Vaccination against Hepatitis A and B is recommended in all HIV positive non immune individuals whatever their risk factor.

Commence vaccination with separate Havrix and double dose Engerix B vaccination according to serology results in all newly diagnosed HIV patients.

Twinrix is not indicated in patients living with HIV

Serology

For PLHIV, newly diagnosed or transferring care check:

• Hepatitis A IgG
• Hepatitis B full serology:     Hep B core Antibody (HepB cAb)
                                           Heb B surface Antigen (HepB sAg)
                                           Hep B surface antibody titre (HepB sAb)

Check prior to vaccination unless high risk of acquisition

Hepatitis A Vaccination Course:

CD4 >350/mm ³ :   2 doses of Havrix  at 0 and 6 months

CD4 <350/mm ³ :  3  doses of Havrix  at 0,1 and 6 months (if at risk – sexually active MSM)

Give a booster every 10 years – record date booster due in standard letter.

Hepatitis B Vaccination Course:

Use a standard vaccination course (0, 1 and 6 months) of double dose (total 40mcg) routinely, with a booster at 5 years.

Use an accelerated course 0, 1, 2 and 12 months for post exposure prophylaxis

Use the super-accelerated course (0,1, 3 and 52 weeks) only in exceptional circumstances ( eg current partner with acute hepatitis B infection)

Dose:

Use a double dose (total 40mcg) Engerix routinely.

If also require Hep A vaccination use Twinrix + Engerix (combined =40mcg Hep B SA) - only applicable if using standard vaccination course.

Checking Immunity/Response:

Standard -  Check HepB sAb level with next routine bloods

                    Recheck annually with routine HIV bloods

                   Give booster if HepB sAb level falls <10 IU/L.

High risk - e.g. current partner with active Hepatitis B infection

                 check HepB sAb level 6-8 weeks after the final dose of the course. 

Management of HepB sAb Levels <10:

Level <10IU/L AND at significant risk of hepatitis B:

Offer repeat course of three double doses of Engerix B at 0,1,3 months recheck HepB sAb level again 6-8 weeks after completion of the second course.

<10 IU/L after second vaccination course:

CD4 >500 and on ARVs –  consider non-responder.
                                       Can consider Fendrix if high risk

If non-responder while not on ARVs or CD4 <350 - offer repeat vaccination course after commencing ARVs/rise in CD4 (better response if undetectable VL and CD4 >500)

Patients who are Hepatitis B cAb pos, sAg neg, sAb neg.

These patients should be given one dose of vaccine and their HepB sAb level should be repeated 2 weeks later.

These patients fall into one of these four categories:

• Resolved Hepatitis B infection with anamnestic Hepatitis B sAb response- HepB sAb level will rise >10IU/L after single vaccination
• False positive HepB  cAb response and susceptible to infection-requires full vaccination course
• Early clearing Hepatitis B infection-immune
• Occult Hepatitis B infection-does not require vaccination

If the HepB sAb level remains < 10 IU/l then they are probably in the second group ie false positive HepB cAb, and should be offered 2  further doses of vaccine at 1 month,  and 6 months.