Hepatitis B viremia in HIV-coinfected individuals under antiretroviral therapy

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w w w . e l s e v i e r . c o m / l o c a t e / b j i d

The

Brazilian

Journal

of

INFECTIOUS

DISEASES

Original

article

Hepatitis

B

viremia

in

HIV-coinfected

individuals

under

antiretroviral

therapy

Leonardo

Weissmann

a,∗

_,

_Camila

_de

_Melo

_Picone

a

_,

Michele

Soares

Gomes

Gouvêa

b

_,

_Paulo

_Roberto

_Abrão

_Ferreira

c

_,

Mônica

Salum

Valverde

Borsoi

Viana

d

_,

_João

_Renato

_Rebello

_Pinho

b

_,

Alex

Jones

Flores

Cassenote

a

_,

_Aluísio

_Cotrim

_Segurado

a

a_Universidade_de_São_Paulo,_Faculdade_de_Medicina,_Departamento_de_Doenc¸as_Infecciosas_e_{Parasitárias,}_São_Paulo,_SP,_Brazil b_Universidade_de_São_Paulo,_Faculdade_de_Medicina,_Laboratório_de_{Gastroenterologia}_e_Hepatologia_Tropical_-_LIM-07,_São_Paulo,_SP,

Brazil

c_Universidade_Federal_de_São_Paulo,_Departamento_de_Medicina,_São_Paulo,_SP,_Brazil

d_Hospital_do_Servidor_Público_Estadual_Francisco_Morato_de_Oliveira,_Servic¸o_de_{Gastroclínica}_e_Hepatologia,_São_Paulo,_SP,_Brazil

a

r

t

i

c

l

e

i

n

f

o

Articlehistory:

Received24July2019

Accepted6October2019

Availableonline9November2019

Keywords: HIVinfections HepatitisB Coinfection Antiretroviralagents Viremia DNA,viral

a

b

s

t

r

a

c

t

Background:Antiretroviraltherapy(ART)hasdecreasedAIDSincidenceandmortality,

ren-dering comorbidities, such ashepatitis B more relevantforpeople livingwith human

immunodeﬁciencyvirus(HIV).SinceantiretroviraldrugsmayalsoinhibithepatitisBvirus

(HBV)replication,analyzingtheimpactofARTonmanagementofhepatitisBinthis

popu-lationisimportant.

Objective:ToassessHBVviremiaamongHIV/HBVcoinfectedindividualsonARTandits

associatedfactors.

Method:Forthiscross-sectionalstudy,HIV/HBV-coinfectedindividuals,agedover18years,

whowereonARTforoversixmonthsandreceivingcareatanoutpatientclinicinSãoPaulo

wererecruited.Sociodemographiccharacteristics,informationaboutviralexposure,clinical

andlaboratorydata,includingevaluationofliverﬁbrosiswereobtained.PlasmaHBVDNA

wasmeasuredbypolymerasechainreaction.Viralgenomesequencingwasconductedfor

genotypingandidentiﬁcationofdrugresistance-conferringmutationsifviralloadexceeded

900IU/mL.

Results:Outof2,946patientswhoattendedtheclinicin2015,83wereeligibleand56

evalu-ated.PlasmaHBVDNAwasdetectedin16(28.6%)(95%CI:18.0–41.3%),allonlamivudineand

tenofovirtreatment.HBVDNAdetectionwasassociatedwithlowereducation(p=0.015),

higherinternationalnormalizedratios(p=0.045),historyofanAIDS-deﬁningillness[OR:

∗ _{Corresponding}_author.

E-mailaddresses:leo.weissmann@usp.br(L.Weissmann),camila.picone@hc.fm.usp.br(C.M.Picone),gomesmic@yahoo.com.br

(M.S.Gouvêa),paulo.abrao.ferreira@gmail.com(P.R.Ferreira),monica.viana@uol.com.br(M.S.Viana),joao.renato@hc.fm.usp.br(J.R.Pinho),

cassenote@usp.br(A.J.Cassenote),segurado@usp.br(A.C.Segurado). https://doi.org/10.1016/j.bjid.2019.10.002

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3.43(95%CI:1.10–11.50)],andHBeAgdetection[OR:6.60(95%CI:1.84–23.6)].Incontrast,alast

CD4+countabove500cells/mm3_in_the_year_prior_to_inclusion_[OR:_0.18_(95%_CI:_{0.04–0.71)]}

anddetectionofanti-HBe[OR:0.21(95%CI:0.04–0.99)]werenegativelyassociated.Patients

withHBVDNAabove900IU/mLwereinfectedwithsubgenotypesA1(n=3)andD2(n=1),

andexhibitedviralmutationsassociatedwithtotalresistancetolamivudineandpartial

resistancetoentecavir.

