2024 China Expert Consensus on HIV with HBV and HCV Coinfection
Screening, Assessment and Antiviral Treatment Recommendations
In 1988 the World Health Organization designated 1 December as World AIDS Day, calling on countries and international organisations to hold activities on that day to publicise and spread knowledge about HIV prevention [1]. The symbol of World AIDS Day is the red ribbon, which stands for public care and support for people living with HIV and for people with AIDS [2]. It symbolises a love of life and a yearning for peace, and a commitment to take part in HIV prevention work with heart. According to data released by China's National Health Commission, by the end of October 2021 China had reported 1.14 million people living with HIV, and the country's HIV epidemic overall remains at a low-prevalence level [3].
Release of the 2024 Consensus
In April 2024, the HIV and Liver Disease Committee of the Chinese Association of STD and AIDS Prevention and Control, together with the Eighth Affiliated Hospital of Guangzhou Medical University, formally published the 2024 edition of the Expert Consensus on the Diagnosis and Treatment of HIV Coinfection with HBV and HCV in the Chinese Journal of AIDS and STD, Volume 30, Issue 4 [4]. The consensus draws on the latest domestic and international research, evidence-based medicine, authoritative guidelines and clinical experience to set out recommendations on screening, diagnosis, assessment and treatment for HIV coinfection with HBV and HCV, providing guidance for standardised clinical management.
AIDS is a systemic disease caused when HIV attacks the immune system after infecting the body. HBV and HCV infection are the main causes of chronic viral hepatitis, cirrhosis, hepatocellular carcinoma (HCC) and liver-related death in China. In clinical practice, HIV coinfection with HBV and HCV is relatively common. Coinfection not only accelerates progression of the HIV disease course and raises the risk of liver-related endpoint events, but also constrains the choice of combination antiretroviral therapy (cART) regimens, and therefore affects patient survival and prognosis. The 2024 consensus sets out detailed recommendations on testing for HIV/HBV and HIV/HCV coinfection and on antiviral treatment.
1. HIV/HBV Coinfection
Screening, Diagnosis and Assessment
- All newly diagnosed HIV patients should receive HBV infection screening. Patients with hepatitis B should also be tested for HIV antibodies before starting nucleos(t)ide analogue antiviral therapy, in order to exclude HIV infection.
- Patients with HIV/HBV coinfection should be assessed every 3 to 6 months. The assessment covers ALT, AST, total bilirubin, serum albumin, quantitative HBsAg, HBsAb (anti-HBs), HBeAg, HBe antibody (anti-HBe), HBcAb (anti-HBc), quantitative serum HBV-DNA, liver ultrasound and non-invasive liver fibrosis testing.
- Patients with HIV/HBV coinfection should be screened for HCC every 3 to 6 months using liver ultrasound and alpha-fetoprotein (AFP), with contrast-enhanced CT or contrast-enhanced MRI when necessary, so that HCC can be detected early.
Antiviral Treatment
- Once HIV infection is confirmed, cART should be started immediately regardless of CD4 cell count, provided there is no indication to defer anti-HIV treatment.
- In HIV/HBV coinfection, both viral infections should be treated simultaneously. The cART regimen should contain two NRTIs with anti-HBV activity. Regimens containing only one anti-HBV active NNRTI are not recommended for treating hepatitis B, because doing so risks inducing HIV resistance mutations to this class of drug. Unlike HBV monoinfection, where treatment may be stopped under certain indications, patients with HIV/HBV coinfection require long-term maintenance antiviral therapy.
- During antiviral treatment, HBV-related markers — including quantitative serum HBV-DNA, liver biochemistry, AFP and liver imaging — should be monitored regularly.
- When a new cART regimen is selected after HIV drug resistance develops, two drugs with anti-HBV activity should likewise be retained, and HBV should be tested for resistance as well.
- For pregnant women with HIV/HBV coinfection, cART should be started as early as possible regardless of CD4 cell level, and the regimen should contain two drugs with anti-HBV activity. If cART was already started before pregnancy and both HIV and HBV are well controlled, the original regimen may be continued.
- For children with HIV/HBV coinfection, cART should be started as early as possible regardless of CD4 cell level, with anti-HBV treatment given at the same time; the principles for regimen selection are the same as for adult patients. When starting cART in coinfected children, regimen selection should take full account of age, HBV infection stage, drug suitability and drug resistance.
- For patients with renal impairment who can use TDF or TAF, entecavir should be added to the cART regimen, with strengthened monitoring of HBV-related markers.
2. HIV/HCV Coinfection
Screening, Diagnosis and Assessment
- All patients with HIV infection should be screened for HCV infection once a year. Patients with HIV/HCV coinfection should undergo routine annual assessment of ALT, AST, total bilirubin, serum albumin, quantitative serum HCV-RNA, liver ultrasound and non-invasive liver fibrosis testing.
- Before starting anti-HCV treatment, the severity of liver disease, renal function, quantitative HCV-RNA, HBsAg, comorbid conditions and concomitant medications should be assessed; HCV genotyping may be performed when necessary.
- Note that even when HCV is cured, regular monitoring and follow-up plus HCC screening are still required, particularly in patients with cirrhosis.
- For patients with low CD4 cell counts, non-invasive diagnostic methods should be actively used to assess the degree of liver fibrosis dynamically.
Antiviral Treatment
- All patients with HIV/HCV coinfection should receive both anti-HIV and anti-HCV treatment. The cART regimen for coinfected patients may follow that used in HIV monoinfection, and drugs with lower hepatotoxicity are preferred. For patients with a history of decompensated cirrhosis, regimens containing an NS3/4A protease inhibitor are not recommended.
