Consensus recommendations for treatment of HCV in the setting of HBV coinfection

Consensus recommendationsGrade
All patients with HCV infection undergoing DAA therapy should be screened for HBV infection with anti-HBc, HBsAg and anti-HBs testing.A1
Non-immune (HBsAg, anti-HBc and anti-HBs-negative) patients should be offered HBV vaccination.A1
HBsAg-positive patients
Patients with HCV infection who are HBsAg-positive should be managed by, or in conjunction with, a specialist experienced in the treatment of both conditions.
Patients should be counselled regarding the risk of HBV reactivation and advised to immediately report any signs or symptoms indicative of serious liver disease.A1
All patients who are HBsAg-positive should undergo HBV DNA testing before commencing DAA therapy.A1
Anti-HBV therapy with tenofovir or entecavir should be commenced in all non-cirrhotic patients with an HBV DNA level > 2000 IU/mL and in all patients with underlying cirrhosis, regardless of HBV DNA level.A1


Non-cirrhotic patients with an HBV DNA level < 2000 IU/mL should be monitored for evidence of HBV reactivation. We recommend the following minimum requirements for monitoring:

§ ALT — every 4 weeks until the end of treatment, and at SVR

§ HBV DNA — every 12 weeks until SVR, plus if ALT level rises

§ If HBV DNA level remains < 2000 IU/mL at SVR, routine monitoring as per HBV guidelines can be reinstituted.

A rise in HBV DNA level > 2000 IU/mL at any time during therapy and/or elevation in ALT level accompanied by any rise in HBV DNA level should prompt consideration of antiviral therapy and intensive monitoring.A1
Coinfected patients who are already receiving anti-HBV therapy and have suppressed HBV DNA levels do not appear to be at increased risk and can continue with routine clinical monitoring.A1
Anti-HBc-positive, HBsAg-negative patients
Patients who are anti-HBc-positive and HBsAg-negative have a low risk of HBV reactivation.
Routine monitoring guidelines for patients treated with HCV DAAs should be followed, as recommended for people who are seronegative for HBV infection.B1
HBV reactivation should be considered in any patient who experiences an ALT flare during or after DAA treatment.

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