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Recommendations for Use of Antiretroviral Drugs in Pregnant HIV-1-Infected Women for Maternal Health and Interventions to Reduce Perinatal HIV Transmission in the United States
HIV/Hepatitis B Virus Coinfection
(Last updated: August 6, 2015; last reviewed: August 6, 2015)
Panel's Recommendations Regarding HIV/Hepatitis B Virus Coinfection
All HIV-infected pregnant women should be screened during the current pregnancy for hepatitis B virus (HBV) and hepatitis C virus, unless they are known to be coinfected (see HIV/Hepatitis C Virus Coinfection) (AIII).
All HIV-infected pregnant women who screen negative for HBV (i.e., HBV surface antigen-negative, HBV core antibody-negative, and HBV surface antibody-negative) should receive the HBV vaccine series (AII).
Women with chronic HBV infection who have not already received the hepatitis A virus (HAV) vaccine series should be screened for immunity to HAV because they are at increased risk of complications from coinfection with other viral hepatitis infections (AIII).
Women with chronic HBV infection who are hepatitis A immunoglobulin G antibody-negative should receive the HAV vaccine series if they have never received it (AII).
The management of HIV/HBV coinfection in pregnancy is complex and consultation with an expert in HIV and HBV is strongly recommended (AIII).
Interferon alfa and pegylated interferon alfa are not recommended during pregnancy (AII).
All pregnant women with HIV/HBV coinfection should receive combination antiretroviral therapy (cART). Antepartum cART in HIV/HBV-coinfected pregnant women should include tenofovir disoproxil fumarate plus lamivudine or emtricitabine (AI).
Pregnant women with HIV/HBV coinfection receiving antiretroviral drugs should be counseled about signs and symptoms of liver toxicity, and liver transaminases should be assessed 1 month following initiation of antiretroviral drugs and at least every 3 months thereafter during pregnancy (BIII).
If antiretroviral drugs are discontinued postpartum in women with HIV/HBV coinfection, frequent monitoring of liver function tests for potential exacerbation of HBV infection is recommended, with prompt re-initiation of treatment for both HIV and HBV if a flare is suspected (BIII).
Decisions concerning mode of delivery in HIV/HBV-coinfected pregnant women should be based on standard obstetric and HIV-related indications alone; HBV coinfection does not necessitate cesarean delivery, if not otherwise indicated (see Intrapartum Care) (AIII).
Within 12 hours of birth, infants born to women with HBV infection should receive hepatitis B immune globulin and should initiate the HBV vaccine series (AI).
Rating of Recommendations: A = Strong; B = Moderate; C = Optional Rating of Evidence: I = One or more randomized trials with clinical outcomes and/or validated laboratory endpoints; II = One or more well-designed, nonrandomized trials or observational cohort studies with long-term clinical outcomes; III = Expert opinion
All HIV-infected women should be screened for HBV and hepatitis C virus (HCV) at entry into general HIV care. All HIV-infected pregnant women should be screened for HBV and HCV during each pregnancy, unless they are known to be coinfected. Screening for HBV should include hepatitis B surface antigen [HBsAg], hepatitis B core antibody [anti-HBc], and hepatitis B surface antibody [anti-HBs]. Women who test positive for HBsAg should have follow-up testing that includes liver function tests, prothrombin time, HB e antigen, HB e antibody, and HBV DNA.1 The male partners of all HIV/HBV-coinfected women should be referred to their own providers for both HIV and HBV counseling and testing, and for HBV vaccination if HBV susceptible, to prevent horizontal transmission of HIV as well as HBV from women to their male partners.
