General principles

Sustained suppression of serum HBV DNA to below the level of detection by the most sensitive available assay method should be the goal of therapy and, at present, treatment of HBV in HIV- HBV co-infection is life-long. Current Australian and US guidelines recommend the consideration of cART in all people with HIV infection regardless of CD4+ T cell count in order to reduce the risk of disease progression. This recommendation is especially important in patients with HIV-HBV co-infection regardless of CD4+ T cell count where liver disease progression is faster and drugs with combined HIV and HBV activity are available. Because emtricitabine (FTC), lamivudine (3TC), tenofovir (TDF) and Tenofovir Alafanemide (TAF) have activity against both HIV and HBV, antiretroviral therapy should be initiated with a combination which includes TDF or TAF in the nucleoside reverse transcriptase inhibitor (NRTI) backbone of a fully suppressive antiretroviral regimen.37

If for any reason antiretroviral therapy is not used, and HBV therapy is indicated then the treatment chosen should have no anti-HIV activity. Current therapeutic options in this setting are pegylated interferon and adefovir. Of particular note, although entecavir had previously been thought to have no anti-HIV activity, more recent studies have shown that it does and can result in resistance of HIV to antiretroviral drugs.38 It should therefore not be used without a concomitant fully suppressive cART regimen.