Conclusions: DespitebeingonART,asigniﬁcantproportionofHIV/HBV-coinfected

individ-ualspresentHBVviremia.Characterizationoffactorsthatareassociatedwiththisﬁnding

mayhelpprofessionalsprovidebettermanagementtothesepatients.

anopenaccessarticleundertheCCBY-NC-NDlicense(http://creativecommons.org/

licenses/by-nc-nd/4.0/).

Introduction

HepatitisBvirus(HBV)infectionisthemostcommonchronic

viralinfectionintheworld,constitutinganimportant

pub-lichealthproblem.1_Globally,_it_is_estimated_that₂₅₇_million

people are living with the infection. However, prevalence

rates vary by geographical region. Hepatitis B resulted in

887,000deathsin2015mainlycausedbycomplicationssuch

ascirrhosisandhepatocellularcarcinoma.Vaccinationisan

effective way of preventing HBV infection; however, most

of the chronic carriers of this infection were born before

this immunization became available.2 _Since _HBV _and _HIV

share common modes of transmission, including

unpro-tectedsexanduseofinjectabledrugs,HIV/HBVcoinfections

are likely to occur.3,4 _In _fact, _the _World _Health

Organiza-tion (WHO) estimated that 36.7 million people were living

withHIVworldwidein2015,ofwhom2.7millionwere

HBV-coinfected.2_Likewise,_HIV/HBV_coinfection_was_identiﬁed_in

5.2% of hepatitis B reported cases in Brazil from 2007 to

2017.5

In a context in which antiretroviral therapy (ART) has

signiﬁcantlydecreasedAIDSincidenceandmortality,

comor-biditiessuchashepatitisBhavebecomemorerelevantfor

the comprehensive care of people living with HIV (PLH).4

CurrentBrazilian,6 American7,8 andEuropean9,10 guidelines

recommend initiating ART forall patients with HIV

infec-tion,eveniftheyareasymptomaticandregardlessofimmune

statusasassessedbyCD4+cell count.Forthosecoinfected

withHBV,however,antiretroviralregimensthatinclude

teno-fovirdisoproxilfumarate(TDF),tenofoviralafenamide(TAF),

TDF/lamivudine(3TC)orTDF/emtricitabinecombinationsare

considered preferable.In Brazil,nationalguidelines

recom-mend HIV/HBV coinfected patients should bereceive with

tenofoviraspartoftheirregimen.Despitebeingregardedas

theidealantiviraltobeusedinthesecases,somepatients

takingtenofovirmayyetexhibitincompleteHBVsuppression

forunclearreasons,yieldingpersistentortransienthepatitis

Bviremia.11

AnalyzingtheimpactofARTonhepatitisBinthis

coin-fectedpopulationduringclinicalfollow-upisthusimportant

tohelpguideproperclinicalmanagement.Thisstudyaimed

toassessplasmaHBVDNAamongHIV/HBVcoinfected

indi-viduals onARTinoutpatientcareinSãoPaulo,Brazil,and

toidentifyfactorsassociatedwithHBVviremia.Furthermore,

viralgenomicsequencingwasusedtodetectdrug

resistance-conferringmutationsamonghepatitisBviremicpatients.

Materials

and

methods

Studydesignandselectionofpatients

Thiscross-sectionalwascarriedoutattheHIV/AidsClinicof

theDivisionofInfectiousandParasiticDiseasesofthe

Hos-pitaldasClínicas,afﬁliatedtotheUniversidadedeSãoPaulo

MedicalSchool(SEAPHIV/AIDS-HCFMUSP),where

interdis-ciplinaryandcomprehensivecareisprovidedtoadultsliving

withHIV.

Medicalchartsofpatientswhoattendedtheclinicin2015

were reviewedinsearchforeligiblesubjects: patientsaged

over18years,diagnosedwithHIVinfectionandchronicHBV

(HBsAgpositivityinserumforsixmonthsormore),andusing

antiretroviralsforatleastsixmonths.Therewasnoexclusion

criterion. Datacollection

Patients who metinclusion criteriawere invitedto

partici-pateinthestudy.Informationregardingvariablesofinterest

wascollected throughindividualinterviews,chartanalysis,

evaluationoflaboratorytestsandtransienthepatic

elastog-raphy,anddatarecordedinastandardizedform,speciﬁcally

elaboratedforthestudy.

Studyoutcomesincluded:

- PresenceofHBVviremia,measuredbyplasmadetectionof

viraldeoxyribonucleicacid(DNA);

- HBVgenotype(ifviremiaabove900IU/mL);

- Presenceofdrugresistance-conferringmutationsidentiﬁed

bysequencingtheRTregionoftheHBVgenome(ifviremia

above900IU/mL).

