HIV Treatment Bulletin - Vol. 5, No. 9/10, October/November 2004
Graham McKerrow, HIV i-Base

Doctors in Melbourne, Australia, report a severe and prolonged flare of hepatitis B in an HIV-HBV co-infected patient, which they believe was caused by the emergence of 3TC-resistant HBV together with a strong and prolonged HBV-specific CD8 T cell response.

The patient was a 40-year-old man diagnosed with HIV and HBV in 1998; treatment with d4T, 3TC and nevirapine was commenced. However, after three months the HIV load remained high and the regimen was changed to AZT, ddI and nelfinavir. The viral load then fell to less than 50 copies/ml. Eighteen months after the initial diagnosis, the man was referred for management of severe hepatitis.

Sequencing of the HBV genome isolated from the patient’s serum did not identify compensatory mutations in the HBV polymerase that may have restored viral replication. “However, a strong HBV-specific CD8 T-cell response was identified and may have resulted in the severe hepatitis,” write Theo Gouskos and colleagues in the journal AIDS.

Comment

This case report adds to the increasing body of literature on the dangers of lamivudine montherapy for the treatment of HBV in HBV/HIV co-infection. Other studies have reported around 90% lamivudine resistance by four years in HBV/HIV co-infected patients. Although not all ‘YMDD’ mutants have increased replicative capacity, this may occur in some cases where further compensatory mutations develop.

As demonstrated here, the mechanism of the flare is multifactorial, and an immune restoration phenomenon resulting from the HAART in the presence of replicating HBV (even at low levels) may be enough.

Current BHIVA guidelines suggest considering a HAART regimen that includes tenofovir and lamivudine for patients with viraemic HBV/HIV co-infection. This should prevent the emergence of lamivudine-resistance mutations in HBV.

Ref: Gouskos T, Wightman, F, Chang J et al. Severe hepatitis and prolonged hepatitis B virus-specific CD8 T-cell response after selection of hepatitis B virus YMDD variant in an HIV/hepatitis B virus coinfected patient. AIDS. 2004 Aug 20;18(12):1734-7.

041010
IB040510-11

©2004. I-BASE HIV Treatment Bulletin. Permission to reproduce courtesy of HIV i-Base, Third Floor East, Thrale House, 44-46 Southwark Street, London SE1 1UN - T: +44 (0) 20 7407 8488 F: +44 (0) 20 7407 8489

AEGiS is a 501(c)3, not-for-profit, tax-exempt, educational corporation. AEGiS is made possible through unrestricted grants from Boehringer Ingelheim, Elton John AIDS Foundation, Bridgestone / Firestone Trust, the National Library of Medicine, and donations from users like you. Always watch for outdated information. This article first appeared in 2004. This material is designed to support, not replace, the relationship that exists between you and your doctor.

AEGiS presents published material, reprinted with permission and neither endorses nor opposes any material. All information contained on this website, including information relating to health conditions, products, and treatments, is for informational purposes only. It is often presented in summary or aggregate form. It is not meant to be a substitute for the advice provided by your own physician or other medical professionals. Always discuss treatment options with a doctor who specializes in treating HIV.

Copyright ©1980, 2004. AEGiS. All materials appearing on AEGiS are protected by copyright as a collective work or compilation under U.S. copyright and other laws and are the property of AEGiS, or the party credited as the provider of the content.