Management of chronic hepatitis B in challenging patient populations

The management of chronic hepatitis B and its liver-related complications remains a significant challenge for many clinicians. Some of the challenges relate to the management of special patient populations, including persons with HIV co-infection, pregnant women, and pediatric patients, for whom minimal clinical data and experience exist. HIV co-infection can modify the natural course of chronic hepatitis B, producing atypical clinical and serologic profiles. The management of hepatitis B virus (HBV) infection in the presence of HIV co-infection is complex, since the therapy must address the need to treat one or both infections, and the planned therapy must take into account the dual activity and resistance profiles of the antiviral agents. Pregnant women with chronic hepatitis B and high HBV DNA levels face the risk of transmitting the infection to the developing fetus in spite of immunoprophylaxis. Challenges in treating hepatitis B infection in children and adolescents arise because of the limited experience with anti-HBV therapies in these age groups. Antiviral therapy for pregnant women, children, and adolescents is controversial, as the indications for treatment are less clearly defined, and defined endpoints in this population are lacking. In addition, there are concerns regarding toxicity associated with long-term treatment. This article reviews the issues relevant to special populations and reports recent data on the efficacy of antiviral therapy for these patients.