HBV viremia was assessed by testing plasma samples

withquantitativereal-timepolymerasechainreaction(Abbott

Real-time HBV®), following manufacturers’ instructions.12

Using a 0.5mL sample preparation, HBV DNA detection

thresholdofthistestis6.4IU/mL(95%CI:3.97–13.03IU/mL).

However,forviralloadquantiﬁcationalowerlimitof10IU/mL

(3)

Samples that exhibited HBV DNA concentrations above

900IU/mLwerethensubmittedtosequencingoftheRTregion

ofthe HBVgenome insearchofdrugresistance-conferring

mutations,aspreviouslyreported.13_An_HBV_DNA_threshold

of900IU/mLwasusedduetothetestsensitivity.

Independentvariablesincluded:

- Sociodemographic characteristics and anthropometric

measures:sex,age,self-reportedethnicity,schooling,and

bodymassindex(BMI);

- ExposuretoHBVand/orHIV:timesincediagnosisofHBV

andHIVinfections,exposurecategories,historyof

impris-onment,andothersexuallytransmittedinfections(STI);

- Alcohol consumption (assessed by a modiﬁed AUDIT

questionnaire14_);

- Clinicaldata:historyofAIDS-deﬁningillnesses,15ART

(pre-scribed antiviral regimens,duration ofuse, self-reported

adherence to ART assessed by a questionnairemodiﬁed

from the Medication Adherence Self-Report Inventory –

MASRI16_),_and_use_of_other_anti-HBV_drugs;

- Laboratory data: serum HBeAg and anti-HBe, last CD4+

count in the year before inclusion, nadir CD4+ count,

last HIV viral load in the six monthsprior to inclusion,

plateletcount,internationalnormalizedratio(INR),serum

transaminases,totalbilirubin,gammaglutamyltransferase,

totalprotein,albumin,gammaglobulin,alpha-fetoprotein,

serumanti-HCVantibodies,andplasmaHCVRNA;

- Transientliverelastographyﬁndings:liverstiffnessand

con-trolledattenuationparameter(CAP).

Datamanagementandanalyses

Data were enteredinto aMicrosoft Excel2010spreadsheet

andanalyzedwiththeaidofthestatisticalprogramIBMSPSS

StatisticsforWindows,Version23.0,Armonk,NY.

Fordescriptivestatistics,categoricalvariables ofinterest

werepresentedinfrequencytables,andquantitativevariables

withcentraltendencymeasuresandvariability.

Factors associated with HBV viremia were then sought

after by correlating HBV DNA detection with patients’

socioeconomicandanthropometriccharacteristics,and

vari-ables related to HIV and HBV exposure, clinical features,

as well as with results of laboratory tests and

imag-ing exams. Fisher’s exact test or the chi-square test with

calculation of odds ratios (OR) and their respective 95%

conﬁdence intervals (95% CI) was used to compare HBV

viremic and nonviremic individuals.Quantitative variables

were assessedwiththe nonparametric Mann–Whitneytest

assessmentofvariabledistributionbytheShapiro–Wilktest.

A statistical signiﬁcance level of 5% was adopted for all

analyses.

Ethicalissues

Datacollectionwasinitiatedonlyafterthestudyprotocolwas

approvedbyInstitutionalReviewBoards.Studyparticipation

wasvoluntaryandfollowedinformedconsent.Conﬁdentiality

andanonymityofparticipantswereassuredthroughoutthe

investigation.

Results

FromJanuary1toDecember31,2015,2,946PLHattended

med-icalfollow-upconsultationsatSEAPHIV/AIDS-HCFMUSP.Of

these,83exhibitedserumHBsAgforatleastsixmonths,

yield-inganoverallprevalenceof2.8%ofPLH,whowerechronically

coinfectedwithHBV(95%CI:2.3–3.4%).Theywereallreceiving

ARTforsixmonthsorlongerandwere,therefore,eligiblefor

thestudy.However,27ofthemcouldnotbeevaluateddueto

refusal(n=11),death(n=4),losstofollow-up(n=4),incorrect

contactinformation(n=5),referraltootherHIVclinics(n=2),

or HBsAg seroreversion (n=1). Therefore, the study cohort

consistedof56HIV/HBVcoinfectedadults.Theseindividuals

whocouldnotbeevaluatedwerenotsigniﬁcantlydifferentin

termsofsex[96%male(95%CI:89–99%)versus93%(95%CI:

78–98%)]andmedianage[53years(95%CI:51–55)versus50

(95%CI:46–54)].