A positive test for anti-HBc alone can be false-positive; alternatively, it may signify remote exposure with subsequent loss of anti-HBs antibody or longstanding chronic HBV infection with loss of surface antigen (“occult” HBV infection, which can be confirmed by detection of HBV DNA).3,4 The clinical significance of isolated anti-HBc is unknown.5,6 Some experts recommend that HIV-infected individuals with anti-HBc alone be tested for HBV DNA to inform decisions about vaccination for HBV and treatment with antiretroviral (ARV) drugs. It may also be important to check HBV DNA levels in women with isolated anti-HBc before ARVs are initiated because of the risk of a paradoxical exacerbation of HBV and the occurrence of immune reconstitution inflammatory syndrome (IRIS). HIV-infected pregnant women with isolated anti-HBc and occult HBV infection typically have very low levels of HBV DNA and are thought to be at extremely low risk of transmitting HBV to their infants.2,7
HIV-infected pregnant women who screen negative for HBV (i.e., HBsAg-negative, anti-HBc-negative, and anti-HBs-negative) should receive the HBV vaccine series. HIV-infected women with remote HBV infection and current isolated anti-HBc antibody (negative HBV DNA, HBsAg , and anti-HBs) may have lost immunity to HBV and should be vaccinated.2 Data indicate no apparent risk to developing fetuses of adverse events from hepatitis B vaccine, and current vaccines contain noninfectious HBsAg.8 Household contacts of HBV-infected women should also be tested for HBV, and if negative, receive the HBV vaccine series.2,9 Anti-HBs titers should be obtained 1 month after completion of the vaccine series in HIV-infected patients; if anti-HBs titers are below 10 IU/mL, a second vaccine series is recommended.2
Because of the added risk of hepatic decompensation from acute infection with hepatitis A virus (HAV) in individuals with chronic HBV or HCV, women who are found to have HBV infection should also be screened for HAV using antibody testing for immunoglobulin G (IgG). If HAV IgG is negative, and if the HAV vaccine was not given previously, HIV/HBV-coinfected women should receive the HAV vaccine series. Women who have already received the HAV vaccine series do not need to repeat it because they are protected but may have undetectable HAV IgG levels. Although the safety of HAV vaccination during pregnancy has not been determined, HAV vaccine is produced from inactivated HAV and the theoretical risk to the developing fetus is expected to be low.8
Therapy for HIV and Hepatitis B Virus in Pregnancy
A combination antiretroviral therapy (cART) regimen that includes drugs active against both HIV and HBV is recommended for all individuals with HIV/HBV coinfection who require HBV treatment or who are starting ARV drugs, including all pregnant women. Initiation of cART may be associated with reactivation of HBV and development of IRIS, particularly in patients with high HBV DNA levels.2,10
In addition, use of ARV drugs with anti-HBV activity during pregnancy lowers HBV viremia, potentially increasing the efficacy of neonatal hepatitis B immune globulin (HBIG) and hepatitis B vaccine in prevention of perinatal transmission of HBV. High maternal HBV DNA levels are strongly correlated with perinatal HBV transmission and with failures of HBV passive-active immunoprophylaxis.11-13 Several small studies and a recent meta-analysis suggest that lamivudine or telbivudine may reduce the risk of perinatal transmission of HBV if given during the third trimester to HBV-infected, HIV-seronegative women with high HBV DNA viremia.14-21 Although a high HBV viral load clearly is important, it is not the only factor predisposing to failure of HBV prophylaxis.7,22 In a study of 2,048 HIV-infected pregnant women in Malawi, 5% (103 women) were HBsAg-positive, 70 of whom were also HBV DNA-positive. Nearly 10% of infants born to HBV/HIV co-infected mothers had HBV DNA detected by age 48 weeks despite being immunized at ages 6, 10, and 14 weeks per standard-of-care health practices in this population.23
Lamivudine, tenofovir disoproxil fumarate (tenofovir), and emtricitabine have activity against both HIV and HBV. Tenofovir with emtricitabine or lamivudine is the preferred dual nucleoside reverse transcriptase inhibitor backbone in women who are HIV/HBV-coinfected (see Table 6). These agents are recommended for use in pregnancy (see Table 6). Please see individual drug sections for tenofovir, emtricitabine, and lamivudine for detailed review of safety, pharmacologic, and other clinical data for use in pregnancy.
Several other antivirals with activity against HBV, including entecavir, adefovir, and telbivudine, have not been well evaluated in pregnancy. Entecavir is associated with skeletal anomalies in rats and rabbits but only at doses high enough to cause toxicity to the mother. Fewer than 57 cases of exposure to each of these drugs during the first trimester have been reported to the Antiretroviral Pregnancy Registry prospectively, with no increased risk of birth defects.24 Telbivudine was given to 135 HBV-positive, HIV-seronegative women during the third trimester and was well tolerated, and perinatal transmission of HBV was lower in telbivudine-treated mothers than in the controls not on telbivudine (0% vs. 8%; P = 0.002).17,25 In 2 separate meta-analyses of the effects of telbivudine in late pregnancy in women infected with HBV alone, telbivudine was effective in interrupting intrauterine HBV infection without significant adverse effects or complications.18,26 For HIV/HBV coinfected pregnant women, both entecavir and telbivudine should be administered only in addition to a fully suppressive cART regimen for HIV. Because these other anti-HBV drugs also have weak activity against HIV, they may select for anti-HIV drug resistance in the absence of fully suppressive cART regimen as well as confer the potential for developing cross-resistance to other ARV drugs (e.g., entecavir can select for the M184V mutation, which confers HIV resistance to lamivudine and emtricitabine). Although adefovir does not have significant anti-HIV activity, it is not recommended for treatment of HBV because it is less potent and has a higher risk of selecting for resistance mutations than the preferred HBV nucleos(t)ides.2 Cases of exposure during pregnancy to any of the ARV drugs and HBV drugs listed should be reported to the Antiretroviral Pregnancy Registry (800-258-4263; http://www.apregistry.com).
