‘Absolute CD4 Vs. CD4 Percentage for Predicting the Risk of Opportunistic Illness in HIV Infection’ for a discussion of the use of CD4 counts and CD4 percentages in clinical practice.
    • in HBV-HIV co-infected patients requiring anti-HBV therapy, an initial tenofovir-based ART regimen is recommended if they have a CD4 cell count of <500 and are HBs-Ag (hepatitis B surface antigen) positive (irrespective of HBV disease phase/state).1
  • Careful monitoring is needed in patients with hepatic cirrhosis and a low CD4 cell count for the first months after starting ART, as immune-reconstitution syndrome may occur along with flares of liver enzymes and liver decompensation1
  • ART has been shown to improve survival in cirrhotic patients1
  • Caution is warranted in HBV-HIV co-infected patients who stop treatment with tenofovir, lamivudine or emtricitabine, because they all have anti-HBV effects1
    • stopping treatment with tenofovir, lamivudine or emtricitabine may lead to a viral escape inflammatory flare, which could be severe, particularly in people with cirrhosis.2

Anti-HBV treatment

  • The need for anti-HBV treatment depends on the degree of hepatic fibrosis present, and the patient’s HBV DNA and alanine aminotransferase (ALT) levels.1
  • Treatment of chronic HBV infection in PLWHIV is primarily with peginterferon or with appropriate nucleoside reverse transcriptase inhibitors (NRTIs)1
    • NRTIs show antiviral activity against HIV and HBV; their use in the treatment of HBV-HIV co-infection requires co-ordination and careful selection to avoid toxicity and selection of resistance mutations3

Anti-HCV treatment

  • Unlike HBV and HIV, it is possible to eradicate HCV within a defined treatment period1
  • If chronic HCV infection is detected before the initiation of ART is necessary, treatment for chronic HCV is advised1
    • the goal of anti-HCV treatment is sustained virological response (SVR), defined as undetectable serum HCV ribonucleic acid at 24 weeks after the end of therapy1
  • Since successful treatment may be advantageous for the subsequent management of PLWHIV, the risk-benefit ratio should be considered for every HCV-HIV co-infected patient1
    • the progression of liver fibrosis is quicker in HCV-HIV co-infected patients than in the general HCV-infected population, and better treatment outcomes can be achieved with optimal management of co-infected patients1
  • Algorithms for management of HCV treatment in PLWHIV are shown below.
  • For additional information, download a document on treatment considerations in HCV-HIV co-infected patients

It is important to identify patients with acute HCV infection, since treatment in the acute phase is more likely to be successful than in chronic infection.1

Refer to the EACS Treatment Guidelines1 and guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents4 from the US Department of Health and Human Services (DHHS) for recommendations on the treatment of acute HCV infection in HCV-HIV co-infected people.

Anti-HDV treatment

Refer to Guidelines from the European AIDS Clinical Society (EACS) for guidance on the management of people co-infected with HIV and the hepatitis delta/D virus (HDV).


  1. European AIDS Clinical Society (EACS). Guidelines Version 6.0. Accessed 30 November 2011.
  2. BHIVA Viral Hepatitis Working Group. British HIV Association Guidelines for the Management of Coinfection with HIV-1 and Hepatitis B or C Virus 2010. Accessed 1 December 2011.
  3. Mendes-Corrêa M, Núñez M. Management of HIV and hepatitis virus coinfection. Expert Opin Pharmacother 2010;11:2497–2516.
  4. Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the Use of Antiretroviral Agents in HIV-1-infected Adults and Adolescents. Department of Health and Human Services. Accessed 14 June 2012.