In the remaining cohort, most participants were male

(n=54,96%), agedover 50 (n=37,66%), white (n=33, 59%),

reported atleasteightyearsofschooling (n=34,61%), and

presentedwithnormalweight(n=36,64%).Themediantime

sinceHIVdiagnosis was18.1years(2.0–28.3years),and the

median time since HBV diagnosis was 15.0 years (1.0–29.0

years).Concerningexposuretoviralinfections,42participants

reportedbeingmenwhohavesexwithmen,andthreehad

beeninprison(for15days,12monthsand44months).Atotal

of41 (73%)individuals hadan informed historyofatleast

oneepisodeofSTI[syphilis(n=31),gonorrhea(n=21),

geni-talwarts(n=10)andherpes(n=2)].Seventeen(30%)patients

reportedmorethanoneSTI.Historyofinjectabledruguseand

ofbloodtransfusionwasreportedbythreepatientseach.

ScreeningforhepatitisC disclosed10 (18%)participants

with evidenceofprevious HCV infection (positiveEIA test,

but HCVRNAPCRnegative)andthree(5%)hadevidenceof

HCVviremiabeforeinclusioninthestudy.AllHCV-coinfected

patients hadbeen treatedwithpegylatedinterferonforsix

months(n=1)or12months(n=2),12,8and11years,

respec-tively,beforeinclusioninthestudyandexhibitedsustained

virologicresponses.

As for alcohol consumption, 44 (79%) reported none or

drinking once amonth or less often; in contrast,13 (28%)

informedatleastoneepisodeofdrinkingsixormoreshots

inasingleoccasion.

In termsofHIVdisease,23 (41%)reportedhaving

expe-rienced an AIDS-deﬁning illness, most often pulmonary

tuberculosis(n=11),Pneumocystis jirovecii pneumonia(n=5),

CMVdisease[retinitisorinotherorgansbuttheliver,spleen

orlymphnodes(n=4)],orKaposi’ssarcoma(n=4).Nine(16%)

participantshadtwoormoreillnesses.

As far as anti-HBV medication is concerned, 54 (96%)

patientsinourcohortweretakinglamivudineandtenofovir

atthetimeofinclusioninthestudy.Twoparticipants,in

con-trast,werenotreceivingtenofoviratbaselineduetoprevious

renaltoxicity,experiencedafter104and137monthsofuseof

thisdrug.Atinclusioninourstudyoneofthesepatientswas

receivinglamivudineplusentecavir,whereas theotherwas

usinglamivudinealone.Asforotheranti-HBVmedications,

three(5%)individualsreportedhavingusedpegylated

(4)

and two (4%) patients received entecavir before inclusion

inthe study,whileonewas usingentecavir atthetime of

inclusionin combinationwithART regimens thatincluded

lamivudinebutnottenofovir.

Additionally, 31 (55%) patients were on ART regimens

thatincludednon-nucleosidereversetranscriptaseinhibitor

drugs, 24 (43%)were on protease inhibitors, ﬁve(9%) were

taking integrase inhibitors and one was receiving

enfuvir-tide.MostpatientsreportedgoodadherencetoART:51(91%)

informedhavingtakenmorethan85%ofprescribedpillsin

thepreviousmonth.

PlasmadetectionofHBVDNAwasachievedin16

individ-ualsinourcohort(28.6%,95%CI:18.0–41.3%),andin12(96%)

HBVviralloadwaslessthan900IU/mL.

Inunivariateanalysistoidentifyfactorsassociatedwith

HBVviremia,internationalnormalizedratios(INR)was

sig-niﬁcantlyhigher(p=0.045)amongviremicpatients(Table1)

comparedwithnonviremicHIV/HBVcoinfectedindividuals.

In contrast, no signiﬁcant difference was shown between

thetwogroupsregardingage,BMI,timesinceHIVandHBV

diagnoses,plateletcount,serumALT,AST,bilirubin,gamma

glutamyltransferase,totalprotein,albumin,gammaglobulin,

andalpha-fetoproteinconcentrations.

Timeusing anti-HBVmedication didnotdiffer between

HBVviremicandnonviremicpatients(Fig.1Aand1B).

AcomparisonofcategoricalvariablesbetweenHBVviremic

and nonviremicpatients isshownin Table2. HBV viremia

waspositivelyassociatedwithlowerlevelsofschooling(0%

viremicamongindividualswithuniversitydegreeversus50%

viremicamongthosewithnoeducationorincompletebasic

education(p= 0.015),historyofanAIDS-deﬁningillness[OR:

3.43(95%CI:1.10–11.50);p= 0.040],andserumHBeAg

detec-tion[OR:6.60(95%CI:1.84–23.6);p= 0.003].Incontrast,last

CD4+countover500cells/mm3 _in_the_year_before_inclusion

[OR: 0.18 (95%CI: 0.04–0.71);p=0.016]and serum anti-HBe

detection[OR:0.21 (95%CI:0.04–0.99);p=0.043]were

nega-tivelyassociatedwithHBVviremia.

