HIV-positive persons with CD4 cell counts < 300 cells/μL should receive three doses of HAV vaccine over 6–12 months instead of the

standard two. 6.1.11 Where the pre-cART CD4 cell count is < 500 cells/μL, cART should be continued postpartum if HBV co-infection exists because of the increased risk of HBV progressive disease. Grading: 1B 6.1.12 Where the pre-cART CD4 cell count is > 500 cells/μL, transaminases are normal, HBV DNA < 2000 IU/mL PD-0332991 nmr and there is minimal or no fibrosis, patients should be given the option to continue tenofovir-based ART or to stop all ART. Grading: 1C 6.1.13 If a decision is taken to discontinue therapy, careful monitoring of liver function is imperative. Grading: 2D 6.1.14 Where the CD4 cell count is > 500 cells/μL and there is HBV viraemia and evidence of liver inflammation or fibrosis, cART containing tenofovir and emtricitabine should be continued.

Grading: 2C 6.1.15 Hepatitis flares that Cabozantinib in vivo occur after cART cessation should be treated by resumption of active anti-HBV treatment before significant liver dysfunction occurs. Grading: 2D The decision to continue ART or not postpartum depends on whether cART was indicated for maternal health and the level of HBV-related hepatic activity/fibrosis. There is consensus that all persons with active (HBsAg-positive and/or HBV DNA-positive) co-infection should receive ARVs if their CD4 cell count is < 500 cells/μL [176, 199]. In those women with CD4 cell counts of > 500 cells/μL with a baseline HBV DNA > 2000 IU/mL and/or evidence of fibrosis or inflammation, HBV treatment should be continued because of the risk of progressive liver disease if discontinued. Women with pre-cART CD4 cell counts > 500 cells/μL who received cART to prevent MTCT and who are not HBV-viraemic (HBV DNA < 2000 IU/mL) nor have evidence of established liver disease should be given

the option of discontinuing cART. Regular monitoring is essential. The management of HBV post partum as per the scenarios above is as for non-pregnant HIV co-infected adults [191]. Inflammatory flares, which may be severe, particularly in persons with cirrhosis can occur as a result of viral escape and HBV viraemia, if drugs with anti-HBV activity are stopped. In an RCT comparing lamivudine with placebo 3-mercaptopyruvate sulfurtransferase for reducing HBV MTCT in patients with HBV mono-infection, an immediate increase in HBV DNA levels was observed on discontinuation of lamivudine postpartum [201]. Similarly, hepatitis flares among HIV/HBV co-infected patients have been reported upon the discontinuation of lamivudine, emtricitabine and tenofovir. In the Swiss HIV observational cohort, liver enzyme elevation occurred in 29% of patients who discontinued lamivudine and in 5% this was severe with three patients presenting with fulminant hepatitis [202] at a median time of 6 weeks after discontinuation.