ASK DIS: Initiation AntiRetroViral in Liver Disease

All classes of ARV agents have been associated with liver toxicity, so extra caution is warranted in prescribing HAART for patients with chronic liver disease.
NVP and RTV have been associated with the highest risk of liver toxicity and should therefore be avoided if other options exist
For patients with chronic hepatitis B (HBV) infection, inclusion of 3TC and/or TDF in the HAART regimen should be considered because these agents are potent inhibitors of HBV replication
However, patients who have a history of 3TC monotherapy while co-infected with HBV and HIV likely developed HIV resistance to 3TC, compromising the efficacy of this agent in HAART regimens.
Discontinuation of either of these agents in a patient with chronic HBV can be associated with an acute exacerbation of HBV
Patients with chronic viral hepatitis (eg, hepatitis B virus [HBV], hepatitis C virus [HCV]) are at increased risk for drug-associated hepatotoxicity

Coinfection with Hepatitis B

We do not treat patients for chronic HBV until they are ready to be treated for HIV
depends upon the patient’s prior treatment history for HIV and/or HBV, as well as their renal function
Treatment-naïve and normal or near-normal kidney function

tenofovir-emtricitabine (coformulated as Truvada) provides optimal coverage for the treatment of HIV when combined with a third agent (ie, protease inhibitor, integrase inhibitor, non-nucleoside reverse transcriptase inhibitor)

Tenofovir also suppresses HBV DNA in patients who are treatment-experienced (eg, previously received lamivudine, emtricitabine and/or entecavir)
Such patients are most often those who received certain nucleoside backbones for their HIV, such as abacavir-lamivudine or zidovudine-lamivudine.

Entecavir can be used as a single agent for the treatment of HBV in patients with a baseline estimated creatinine clearance <50 mL/min/1.73m2 since HBV resistance to this agent rarely develops in patients who are treatment-naïve.
The dose of entecavir must be adjusted according to renal function
However, patients treated with entecavir must also be treated with a separate, fully suppressive HIV regimen

Coinfection with Hepatitis C

ART-naïve HIV/HCV-coinfected patients should be initiated on ART for their HIV disease, regardless of their CD4 cell count
In most instances, it is preferable to start ART first and begin HCV therapy later.
However, it is reasonable to delay ART initiation until after HCV treatment among patients with a CD4 cell count above 500 cells/microL
HCV treatment

Because the efficacy of direct-acting antiviral-containing regimens among HIV/HCV coinfected patients overall appears to be comparable to that among HCV monoinfected patients, decisions on regimen selection are similar between the two groups
Recommended to use direct-acting antivirals such as sofosbuvir, ledipasvir, ombitasvir-paritaprevir-ritonavir, dasabuvir, and simeprevir
Other less preferable regimens may be warranted for patients who cannot defer therapy but live in locations where these agents are unavailable

Monitoring

Increased transaminase levels are usually asymptomatic and most elevations revert to normal levels despite continuation of the implicated drugs.
However, some authorities recommend careful monitoring when aminotransferases reach five times the upper limit of normal (grade 3 toxicity)
ART should also be stopped in the event of symptomatic hepatotoxicity (eg, right upper quadrant pain, nausea, vomiting, jaundice).
Clinicians should be aware that the risk of drug-induced liver injury is higher in patients with underlying chronic viral hepatitis

References:

http://www.chartcaribbean.org/
www.uptodate.com
https://aidsinfo.nih.gov/guidelines/html/1/adult-and-adolescent-arv-guidelines/10/initiating-art-in-treatment-naive-patients
Guidelines for the Use of Antiretroviral Agents in HIV-1-Infected Adults and Adolescents

ASK DIS