Furthermore,age,ethnicity,HIVexposurecategory,alcohol

consumption,nadirCD4+count,HIVviralload,anti-HCV,and

HCVRNAdetection werenotassociatedwithHBVviremia.

Likewise,transientliverelastographyﬁndings(liverstiffness

andCAP)didnotdifferaccordingtoHBVviremia.

OutoffourpatientswhoexhibitedHBVviralloadsabove

900IU/mL, three were infected with HBV subgenotype A1

and the fourth with subgenotype D2. In all of them,drug

resistance-conferringmutationsassociatedwithtotal

resis-tancetolamivudineandwithpartialresistancetoentecavir

(Table3)weredemonstrated.

Furthermore,positionsrt106,rt126,rt134,andrt269were

alsoanalyzed.InindividualsinfectedwithHBVsubgenotype

A1,thefollowingaminoacidpatternswereidentiﬁedatthese

positions:rtS106,rtY126,rtD134,andrtI269,whereasinthe

individualinfectedwithsubgenotypeD2,wefound:rtS106,

rtR126,rtD134andrtI269.

Discussion

Inourcohort,followedupatanUniversityoutpatientclinic

inSãoPaulo,83(2.8%)ofpatientswereidentiﬁedas

HIV/HBV-coinfected(95%CI:2.3–3.4%),andamongthem,56/83(28.6%,

95% CI: 18.0–41.3%) presented HBV viremia despite being

treatedwithanti-HBVantivirals.

Itisimportanttohighlightthatparticipantsinourcohort

were predominantlymenwhohadsexwithmen,in

accor-dancewithﬁndingsofpreviousstudiescarriedoutinthesame

clinic.17,18_As_far_as_education_was_concerned,_61%_reported_at

least11schooling years,afeatureoftheclinicclientele,as

previouslyreported.19

Nevertheless,therateofHBVviremicindividuals-28.6%

-washigh,despitelong-termuseofantiviralsthatareactive

againstthevirus(mediantime10.3yearsfortenofovirand18.0

yearsforlamivudine).Tenofovirandlamivudinewereusedby

allviremicpatients.Inaddition,patientsnottakingtenofovir

duetopastrenaltoxicityhadnoHBVviremia.

HBV suppression in HIV/HBV-coinfected individuals on

ARThasbeenpreviouslyinvestigatedinlongitudinalstudies

inseveralcountries,andusuallyamorefavorableresponse

was seencomparedtoourﬁndings.deVries-Sluijs etal.,20

forinstance,inamulticenterstudy withmedianfollow-up

of 55 months, showed that among HBeAg-positive

indi-viduals, the cumulative probability of achieving virologic

response after 1, 2, 3, 4 and 5 years of treatment was

31%, 70%, 83%,88% and 92%,respectively. Among

HBeAg-negative patients, the virologic response in the ﬁrst four

years of therapy was 47%, 85%, 85% and 100%,

respec-tively. Likewise,Price et al.21 _reported _HBV _suppression _in

more than 85% ofcasesafterthree yearsof tenofovir use.

Studying patients from Australia, United States and

Thai-land, Matthewset al.22_detected_HBV_viremia_in_20.8%,_and

the outcome was associatedwith serum HBeAg detection,

HIV viral load, CD4+ cell count lower than 200cells/mm3_,

use of ART for less than two years, self-reported

adher-ence to therapy below 95%, and HBV monotherapy with

lamivudine/emtricitabineorTDF.Morerecently,Huangetal.23

highlightedthattheuseoftenofovir-containingregimensas

initialantiviraltherapyisindependentlyassociatedwithHBV

suppression.

LowereducationwasassociatedwithHBVviremiainour

cohort. One may hypothesize thatthis association may be

aconsequenceofloweradherence totherapy,aspreviously

proposedbyCarvalhoetal.24_In_this_cohort_patients_with

uni-versitydegreesweremoreadherenttotherapycomparedto

thosewithmedium-leveleducationorless(OR:7.0;p=0.037).

Fromabroaderperspective,Tavaresetal.25_pointed_out_that

amongBrazilianpatientswithotherchronicdiseases,lower

educationwasalsoassociatedwithpooreradherenceto

ther-apy,highlightingtheneedtotakethisintoconsiderationina

comprehensivecareapproach.However,wewerenotableto

showacorrelationbetweeneducationandadherenceto

ther-apyinourstudy.As95%ofcohortparticipantsreportedhaving

takenmorethan85%ofprescribedpillsinthe30daysprior

toinclusion,adherencetotreatmentcouldnotbeincludedin

theanalysis.