- When starting anti-HCV treatment, particular attention must be paid to interactions between direct-acting antivirals (DAAs) and anti-HIV drugs such as efavirenz (EFV), nevirapine (NVP) and lopinavir/ritonavir (LPV/r). When the original cART regimen is changed for HCV treatment reasons, HIV RNA should be monitored 2 to 8 weeks after the switch to assess whether the new treatment effectively suppresses HIV.
- For pregnant women with HIV/HCV coinfection, cART should be started as early as possible regardless of CD4 cell level, following the Chinese Guidelines for Diagnosis and Treatment of HIV/AIDS (2021 edition) [5]. Anti-HCV treatment in these women should be given after delivery and the breastfeeding period, using DAAs according to the regimen for the general population.
- For children with HIV/HCV coinfection, cART should be started as early as possible regardless of CD4 cell level, following the 2021 guidelines [5]. When starting anti-HCV treatment in coinfected children, the appropriate DAA regimen and dose should be selected with reference to age, drug suitability and drug-drug interactions, as described in the Guidelines for the Prevention and Treatment of Hepatitis C (2022 edition) [6].
- Both HIV and HCV infection are independent risk factors for chronic kidney disease (CKD). For coinfected patients diagnosed with CKD, cART and anti-HCV treatment should be started as early as possible, with reference to the 2022 hepatitis C guidelines [6].
- People who inject drugs should be offered regular voluntary testing for anti-HCV and HCV-RNA. All people who inject drugs should receive antiviral treatment promptly, with the same regimen as the general population, paying attention to drug-drug interactions. Those who continue high-risk behaviour should be monitored for HCV reinfection after achieving sustained virological response (SVR), with HCV-RNA assessment at least once a year. Reinfection detected during post-SVR follow-up should be treated with anti-HCV therapy again.
- Before DAA treatment in HIV/HCV coinfection, HBV markers should be screened routinely. In HIV/HBV/HCV triple infection, HBV reactivation during DAA therapy has been reported to cause liver failure. Patients with triple infection must therefore start HCV DAA therapy only after their condition is stable on a cART regimen that includes anti-HBV active drugs.
3. Key Monitoring Intervals at a Glance
| Population | Recommended interval | What is monitored |
|---|---|---|
| HIV/HBV coinfection | Every 3–6 months | ALT, AST, total bilirubin, serum albumin, quantitative HBsAg, anti-HBs, HBeAg, anti-HBe, anti-HBc, quantitative HBV-DNA, liver ultrasound, non-invasive liver fibrosis testing |
| HIV/HBV coinfection | Every 3–6 months | HCC screening with liver ultrasound and AFP; contrast CT or MRI when necessary |
| HIV infection (for HCV) | Once a year | HCV infection screening |
| HIV/HCV coinfection | Annually | ALT, AST, total bilirubin, serum albumin, quantitative HCV-RNA, liver ultrasound, non-invasive liver fibrosis testing |
| People who inject drugs after SVR | At least once a year | HCV-RNA to detect reinfection |
4. VirtueDx Pre-NAT II Molecular Testing Solution
Qualitative Blood Screening
VirtueDx provides a hepatitis B virus, hepatitis C virus and human immunodeficiency virus (type 1) nucleic acid detection kit (PCR-fluorescence method). Built on the Pre-NAT II fully automated workflow, it focuses on the blood screening field, delivering timely and reliable screening results for clinical departments and laboratories at all levels of blood centres, and contributing to the safety of the human blood supply.
HBV/HCV/HIV-1 Triplex Kit
A single kit detects HBV, HCV and HIV-1 nucleic acid in one tube, raising testing efficiency while reducing testing cost and reporting time.
- High sensitivity: the triplex assay is designed to detect low viral loads in blood screening settings.
- Fully automated platform: on the Pre-NAT II workflow, the entire process — from nucleic acid extraction of the original sample tube to construction of the PCR reaction system — runs automatically, reducing manual error and improving precision.
- Accurate interpretation: a dual DNA and RNA internal control system monitors the validity of both nucleic acid extraction and PCR amplification, preventing false-negative results.
- Contamination prevention: unique self-rotating magnetic rod mixing and a UNG-dUTP system provide dual protection against PCR amplicon contamination.
High-Sensitivity Quantitative Kits
The hepatitis B virus nucleic acid detection kit (fluorescence PCR), the hepatitis C virus nucleic acid detection kit (fluorescence quantitative PCR) and the human immunodeficiency virus (HIV-1) nucleic acid detection kit (fluorescence PCR) together form an integrated solution built around the Pre-NAT II high-throughput fully automated platform and high-sensitivity reagents. The solution provides timely, reliable testing for centres for disease control and prevention, medical institutions and clinical laboratories at all levels.
References
[1] World Health Organization. World AIDS Day. Designated 1 December 1988.
[2] World AIDS Day red ribbon symbolism.
[3] National Health Commission of the People's Republic of China. Reported HIV infections in China, data to end-October 2021.
[4] HIV and Liver Disease Committee, Chinese Association of STD and AIDS Prevention and Control; Eighth Affiliated Hospital of Guangzhou Medical University. Expert Consensus on the Diagnosis and Treatment of HIV Coinfection with HBV and HCV (2024 edition). Chinese Journal of AIDS and STD, 2024, 30(4).
[5] Chinese Guidelines for Diagnosis and Treatment of HIV/AIDS (2021 edition).
[6] Guidelines for the Prevention and Treatment of Hepatitis C (2022 edition).