Interferon alfa and pegylated interferon alfa are not recommended for use in pregnancy and should be used only if the potential benefits outweigh the potential risks. Although interferons are not teratogenic, they are abortifacient at high doses in monkeys and should not be used in pregnant women because of their direct antigrowth and antiproliferative effects.27
Monitoring of HIV/Hepatitis B Virus-Infected Women during Pregnancy
Following initiation of ARV drugs, an elevation in hepatic enzymes can occur in HIV/HBV-coinfected women—particularly those with low CD4 T lymphocyte counts at the time of treatment initiation—as a result of an immune-mediated flare in HBV disease triggered by immune reconstitution with effective HIV therapy. HBV infection also can increase hepatotoxic risk of certain ARV drugs, specifically protease inhibitors and nevirapine. Pregnant women with HIV/HBV coinfection should be counseled about signs and symptoms of liver toxicity, and transaminases should be assessed 1 month following initiation of ARV drugs and at least every 3 months thereafter. If hepatic toxicity occurs, it may be necessary to consider substituting a less hepatotoxic regimen or, if clinical symptoms or significant elevations of transaminases occur, drugs may need to be temporarily discontinued. Differentiating between a flare in HBV disease due to immune reconstitution and drug toxicity often can be difficult, and consultation with an expert in HIV and HBV coinfection is strongly recommended. Because tenofovir has potential to cause renal toxicity, kidney function also should be monitored regularly in pregnant women as in non-pregnant adults.
Following delivery, considerations regarding continuation of the ARV drug regimen are the same as for other non-pregnant individuals (see General Principles Regarding Use of Antiretroviral Drugs During Pregnancy). Therefore, once HBV therapy with nucleos(t)ide analogs is initiated, treatment is recommended to be continued indefinitely.1,2 Discontinuation of agents with anti-HBV activity may be associated with hepatocellular damage resulting from reactivation of HBV. Frequent monitoring of liver function tests for potential HBV flare is recommended in women with HIV/HBV coinfection who choose to stop their ARV drugs postpartum, with prompt reinitiation of treatment for both HIV and HBV if a flare is suspected.
Mode of Delivery
Decisions concerning mode of delivery in HIV/HBV-coinfected pregnant women should be based on standard obstetric and HIV-related indications alone (see Intrapartum Care). There are no data on the role of cesarean delivery in reducing perinatal transmission of HBV in HIV/HBV-coinfected women or when HBV-infected women receive antiviral therapy active against HBV. Current guidelines for HBV-monoinfected women advise that cesarean delivery is not indicated to prevent perinatal transmission of HBV.28-30
Treatment of HIV/HBV coinfected pregnant women with cART that includes tenofovir and emtricitabine will result in low or suppressed HBV viral loads near delivery, which should further reduce risk of HBV perinatal transmission
Evaluation and Management of Hepatitis B Virus-Exposed Infants
Within 12 hours of birth, all infants born to mothers with chronic HBV infection should receive HBIG and the first dose of the HBV vaccination series. For infants weighing ≥2,000 g at birth, the second and final doses of the vaccine series should be administered at ages 1 and 6 months, respectively. For infants with birth weights <2,000 g at birth, do not count the birth dose as part of the vaccine series and administer three additional doses at ages 1, 2–3, and 6 months.31,32 This regimen is >95% effective in preventing HBV infection in these infants.