Assessingadherencetotherapybymeansofpatients’

self-reportshouldalsobeputincontextsincelimitationsofthis

techniquehavebeendiscussedinapreviousstudyconducted

atthesameclinic.Amongthoseself-reportinggoodadherence

toART,Gutierrezetal.26_evaluated_drug_dispensation_registries

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Table1–QuantitativevariablesaccordingtoHBVviremia.

HBVviremia

Variables No Yes p-value

Median IQR Median IQR Sociodemographiccharacteristicsandanthropometricmeasures

Age(years) 52.0 48.0–57.0 55.0 49.0–59.0 0.643

BMI(kg/m2₎ _23.8 _22.0–25.6 _24.8 _20.7–27.0 _0.663

Timesincediagnosis(years)

HIV 17.9 15.7–20.9 19.8 15.0–22.0 0.828

HBV 15.0 10.5–18.0 12.5 3.5–16.5 0.167

TimeusingART(years)

Lamivudine 16.0 13.0–18.0 18.0 16.0–20.0 0.130 Tenofovir 10.2 7.5–11.4 10.3 5.9–11.2 0.779 Laboratorydata Plateletcount(x103_/mm3₎ _193.5 _{163.0–232.5} _181.0 _{163.0–232.5} _0.663 ALT(IU/L) 25.0 19.0–39.0 31.0 20.0–51.0 0.268 AST(IU/L) 24.0 19.0–36.0 27.0 22.0–33.0 0.280 Totalbilirubin(mg/dL) 0.40 0.29–0.70 0.60 0.41–1.02 0.102 GGT(IU/L) 34.0 22.0–79.0 44.0 23.0–81.0 0.580 INR 1.00 0.97–1.07 1.06 1.03–1.10 0.045 Totalprotein(g/dL) 7.5 7.2–7.8 7.6 7.3–8.3 0.501 Albumin(g/dL) 4.1 3.9–4.3 4.0 3.8–4.1 0.065 Gammaglobulin(g/dL) 1.3 1.1–1.6 1.6 1.3–1.8 0.147 Alpha-fetoprotein(ng/mL) 2.5 2.1–3.3 2.6 2.2–3.7 0.771 HBV,hepatitisBvirus;IQR,interquartilerange;BMI,bodymassindex;HIV,humanimmunodeﬁciencyvirus;ALT,alanineaminotransferase; AST,aspartateaminotransferase;GGT,gammaglutamyltransferase;INR,internationalnormalizedratio.

25 20 15 10 5 0 20 15 10 5 0 Nonviremic Viremic Viremic Nonviremic

Time using Iamivudine (y

ears)

Time using tenof

o

v

ir (y

ears)

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Table2–CategoricalvariablesaccordingtoHBVviremia.

HBVviremia

Variables No(N=40) Yes(N=16) OR 95%CI p-value

N % N % Sex 0.506 Male 38 70 16 30 1 – Female 2 100 0 0 0 0 Ethnicity 0.123 White 26 79 7 21 1 – Non-White 14 61 9 39 2.30 0.73–7.70 Schooling 0.015a

Noneorincompletebasiceducation 6 50 6 50 1 –

Basiceducation 7 70 3 30 0.42 0.07–2.49

Mediumeducation 15 68 7 32 0.46 0.10–2.10

Universitydegree 12 100 0 0 0 0

HIVexposurecategories 0.111

Heterosexual 10 91 1 9 1 – – MSM 26 67 13 33 5.00 0.89–11.90 IDU 1 33 2 67 20.00 0.12–68.00 Bloodtransfusion 3 100 0 0 0 0 Alcoholconsumption 0.269 Never 20 80 5 20 1 – ≤Once/month 12 63 7 37 2.33 0.60–9.02 ≥Twice/month 8 67 4 33 2.00 0.40–9.40 AIDS-deﬁningillness 0.040 No 27 82 6 18 1 – Yes 13 57 10 43 3.43 1.10–11.50

LastCD4+count(cells/mm3₎ _0.016a

≤500 5 42 7 58 1 –

>500 35 80 9 20 0.18 0.04–0.71

NadirCD4+count(cells/mm3₎ _0.660a

<100 14 64 8 36 1 –

100–500 19 76 6 24 0.55 0.15–1.55

>500 7 78 2 22 0.50 0.08–3.00

HIVviralload 0.135

Undetectable 38 75 13 25 1 – Detectable 2 40 3 60 4.38 0.65–29.20 HBeAg 0.003 Nonreactive 30 86 5 14 1 – Reactive 10 48 11 52 6.60 1.84–23.60 Anti-HBe 0.043 Nonreactive 24 63 14 37 1 – Reactive 16 89 2 11 0.21 0.04–0.99 Anti-HCV 0.301 Nonreactive 34 74 12 26 1 – Reactive 6 60 4 40 1.89 0.45–7.89 HCVRNAb Undetectable 4 57 3 43 1 – 0.666 Detectable 2 67 1 33 0.66 0.03–11.28

