Spontaneous loss of HBeAg and the prevalence of HTLV-III/LAV infection in a cohort of homosexual hepatitis B virus carriers and the implications for antiviral therapy

Natural history of chronic hepatitis B in co-infected patients

HIV co-infection influences the course and natural history of hepatitis B virus (HBV) infection by impairing the quantity and quality of the innate and adaptive immune response. The rates of spontaneous resolution after acute infection and spontaneous anti-HBe and anti-HBs seroconversions are decreased, and levels of HBV replication are increased in HIV-infected patients. A more rapid progression of liver fibrosis and a higher rate of cirrhosis decompensation (but not hepatocellular carcinoma) have been demonstrated in co-infected patients. The risk of HBV-associated end-stage liver disease and liver-related mortality may be increased by HIV co-infection. Antiretroviral therapy may trigger spontaneous anti-HBe and anti-HBs seroconversion and/or a better immune control of HBV replication by restoring adaptive immunity, but can also increase hepatitis flares. Reactivation of chronic hepatitis B has been observed after suspension of anti-retrovirals with anti-HBV activity or after occurrence of HBV resistance to lamivudine. Future research should focus on: the impact of HIV-induced changes in innate and adaptive immune response and modifications induced by anti-retroviral therapy that may impact on progression of advanced chronic hepatitis B; the association between HBV genotype and clinical course of disease; and the role of occult HBV infection as a co-factor with other causes of liver injury.

Failure to deliver hepatitis B vaccine: confessions from a genitourinary medicine clinic

OBJECTIVE

To audit hepatitis B immunisation of homosexual or bisexual men in a genitourinary medicine clinic.

DESIGN

Retrospective case note review of all homosexual and bisexual men presenting to a genitourinary clinic as new patients during 12 months in 1988 and follow up review of notes to May 1990.

SETTING

One department of genitourinary medicine, Middlesex Hospital.

PATIENTS

758 homosexual or bisexual men, of whom 207 started a course of hepatitis B vaccine in 1988. Case notes were unavailable for one patient.

MAIN OUTCOME MEASURES

The proportion of patients screened for hepatitis B virus markers, the proportion of susceptible patients immunised, the proportion completing the vaccine course, and the proportion rendered immune.

RESULTS

25 men had been previously tested for hepatitis markers; of the 732 not previously tested, 440 (60.1%) were screened for hepatitis B markers. 207 (69%) of the 300 patients without hepatitis B serological markers started the vaccine course, and 141 (68%) completed it, with 75 (84%) of the 89 tested after immunisation being immune. An estimated 24% of susceptible new patients were rendered immune as a result of the immunisation policy. Patients who presented with a further episode of a sexually transmitted disease were more likely to have been screened (25% v 12%, p less than 0.0001) and immunised (31% v 18% p = 0.02); those known or found to be positive for HIV antibody were more likely to have been screened (23% v 14%, p = 0.047) but less likely to have been immunised (6% v 17%, p = 0.004).

CONCLUSIONS

The major failure was that in not screening; failure to immunise patients found to be susceptible and failure of compliance with the vaccine course contributed. Non-response to the vaccine was of minor importance. Improvements in vaccine delivery are required.

IMPLICATIONS

Other providers should be encouraged to review their performance.

Remission of hepatitis B-associated membranous glomerulonephritis in human immunodeficiency virus infection

Hepatitis B virus (HBV) infection has been associated with several renal diseases, the most common being membranous glomerulonephritis (MGN). The role of concurrent human immunodeficiency virus (HIV) infection in affecting the course of the renal involvement is largely unknown. We report the case of a HIV-infected adult male with chronic HBV-associated MGN who had complete remission of the nephrotic syndrome associated with spontaneous seroconversion from hepatitis B e antigen (HBeAg)-positive to HBeAg-negative. The present case illustrates that HIV infection does not preclude improvement of chronic HBV infection or an associated membranous nephropathy. Such improvement may be dependent on the ability of the host immune system to clear HBeAg.

A randomised controlled trial of adenine arabinoside 5'-monophosphate (ARA-AMP) in chronic hepatitis B virus infection

Twenty-nine HBV carriers were randomised to receive ARA-AMP 10 mg/kg/day given as intramuscular injections 12 h apart for 5 days followed by 5 mg/kg/day for 23 days (15 patients) or no treatment (14 patients). Serum HBV-DNA polymerase and DNA decreased in all patients during therapy and 6 patients lost HBeAg. Five developed anti-HBe and 1 lost HBsAg and developed anti-HBs. No such changes occurred in the untreated control group over the 18-month period of observation. A 1-month course of ARA-AMP inhibits productive HBV replication and in some patients this is associated with a later loss of HBeAg and development of anti-HBe. However, intercurrent infection occurred in 3 of the treated patients with other hepatotrophic viruses known to inhibit HBV replication.