Hello Doctor: Im an HIV+ male (41yrs) with consistent 500+ CD4 counts and viral load consistently around 20,000. About a year ago however, in between vaccinations for hepatitis, I contracted hepatitiss B as this shoed up in my blood analysis. Though I have never had any symptoms of hepatitis.

About 12 months later I still have transaminases levels too high - about 81 and 116 (the test range was 0-45). My doctor fears chronic hepatitis B.

If this were the case, my doctor said I should start therapy on truvada and sustiva. I have to have some other tests.

Questions please:

Can I simply treat the hepatitis B at this time? If so, with what?

Would truvada and sustiva treat the hepatitis B?

What are my other options instead of beginning HIV treatment?

What is the best advice for someone who is co-infected like this? Is waiting an option?

Thank you.

Excellent questions.

1. It is unfortunate that you acquired hepatitis B before fully being immunized. However, I would wonder if your doctor firmly established that you just got your infection (eg, was a anti-core IgM antibody performed? If so, then at least we know you have had your infection for a short time and that would be helpful. I suspect you may not have this information since you did not mention it.

2. You could consider getting a liver biopsy to get a sense of how much disease you have.

3. Alternatively, you could start HIV treatment with the drugs your doctor suggested. Already the treatment guidelines for HIV suggest that earlier initiation of treatment for HIV can be considered if a person has other comorbidities, like HBV and HCV. I think HBV is an excellent reason to give this a lot of thought since this particular combination is effective...

4. New treatment guidelines will be coming out for HIV and I suspect the pendulum will probably swing towards earlier treatment for HIV in terms of CD4 counts.

5. If you don't want to start treatment for HIV and want to just try only HBV treatment, I would suggest pegylated interferon alfa 2a. I would strongly consider this an option if your HBV DNA is not too high (less than 10(7) logs) and you are HBe antigen positive. Then you may have a chance of complete seroconversion. However, there are few data on the treatment of HIV infected patients with this drug.

Adefovir could also be considered - again if your HBV viral load is relatively low. However, the chance of complete seroconversion with this drug is lower. If you have HBeAg negative disease, I would favor adefovir over interferon.

We have written up guidance for patients with HIV/HBV coinfection in the most recent USPHS guidelines document on opportunistic infections in HIV infected at the following URL: persons.http://www.aidsinfo.nih.gov/Guidelines/GuidelineDetail.aspx?GuidelineID=13