Liverstiffness(kPa)c _0.223

<7.2 19 76 6 24 1 – 7.2–11.0 8 80 2 20 0.79 0.13–4.70 >11.0 3 50 3 50 3.16 0.50–20.00 CAP(dB/m)c _0.398 <215 12 80 3 20 1 – 215–300 15 68 7 32 1.80 0.39–8.80 >300 3 75 1 25 1.33 0.09–17.80

HBV,hepatitisBvirus;OR,oddsratio;95%CI,95%confidenceinterval;HIV,humanimmunodeficiencyvirus;MSM,menwhohavesexwithmen; IDU,injectiondruguse;AIDS,acquiredimmunodeficiencysyndrome;HBeAg,hepatitisBe-antigen;Anti-HBe,hepatitisBe-antibody;Anti-HCV, hepatitisCantibody;HCVRNA,hepatitisCvirusRNA;CAP,controlledattenuationparameter.

a _Chi-square_test_for_linear_trend.

b _Performed_only_for₁₀_{anti-HCV-reactive}_individuals. c _Information_available_for₄₁_patients_only.

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z j i n f e c t d i s . 2 0 1 9; 2 3(6) :441–450

447

Table3–HBVviralload,HBVsubgenotypes,viralmutations,drugresistanceproﬁle,andtimeusinglamivudineandtenofovirinpatientswhopresentedHBVviralload greaterthan900IU/mL.

Patient HBVviralload

(IU/mL)

HBVsubgenotype RTregionmutations Drugresistanceproﬁle Timeusing

lamivudine(years)

Timeusingtenofovir (years)

LAM ADV ETV TDF

1 929 A1 rtL180M+rtM204V+rtL229F R S I S 19.5 11.1

2 2,877 D2 rtV173L+rtL180M+rtM204V R S I S 19.2 11.1

3 49,425,077 A1 rtL180M+rtA200V+rtM204I R S I S 20.9 7.1

4 2,518 A1 rtL180M+rtM204V+rtL229V+rtV253I R S I S 17.6 2.1

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infactcollectedgreaterthanorequalto95%,90%and80%of

prescribedpillsinthepreviousyear,respectively.Ina

system-aticreview,Lieveldetal.27_reported_that_mean_adherence_to

hepatitisBtherapyrangesfrom81to99%,andfulladherence

from66to92%ofpatientsindifferentstudies.Higher

adher-enceratesarefoundbypatients’self-report,whereassurveys

thatemployedpillcountsusuallyyieldpoorerrates.However,

theseinvestigatorsemphasizethatsofarthereisno

consen-susonwhatadherenceratetoHBVtherapyshouldberegarded

as optimal. We believe that assessment by patients’

self-reportmighthaveoverestimatedadherencetotherapyinour

study.

AlthoughHIVviralload wasnotsigniﬁcantlyassociated

withHBVviremiainourcohort,weshouldhighlightthat60%

ofthosewithdetectableHIVRNAinthelasttestperformed

180days before inclusion alsoexhibited HBV viremia. The

patientwhopresentedthehighesthepatitisBviralloadinour

cohort(49,425,077IU/mL)reportedhavingdiscontinuedART

inthemonthpriortoinclusioninthestudybecauseofa

sur-gicalprocedure. Asamatteroffact, hisHIVviralloadwas

3,297RNAcopies/mLonthesamedate.Inaddition,twoother

individualsexhibitedsimultaneousHIVandHBVviremia.Of

these,oneexhibitedanHBVDNAconcentrationof929IU/mL,

whereastheotherhadanHBVloadbelowquantitation

thresh-old(lessthan10IU/mL).ThelimitednumberofHIVviremic

patientsinourcohortmayhavereducedthestatisticalpower

to demonstrate association of HIV viremia with the study

outcome.

InacohortstudyofHIV/HBV-coinfectedindividualsinthe

UnitedStates,28_it_has_been_shown_that_in_patients_diagnosed

withHBVinfectionafterdiagnosisofHIVinfection,combined

antiretroviraltherapywasassociatedwithareductioninthe

riskofchronicHBVinfection(OR:0.18;95%CI:0.04–0.79).

Sim-ilarly,inthepresentstudy,historyofAIDS-deﬁningdiseases

resultedinanincreasedriskofHBVDNAdetection(OR:3.43;

p=0.040).Conversely,aCD4+countabove500cells/mm3_in_the

365dayspriortoinclusionwasprotectiveoftheoutcome(OR:

0.18;p=0.016).

