Management of HBV in Special

Populations
Dr May Kyi Kyaw
Senior consultant Hepatologist
Department of Hepatology
Yangon Specialty Hospital

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 Outlines

• Pregnant Women
• Children
• HIV/HBV Co-infected Person
• Decompensated Cirrhosis
• Dialysis and Renal Transplant Patients

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 Pregnant Women

• In HBV mono-infected pregnant women, the indications for treatment are

the same as for other adults
• All the pregnant women who do not meet the criteria for treatment
indications should receive tenofovir disoproxil fumarate (TDF) 300 mg once
a day from 28 week of pregnancy until 3 months after delivery
• TAF and ETV should not be used
• Pregnant women already on the other antivirals should be switched to TDF.
• IFN-based therapy is contraindicated
• In HIV-infected pregnant and breastfeeding women (including pregnant
women in the first trimester of pregnancy and women of childbearing age),
a once-daily fixed-dose combination of tenofovir + lamivudine (or
emtricitabine) + efavirenz is recommended as first-line ART

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 Children

• Although 70–90% of children who are exposed perinatally will become chronically
infected, HBV-related morbidity is low during childhood as they are generally in
the immune-tolerant phase and typically will maintain normal ALT through
childhood until moving into the ‘immune active’ phase.
• Given the low curative rates of treatment and concerns of safety and drug
resistance from long-term use, the initiation of antiviral therapy should be based
on evidence of severe ongoing necroinflammation and significant fibrosis and
cirrhosis.
• While most children will not require antiviral therapy, early identification and
monitoring of children to determine if therapy may be indicated in the future to
prevent progressive liver disease is critical.
• TDF is approved for use in adolescents and children above the age of 12 years for
HBV treatment, and ETV above 2 years of age.
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 Dosage per
Regimen Frequency and Dosing
Tablet
Tenofovir Disoproxil Once Daily (in children 12 years of age
300 mg
Fumarate (TDF) and older, and weighing at least 35 kg)
In children 2 years of age or older and
weighing at least 10 kg up to 30 kg.
Children with body weight more than 30
Entecavir (ETV) 0.5 mg
kg should receive 0.5 mg once daily.
Dosing dependent on body weight (see
table below*)

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 HBV/HCV Co-infected Persons

• Greater risk of progression to cirrhosis and HCC

• Treatment indications for HBV are the same as in mono-infected
patients
• If HBV treatment criteria (+) HBV treatment should be started on prior
to initiating HCV treatment
• If a decision is made not to start HBV treatment first, evidence of HBV
flare should be closely monitored for HBV reactivation during or after
HCV treatment
• If the close monitoring is not feasible for HBV flare, concomitant NA
treatment should be started until week 12 post HCV treatment.

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 HBV/HCV

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 HIV/HBV Co-infected Persons

• Co-infected patients face higher rates of conversation to chronicity

after acute HBV infection, higher levels of HBV replication, a greater
risk of progression to cirrhosis and HCC, and lower treatment
response rates, leading to higher liver-related mortality.
• ART that includes TDF/TAF should be initiated regardless of stage of
liver disease

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 HBV/HIV

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 HBV/HIV Nucleos(t)ide Activity

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 Decompensated Cirrhosis

• Patients with decompensated cirrhosis should be immediately treated

with recommended NAs (TDF or ETV) irrespective of ALT and HBV
DNA level. Then the patients need to be referred to specialist center
preferably with liver transplant facility.

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 Dialysis and Renal Transplant Patients

• Patients with end-stage renal disease (ESRD) should be screened for

HBV infection. All HBsAg positive patients with ESRD should be
referred to a specialist for liver disease severity assessment

• ETV is recommended for NA naïve patients with ESRD. TAF could be

used in both NA naïve or experienced patient. Doses of ETV should be
adjusted according to eGFR values. TAF does not need dose
adjustment if the patient has eGFR > 15 ml/min. If eGFR < 15 ml/min,
TAF is not recommended

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 Key Takeaways
• TDF is the preferred antiviral in pregnant women.
• Initiation of treatment in children should be based on evidence of
severe liver disease.
• Concomitant NA treatment should be considered in HBV/HCV
coinfection.
• Initiated ART include TDF in HBV-HIV co-infected person regardless of
stage of liver disease.
• Immediately treated with recommended NA in decompensated
cirrhosis.
• Treatment of choice in dialysis and renal transplant patients is ETV in
Na naïve and TAF in both Na naïve or experience patient.

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