The increasing adoption of tenofovir (TXF)-sparing antiretroviral therapy (ART) raises concerns regarding hepatitis B virus (HBV) susceptibility and reactivation risk among people with HIV (PWH). We characterized HBV serological profiles and vaccination status according to ART composition in a real-world cohort. A cross-sectional study of all PWH in active follow-up at Hospital Clínic, Barcelona, as of 30 June 2025. ART regimens were categorized as TXF-containing or TXF-sparing, with or without lamivudine (3TC). HBV serological patterns were classified as chronic infection, serologically resolved infection, isolated HBV core antibody (anti-HBc), no exposure/immunity, and vaccine-induced immunity. Demographic and clinical characteristics were compared using nonparametric and chi-squared/Fisher’s tests. Among the 6437 participants included (82% cisgender men; median age 48 years IQR 39–58), 3519 (55%) received TXF-containing and 2918 (45%) TXF-sparing regimens, of whom 1702/2918 (58%) were with 3TC. HBV serological distribution was: 2% chronic infection, 26% serologically resolved infection, 5% isolated anti-HBc, 52% vaccine-induced immunity, and 15% without exposure/immunity (50% documented prior vaccination attempts, 32% nonresponders, and 31% with prior anti-HBs detection). Overall, 1280 (20%) lacked protective HBV immunity (isolated anti-HBc or negative serology for all markers), including 530 (41%) on TXF-free regimens. TXF recipients were younger (47 versus 50 years, p < 0.001), more often migrants (58% versus 49%, p < 0.001), had lower suppression rates (91% versus 97%, p < 0.001), a higher proportion of previous virological failure(s) (26% versus 21%, p < 0.001), and a lower number of prior ART regimens (median 3 versus 4, p < 0.001). One in five PWH lacked effective HBV immunity, including 41% of whom were receiving TXF-sparing strategies. In the context of increasing use of TXF-sparing strategies, improvements in systematic HBV screening, vaccination, and risk-based monitoring are essential to prevent HBV-related morbidity. People with human immunodeficiency virus (PWH) often share risk factors for infection with hepatitis B virus (HBV), a virus that can cause long-term liver disease. Classical treatments for HIV also protect against HBV, particularly those including the drug tenofovir. In addition, PWH exposed to HBV, can potentially reactivate it many years later, particularly if immunosuppression increases, for any reason (e.g., chemotherapy). However, newer treatment strategies, which increasingly avoid tenofovir, may not protect against HBV exposure or reactivation. We studied HBV immune status in all PWH receiving care at Hospital Clínic in Barcelona in June 2025. We reviewed whether a person had a current HBV infection, past infection, vaccine-related protection, or no protection at all. We also examined which HIV treatments people were receiving. Among more than 6000 people included in the study, almost half were receiving treatments that did not include tenofovir. One in five people lacked clear protection against HBV. This included individuals with no immunity and those with evidence of past exposure but without protective antibodies. These profiles indicate a risk of acquiring HBV or experiencing reactivation of a past infection. People receiving tenofovir were generally younger and more often migrants, while those receiving tenofovir-sparing treatments had longer treatment histories and more medical conditions. Our findings show that many PWH may be vulnerable to HBV, especially when receiving treatments that do not protect against it. As treatment strategies evolve, routine HBV testing, vaccination, and careful treatment selection are essential to reduce liver-related complications and improve long-term health outcomes.
Foncillas et al. (Sat,) studied this question.