Academy Exchange

My providers and I have ongoing discussion when HIV patients have the following HBV serologic profiles:
  1) HBV Core Ab (+), HBV Surface Ab (+), and HBV Surface Ag (-)
 2) HBV Core Ab (+), HBV Surface Ab (-), and HBV Surface Ag (-) ... these results have been confirmed (not a false-positive Core Ab)

Scenario #1) We all agree that these serologies are telling us that the patient has HBV immunity due to natural infection; however, due to HBV Core Ab (+), does this still warrant the need for the patient's ART regimen to include 2 (or even 1) HBV-active NRTI agent? Based on some non-HIV guidelines (i.e., NCCN and AASLD), they recommend HBV prophylaxis for patients with sole HBV Core Ab positivity to prevent HBV reactivation. Based on this, some of our providers will still advocate for ART regimens that include 2 HBV-active agents or even add entecavir to ART regimens without HBV activity (i.e., Juluca). However in theory, there is no risk for HBV infection/reactivation since they're naturally immune (HBsAb +)? 

Scenario #2) Since this serologic profile could represent resolved infection (without an antibody response), low level chronic or resolving active infection, this patient would be at risk for HBV infection / reverse seroconversion. In either case, this patient should receive ART that has activity against HBV. 

My overarching question: would you handle these two HBV Core Ab(+) serologies differently in terms of ART? Or just give ART with 2 HBV-active NRTI agents to all HBV Core Ab(+) patients to be on the safe side? 

Just an opinion-

If a patient is HBV S Ag negative-  I would not concern myself with adding additional ARVs to cover HBV solely based on antibody results (core or surface). I think this has the potential to complicate regimens and miss some opportunities with patients. 

I think the more important questions are:
1) Is the patient Surface antigen negative? (If they are- strongly consider vaccinating if they don't have a documented series of HBV vaccines. In patients with one documented series in place- there is some evidence to suggest a second series could be effective- so I would do a second series if one was not documented. There is an ACTG study right now in process looking at using Heplisav for non-responders. I have a couple patients in this study-- and they are now S Ab positive after previously failing two series with Engerix. Heplisav is available commercially). 
2) Patients who have done two series of vaccines- they are not recommended to keep getting vaccines. If the patient is truly a non-responder to vaccine -- are they at risk for Hep B? If there was above average risk for Hep B, I might consider a regimen that involved coverage (multiple partners, a current partner with positive Hep B surface antigen, or someone who works in a setting where they have high chance of contact with body fluids in an uncontrolled situation-- such as an EMT or other healthcare worker). 

Since you're likely in a place that is seeing patients regularly (unlike GI providers who probably sign off on patients with negative HBV S Ag and positive core AB)-- I don't know how much I would weigh those guidelines for an HIV practice. Your providers keep the patients on their panel forever (in theory) and can always send a HBV viral load and HBV S Ag once in a while a "spot" check. It's not like we are seeing tons of patients who are HBV Core Ab positive suddenly "reactivating"-- especially if they have a positive surface antibody. It would more be about concern for new infection (for me). For those with positive core antibody and negative surface antibody- I would take the approach above and spot check the RNA and surface antigen as needed. Patients with Hep B flair - will often have raised in liver enzymes-- that would be one of the things that would prompt me to check the S Ag and viral load.