Anotherfactordirectlyassociatedwithdetectionofplasma

HBVDNAinourstudywasthedetectionofthevirale

anti-gen (HBeAg).Incontrast,anti-HBedetection wasshown to

beprotectiveofthe outcome.Theassociation ofboth

vari-ableswiththemainstudyoutcomewasexpected,giventhat

HBeAgisarecognizedbiomarkerofHBVreplication,whereas

anti-HBeseroconversioncorrespondstosuppressionof

repli-cation.Thesame ﬁnding had previouslybeen described in

coinfectedpatientsfromthesameclinic,byMendes-Correa

etal.29

AdirectassociationofhighervaluesofINRwiththe

detec-tionofHBVDNAwasalsoveriﬁedinthisstudy,suggestingthe

possibilityofarelationshipbetweentheoutcomeandmore

advancedliverdisease.Nonetheless,therewasnoassociation

ofHBVviremiaandsigniﬁcantalterationsofotherbiomarkers,

suchasaminotransferases,totalbilirubin,gammaglobulins

andalbumin,hasbeenobserved,norwasitrelatedto

hep-aticrigidity.Althoughwehadnobaselinedataofthestudied

individuals,duetothestudycross-sectionaldesign,itiswell

knownthatnucleos(t)ideanaloguetherapycanreverse

ﬁbro-sis,inadditiontoimproving liverfunctioninasubstantial

numberofpatients.30,31

Inpatientsfromwhomitwastechnicallyfeasibleto

per-formHBV DNA sequencing, apredominance ofindividuals

withthe A1subgenotype wasdetected,followedbytheD2

subgenotype,whichagreeswithotherBrazilianstudies.32–34

Thisobservationsuggestsaneffectof“Afrodescendence”in

additiontotheinﬂuenceofEuropeancolonizationinour

coun-try.Sorianoetal.35_using_EuroSIDA_study_data_demonstrated

thatmostpatientswithgenotypeAinfectiononthat

conti-nentweremenwhohadsexwithmen,whileinjectingdrug

usershadgenotypeD.Moreover,Boydetal.11_identiﬁed

geno-typeAin63%ofpatientswithtransientviremiaandin77%of

thosewithpersistentHBVviremia.

Mutations in the RT region of the HBV genome were

detected in the four individuals assessed by sequencing.

Although there were different combinations of mutations,

complete resistance to lamivudine and partial resistance

to entecavir was observed in all proﬁles. The most

fre-quently encountered combination was rtL180M+rtM204V,

whichcoincideswithapreviousBrazilianstudy.36

AsfortheaminoacidpatternsrtY126 andrtI296,which

havebeenrecentlyreportedbyParketal.37_as_associated_with

resistancetotenofovirforgenotypeC,thereissofarno

evi-dencethat thesamephenotypewould occurinindividuals

infectedwithgenotypesAorD.However,theseproﬁleshave

beenpreviouslyreportedascharacteristicofwild-typestrains

forHBVgenotypesA1andD2.13,38 _We_can_thus_hypothesize

thatincasetheseproﬁlesareproventoreduceHBVgenotype

AandDsensitivitytotenofovir,likewisegenotypeC,areduced

geneticbarriertothisantiretroviralshouldbeconsideredfor

Brazilianpatients.

Somelimitationsshouldbepointedoutinourstudy:the

single-centersurveydesignandlossestofollow-upor

serore-version. Althoughit does notpresent selectionbias, asno

signiﬁcantdifferencewasshownbetweenincludedand

eligi-blebutnonincludedpatientswithrespecttosexandage,the

reducedsamplemayhavecompromisedthestatisticalpower

ofthestudybesidesimpairingthepossibilitytoperform

mul-tivariateanalysis.Inaddition,thecross-sectionaldesignofour

studyprecludesanyconclusiononacausallinkbetweenthe

identiﬁedrisk/protectionfactorsandHBVviremia.

Nevertheless, ourﬁndings show the importanceof

ade-quate management of HIV/HBV-coinfected patients during

long-termuseofantiretroviraldrugs.Theneedforstrict

con-trol and long follow-up is emphasized, since even in the

presenceofundetectedHIVRNA,HBVsuppressionmayoccur

onlyaftermorethanfouryearsonproperantiviral

chemother-apy.Moreover,insomecoinfectedindividuals,itispossibleto

ﬁnd sustainedHBV viremiaasconsequenceofpoor

adher-ence to therapy or emergence of drug-resistant mutants.

Futureanalyses,preferablyinmulticenterstudieswithlarger

numberofparticipantsandlongerfollow-up,maycontribute

to better elucidate the virologic response of

HIV/HBV-coinfected individuals on HBV therapy and its associated

factors.

Conﬂicts

of

interest

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