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Choosing ART With Coinfections
Choosing ART for HIV With HBV and HCV Coinfections: Using HIV-ASSIST

Released: April 27, 2023

Carolyn Chu
Carolyn Chu, MD, MSc, FAAFP, AAHIVS
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Key Takeaways
  • HBV, HCV, and HIV coinfections commonly occur and affect drug therapy selection for each virus being treated.
  • HIV-ASSIST can provide guidance on choosing ART in the setting of HBV and HCV coinfections.

Primary care providers (PCPs) are needed to help address ongoing nationwide shortages in the HIV-focused healthcare professional (HCP) workforce. PCPs are important to ensuring comprehensive and coordinated medical care for people with HIV (PWH) and expanding access to HIV prevention options, especially in communities that have been (or may be) heavily affected by HIV.

Although the need for primary care integration with HIV services is not new, antiretroviral therapy (ART) decision-making and epidemiologic patterns of co-occurring conditions have shifted and necessitate primary care involvement in the care of PWH now more than ever.

HIV-ASSIST Supports ART Selection in Primary Care
Educational tools such as HIV-ASSIST have been designed to support delivery of evidence-based HIV care by HIV specialists and nonspecialists by incorporating current clinical guidelines with relevant individual patient factors to create personalized ART options.

Furthermore, HIV-ASSIST uniquely streamlines ART decision-making for HCPs through an easily accessible interface that not only directs users to relevant guidelines-based information, but also provides detailed supplementary context by consolidating multiple educational resources. HIV-ASSIST therefore can be a time-saving aid for busy HCPs. Real-time incorporation of the use of HIV-ASSIST into clinical encounters also may help facilitate patient engagement and collaborative information sharing when selecting ART.

Let’s look at some specific examples of HIV coinfection with hepatitis B virus (HBV) or hepatitis C virus (HCV).

Updates to Viral Hepatitis Recommendations
The CDC recently released updated HBV screening and testing recommendations, adopting a much simpler and more inclusive approach that, we hope, will ease implementation challenges and advance the United States toward meeting viral hepatitis elimination goals.

Similarly, last fall the American Association for the Study of Liver Diseases updated their HCV testing, management, and treatment guidance to indicate that HIV infection is no longer considered a contraindication to adopting a simplified HCV treatment approach.

Current and future HIV-focused HCPs should be familiar with evolving viral hepatitis guidelines and best practices, as HBV, HCV, and HIV have long-standing connections. In addition to sharing routes of transmission, coinfection may be relatively common in some at-risk populations, and careful medication selection and clinical monitoring is warranted when coinfection is present.

HIV-ASSIST for Managing HIV/HBV Coinfections
For people with HIV/HBV coinfection, HIV-ASSIST can be highly useful to ensure appropriate ART selection, including consideration of hepatic dysfunction when present. For example, for a person with newly diagnosed HIV/HBV coinfection who has Child-Pugh class A liver disease, the tool identifies several preferred ART options based on the likelihood of achieving HIV viral suppression and maximal medication tolerability (Figure 1).

  • Bictegravir (BIC)/tenofovir alafenamide (TAF)/emtricitabine (FTC)
  • Dolutegravir (DTG) + TAF/FTC
  • Doravirine (DOR) + TAF/FTC

The tool also highlights that inclusion of TAF, tenofovir disoproxil fumarate (TDF), lamivudine (3TC), and FTC has been prioritized because these drugs have activity against both HIV and HBV.

If a streamlined 2-drug regimen approach to HIV treatment is preferred (eg, scenarios where tenofovir exposure is not desired), HIV-ASSIST appropriately notes that persons with HIV/HBV coinfection will need an additional HBV treatment agent if they were to transition to DTG/3TC for HIV treatment.

Figure 1. HIV-ASSIST output for a patient coinfected with HIV/HBV.

HIV-ASSIST for Managing HIV/HCV Coinfections
PCPs providing HIV care are well positioned to offer HCV screening and treatment alongside HIV services. One key feature that may be particularly helpful is the drug‒drug interaction checker integrated into HIV-ASSIST. This resource can be easily used to assess for potential interactions between a person’s ART, other comedications, and HCV treatment options.

For example, a person whose HIV-1 RNA has been stably suppressed on the single-tablet regimen of darunavir (DRV)/cobicistat (c)/TAF/FTC and is now planning to start HCV treatment may need to consider switching ART if the direct-acting antiviral combination glecaprevir/pibrentasvir will be used because coadministration may increase systemic glecaprevir concentrations (Figure 2). Such interactions are easy to identify by using the HIV-ASSIST drug‒drug interaction checker, which is integrated with the University of Liverpool HIV Drug Interaction Checker.

Figure 2. HIV-ASSIST comedication interaction for a patient coinfected with HIV/HCV.

Your Thoughts?
What are your approaches to managing PWH who have HBV and/or HCV coinfections? Join the conversation by posting a comment below.