UNIR Health Sciences School, Madrid.
Puerta de Hierro University Hospital, Madrid.
AIDS Rev. 2023;25(1):1-13. doi: 10.24875/AIDSRev.M23000061.
Coinfection with hepatitis viruses A to E is frequent in persons living with HIV (PLWH) and causes significant morbidity and mortality. Oro-fecal transmissible hepatitis A and E mostly produce acute self-limited episodes in poor income regions and in non-vaccinated travelers. In high-income countries, outbreaks of hepatitis A occur in men having sex with men (MSM) and chronic hepatitis E is occasionally reported among PLWH with severe immunodeficiency. Chronic hepatitis B, C, and D are frequent in PLWH in highly endemic regions and globally in persons who inject drugs (PWID) and MSM. Progression to liver cirrhosis and development of hepatocellular carcinoma (HCC) is major clinical complications in coinfected patients. Current estimates for PLWH are of 38 million worldwide. Roughly 12% have chronic viral hepatitis (5 million). Coinfection figures are of 5-10% for HBV (2-4 million), 4% for HCV (1.5 million), and 15% of HBsAg+ for HDV (0.5 million). Oral direct-acting antivirals (DAA) cure almost all treated patients with hepatitis C. However, given that there is no protective HCV immunity, PLWH with high-risk behaviors may experience HCV reinfection episodes. Tenofovir is the drug of choice in PLWH with chronic hepatitis B, given its dual effect on HIV and HBV. Lifelong oral tenofovir suppresses HBV replication and ameliorate liver damage. However, the risk of HCC persists even in the absence of cirrhosis. Finally, HDV causes the worst of viral hepatitis with faster progression to cirrhosis and HCC. An entry inhibitor, bulevirtide, has recently been approved and another drug, lonafarnib, is completing Phase 3 trials. Combination antiviral therapy for hepatitis D could improve dramatically the poor prognosis of HIV-HDV coinfected patients. The resumption of good medical practices in PLWH after the big disruption caused by COVID-19 will reduce the burden of viral hepatitis coinfections. Renewed efforts on HAV and HBV vaccination of susceptible individuals and earlier and wider prescription of antiviral therapy for HBV, HCV, and/or HDV coinfection should be prioritized in PLWH. The benefits of innovative strategies for viral hepatitis, including pre-exposure prophylaxis or use of long-acting antivirals, warrant further consideration in PLWH.
甲型肝炎、乙型肝炎、丙型肝炎、丁型肝炎和戊型肝炎病毒合并感染在 HIV 感染者（PLWH）中很常见，可导致严重的发病率和死亡率。在收入较低的地区和未接种疫苗的旅行者中，经口-粪传播的甲型肝炎和戊型肝炎主要引起急性自限性发作。在高收入国家，甲型肝炎疫情发生在男男性行为者（MSM）中，慢性戊型肝炎偶尔在严重免疫缺陷的 PLWH 中报告。乙型肝炎、丙型肝炎和丁型肝炎在高度流行地区的 PLWH 中很常见，在全球范围内，注射毒品者（PWID）和 MSM 中也很常见。合并感染患者的主要临床并发症是肝硬化和肝细胞癌（HCC）的发展。目前全球估计有 3800 万 PLWH，其中约 12%（500 万）患有慢性病毒性肝炎。HBV 合并感染率为 5-10%（2-400 万），HCV 为 4%（150 万），HBsAg+为 15%（50 万）。口服直接抗病毒药物（DAA）几乎可以治愈所有接受丙型肝炎治疗的患者。然而，由于没有保护性 HCV 免疫，有高危行为的 PLWH 可能会经历 HCV 再感染发作。替诺福韦是 PLWH 慢性乙型肝炎的首选药物，因为它对 HIV 和 HBV 具有双重作用。长期口服替诺福韦可抑制 HBV 复制并改善肝损伤。然而，即使没有肝硬化，HCC 的风险仍然存在。最后，HDV 导致病毒性肝炎中最严重的一种，导致更快地发展为肝硬化和 HCC。最近，一种进入抑制剂（bulevirtide）已获得批准，另一种药物（lonafarnib）正在进行第 3 阶段试验。对丁型肝炎的联合抗病毒治疗可以显著改善 HIV-HDV 合并感染患者的不良预后。在 COVID-19 大流行造成的巨大干扰之后，PLWH 恢复良好的医疗实践，将降低病毒性肝炎合并感染的负担。在 PLWH 中，应优先考虑对易感人群进行甲型肝炎和乙型肝炎疫苗接种、更早和更广泛地使用抗病毒药物治疗 HBV、HCV 和/或 HDV 合并感染。包括暴露前预防或使用长效抗病毒药物在内的病毒性肝炎创新策略的益处，值得在 PLWH 中进一步考虑。
