Trends in acute hepatitis B among people living with HIV over 25 years: Incidence and clinical outcomes.

BACKGROUND

Hepatitis B virus (HBV) infection remains a significant concern among people with HIV (PWH), who are at higher risk of acquiring HBV and often show suboptimal responses to vaccination. In this context, we aimed to update the incidence of acute hepatitis B (AHB) in a cohort of PWH, given recent epidemiological shifts including the increase in migrant populations and the wider use of antiretroviral therapy (ART) regimens lacking anti-HBV activity.

METHODS

We conducted a retrospective single-centre study including PWH under follow-up between 2000 and 2024. AHB cases were confirmed based on the recent positivity of HBsAg and anti-HBc IgM. Demographic, clinical, serological and ART-related data were collected. Incidence was calculated as cases per 100 person-years, and trends were analyzed in both the overall population and the susceptible subgroup (anti-HBc-negative).

RESULTS

A total of 22 AHB cases were diagnosed among 5986 PWH. The overall incidence rate was 0.02 (0.01-0.15) cases per 100 person-years, and 0.05 (0.01-0.3) cases per 100 person-years in the susceptible subgroup. Incidence decreased over time, with no new cases from 2015 to 2022, and isolated cases re-emerged in 2023-2024. Most AHB cases (78.3%) were unvaccinated; 21.7% had received full vaccination but failed to develop a serologic response. Only 26.1% of cases were on ART at AHB diagnosis, and no one was receiving tenofovir. The rate of progression to chronic hepatitis B (CHB) was 17.4%, higher than in the general population; all CHB cases occurred in ART-naïve individuals.

CONCLUSIONS

AHB incidence among PWH has declined over the past 25 years but remains higher than in the general population. The recent reappearance of isolated cases may reflect changes in HBV exposure risk, suboptimal vaccination coverage, or the increasing use of ART regimens without anti-HBV activity. Universal HBV vaccination and the use of tenofovir-based therapies in non-responders remain critical strategies for prevention and control.