Post-vaccination testing for anti-HBs and HBsAg should be performed after completion of the vaccine series, at age 9 months to 18 months. Testing should not be performed before age 9 months to avoid detection of anti-HBs from HBIG administered during infancy and to maximize the likelihood of detecting late HBV infection. Anti-HBc testing of infants is not recommended because passively acquired maternal anti-HBc might be detected in infants born to HBV-infected mothers up to age 24 months. HBsAg-negative infants with anti-HBs levels >10 mIU/mL are protected and need no further medical management. HBsAg-negative infants with anti-HBs levels <10 mIU/mL should be revaccinated with a second three-dose series and retested 1 to 2 months after the final dose of vaccine.
Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents. 2014. Available at https://aidsinfo.nih.gov/contentfiles/lvguidelines/AdultandAdolescentGL.pdf. Accessed July 6, 2015.
Panel on Opportunistic Infections in HIV-Infected Adults and Adolescents. Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: recommendations from the Centers for Disease Control and Prevention, the National Institutes of Health, and the HIV Medicine Association of the Infectious Diseases Society of America. 2014. Available at https://aidsinfo.nih.gov/contentfiles/lvguidelines/adult_oi.pdf. Accessed June 6, 2015.
Grob P, Jilg W, Bornhak H, et al. Serological pattern "anti-HBc alone:" report on a workshop. J Med Virol. 2000;62(4):450-455. Available at http://www.ncbi.nlm.nih.gov/pubmed/11074473.
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Khamduang W, Gaudy-Graffin C, Ngo-Giang-Huong N, et al. Analysis of residual perinatal transmission of hepatitis B virus (HBV) and of genetic variants in human immunodeficiency virus and HBV co-infected women and their offspring. J Clin Virol. 2013;58(2):415-421. Available at http://www.ncbi.nlm.nih.gov/pubmed/23916828.
Centers for Disease Control and Prevention. Guidelines for vaccinating pregnant women, hepatitis A. 2014. Available at http://www.cdc.gov/vaccines/pubs/preg-guide.htm#hepa. Accessed March 8, 2015.
Centers for Disease Control and Prevention. Prenatal care provider policies and procedures to prevent perinatal hepatitis b virus transmission. 2010. Available at http://www.cdc.gov/hepatitis/HBV/PDFs/PrenatalCareProviderPoliciesAndProcedures.pdf. Accessed July 6, 2015.
Crane M, Oliver B, Matthews G, et al. Immunopathogenesis of hepatic flare in HIV/hepatitis B virus (HBV)-coinfected individuals after the initiation of HBV-active antiretroviral therapy. J Infect Dis. 2009;199(7):974-981. Available at http://www.ncbi.nlm.nih.gov/pubmed/19231993.
del Canho R, Grosheide PM, Schalm SW, de Vries RR, Heijtink RA. Failure of neonatal hepatitis B vaccination: the role of HBV-DNA levels in hepatitis B carrier mothers and HLA antigens in neonates. J Hepatol. 1994;20(4):483-486. Available at http://www.ncbi.nlm.nih.gov/pubmed/8051386.
Ngui SL, Andrews NJ, Underhill GS, Heptonstall J, Teo CG. Failed postnatal immunoprophylaxis for hepatitis B: characteristics of maternal hepatitis B virus as risk factors. Clin Infect Dis. 1998;27(1):100-106. Available at http://www.ncbi.nlm.nih.gov/pubmed/9675462.
Wiseman E, Fraser MA, Holden S, et al. Perinatal transmission of hepatitis B virus: an Australian experience. Med J Aust. 2009;190(9):489-492. Available at http://www.ncbi.nlm.nih.gov/pubmed/19413519.
van Nunen AB, de Man RA, Heijtink RA, Niesters HG, Schalm SW. Lamivudine in the last 4 weeks of pregnancy to prevent perinatal transmission in highly viremic chronic hepatitis B patients. J Hepatol. 2000;32(6):1040-1041. Available at http://www.ncbi.nlm.nih.gov/pubmed/10898328.
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Cheung KW, Seto MT, Wong SF. Towards complete eradication of hepatitis B infection from perinatal transmission: review of the mechanisms of in utero infection and the use of antiviral treatment during pregnancy. Eur J Obstet Gynecol Reprod Biol. 2013;169(1):17-23. Available at http://www.ncbi.nlm.nih.gov/pubmed/23465469.
Zhang H, Pan CQ, Pang Q, Tian R, Yan M, Liu X. Telbivudine or lamivudine use in late pregnancy safely reduces perinatal transmission of hepatitis B virus in real-life practice. Hepatology. 2014. Available at http://www.ncbi.nlm.nih.gov/pubmed/25227594.
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