Treatment of viral hepatitis B infection in patients receiving intensive immunosuppressive therapies

To the editor:

We read with great interest the paper written by Raymond Liang,¹  which represents an excellent and complete overview of the management of hepatitis B virus (HBV) infection during treatment of hematologic malignancies. Nevertheless, we would like to focus on the particular situation of HIV-HBV–coinfected patients. In our opinion, several points must be underlined because they lead to special attention when a hematologic malignancy, especially high-grade B lymphoma, is diagnosed in this population.

Prevalence of HBV infection is higher in HIV patients than in the general population. Moreover, in these cases, immunosuppression is generally more severe due to the coexistence of lymphoma and HIV. Addition of rituximab to the CHOP (cyclophosphamide, adriamycin, vincristine, and prednisone) regimen in HIV lymphoma patients has increased the response rate, but its immunosuppressive effects have, in some reports, led to an increase in infectious complications.² 

Specific therapeutic considerations on the use of anti-HBV drugs must also be made. At first, it is important to remember that in HBV-HIV–coinfected patients, unlike HIV-negative patients, the use of 2 anti-HBV drugs is generally recommended.³  Tenofovir and lamuvidine are generally the recommended choices. Furthermore, several anti-HBV drugs (lamuvidine, tenofovir, emcitrabine, and entecavir) also have a potent activity against HIV. So these drugs should be used not alone, but as part of a highly active antiretroviral therapy against HIV. To omit this important aspect could lead to the appearance of mutations in HIV genome and, finally, to resistance to antiretroviral therapy.