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considering Truvada start in patient with newly diagnosed chronic hep B

  • 1.  considering Truvada start in patient with newly diagnosed chronic hep B

    Posted 08-13-2020 15:57

    Mid 20's MSM contacted us to start PrEP.   Initial lab panel: negative for HIV, but has chronic hepatitis B (he was unaware), with eAg negative dz, low viral load at 328 IU/mL, mildly elevated ALT only at 77. No liver imaging yet.  From social history we have reason to think he acquired it at birth.

     

    Questions and concerns: 

    1. Would you delay starting PrEP until hepatology can consult?
    2. IF you start someone on Truvada (for PrEP) with Hep B coinfection, how long in general until hepatitis B is suppressed?  How long until he would be considered unable to transmit hep B and therefore potentially not use condoms?
    3. I'm getting the sense from a colleague that treatment for hepatitis B won't be advised due to the low viral load and mild ALT elevation, but that would put him in a dilemma for whether or not to start Truvada because stopping therapy may cause a hep B flare.  If he started Truvada, they would be advising lifelong therapy.

     

    Thanks in advance,

    Josh Rohr PA-C, AAHIVS

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  • 2.  RE: considering Truvada start in patient with newly diagnosed chronic hep B

    Posted 08-14-2020 15:43

    Hi Joshua
    i would start him on PrEP because he is at high risk for contracting HIV. I would advise him that since TAF/FTC  or TDF/FTC will suppress his HBV, the most important thing is if he decides to discontinue PrEP, he is at risk for an HBV flare, so would need LFTs checked monthly for a few months after stopping. You are correct that based on HBV guidelines, with very low HBV DNA and mildly elevated LFTs, he would not otherwise be started on HBV treatment, but that his PrEP treatment will suppress his HBV.  Given his already low DNA I'm not sure that he has much risk of transmitting HBV anyway, but others can weigh in on that. He should be counseled re HCV risk and screened periodically for that.  If he is not HAV immune he should be vaccinated. 


    Gary



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    Gary F. Spinner PA,MPH,AAHIVS
    Southwest Community Health Center
    Bridgeport, CT
    gspinner@swchc.org
    Gary.spinner@aya.yale.edu
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  • 3.  RE: considering Truvada start in patient with newly diagnosed chronic hep B

    Posted 08-15-2020 17:27
    I agree with Dr Spinner, be sure the patient understands that abrupt discontinuation must be watched closely as they sometimes precipitate flare ups.

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    Thomas Kaspar
    Victoria TX
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