All pregnant women should be tested for hepatitis B surface antigen (HBsAg) during an early prenatal visit (AI). Testing should be repeated in late pregnancy for HBsAg-negative women at high risk of hepatitis B virus (HBV) infection (e.g., injection-drug users, women with intercurrent sexually transmitted diseases, women with multiple sex partners) (BIII).
All infants born to HBsAg-positive women, including HIV-co-infected women, should receive hepatitis B vaccine and hepatitis B immune globulin within 12 hours after birth, a second dose of hepatitis B vaccine at age 1 to 2 months, and a third dose at age 6 months (AI).
HIV-infected infants, children, and adolescents should be tested for HBsAg as soon as possible after HIV diagnosis (AII).
HIV-infected infants, children, and adolescents should be tested for quantitative anti-HBs and HBsAg 1 to 2 months after completing the vaccination series. If anti-HBs levels are <10 mIU/mL and the HBsAg result is negative, they should be revaccinated with a second, 3-dose series of HBV vaccine followed in 1 to 2 months by repeat testing for anti-HBs (AIII).
Antiviral therapy is not warranted in children without necroinflammatory liver disease (BIII). Treatment is not recommended for children with immunotolerant chronic HBV infection (i.e, HBeAg positive, normal serum transaminase levels despite detectable HBV DNA) or inactive carriers (i.e. HBeAg negative, normal serum transaminase levels despite detectable HBV DNA) (BII).
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Indications for treatment of chronic HBV infection in HIV-co-infected children are the same as in HBV-infected and HIV-uninfected children:
Evidence of ongoing HBV viral replication, as indicated by serum HBV DNA (>10,000–100,000 international units/ml for >6 months) and persistent elevation of serum transaminase levels (at least twice the upper limit of normal for >6 months), or.
Evidence of chronic hepatitis on liver biopsy (BII).
Standard interferon-alfa (IFN-α), IFN-2a or IFN-2b, is recommended for treating chronic HBV infection with compensated liver disease in HIV-uninfected children aged ≥2 years to <12 years who warrant treatment (AI). IFN-α therapy or oral antiviral therapy with adefovir or tenofovir is recommended for treating chronic HBV infection with compensated liver disease in HIV-uninfected children aged ≥12 years (AI). IFN-α therapy in combination with oral antiviral therapy cannot be recommended for pediatric HBV infection in HIV-uninfected children until more data are available (BII).
In HIV/HBV coinfected children who do not require combination antiretroviral therapy (cART) for their HIV infection, IFN-α therapy is the preferred agent to treat chronic hepatitis B (BIII), whereas adefovir can be considered in children age 12 years or older (BIII).
Treatment options for HIV/HBV co-infected children who meet criteria for HBV therapy and who are already receiving lamivudine-or emtricitabine-containing, HIV-suppressive cART include standard IFN-α therapy (BIII), or adefovir if the child can receive adult dosing (BIII), or use of tenofovir disoproxil fumarate (tenofovir) (with continued lamivudine or emtricitabine) in the cART regimen in children aged ≥2 years (BIII).
HIV/HBV-coinfected children should not be given lamivudine or emtricitabine for treatment of chronic HBV unless accompanied by additional anti-HIV drugs in a cART regimen (CIII).
For HIV/HBV-coinfected children who require treatment of both infections, a cART regimen that includes lamivudine (or emtricitabine) is recommended (BIII).
For HIV/HBV-coinfected children aged ≥ 2 years who require treatment for HIV but not HBV infection or treatment for both infections, a cART regimen that includes tenofovir and an anti-HBV nucleoside (either lamivudine or emtricitabine) can be considered (BIII).
The dose of lamivudine required to treat HIV infection is higher than that used to treat pediatric chronic hepatitis B infection; therefore, the higher dose of lamivudine should be used in HIV/HBV-coinfected children to avoid development of lamivudine-resistant HIV (AIII).
Lamivudine and emtricitabine should be considered interchangeable for treatment of chronic hepatitis B and not additive (BIII).
For hepatitis B e antigen (HBeAg)-positive patients who are HIV-uninfected, treatment with anti-HBV drugs should be continued until HBeAg seroconversion has been achieved and >6 months of additional treatment has been completed after the appearance of anti-HBeAg (BI*). However, treatment with lamivudine or other anti-HBV drugs with anti-HIV activity should be continued indefinitely in children with HIV/HBV co-infection, even if HBeAg seroconversion occurs (CIII).
If discontinuation of therapy for chronic HBV results in hepatic flare, therapy for chronic HBV infection should be reinstituted (BIII).
