40. We recommend ART should be discontinued if grade 4 hepatotoxicity (transaminases >10 times upper limit of normal) develops, even if the patient is asymptomatic. 5.1.3 Auditable outcome Proportion of patients with baseline transaminase checked before and one month after starting a new ARV 6 Hepatitis B (HBV) 6.2 HBV resistance, genotype testing and treatment response 6.2.1 Recommendations  41. We recommend against HBV resistance testing at baseline www.selleckchem.com/products/PLX-4032.html in those previously unexposed to antivirals (1C).  42. We recommend, where feasible, HBV resistance

testing at baseline in those with detectable HBV DNA and previously exposed to antiviral drugs with anti HBV activity if not on treatment, where there is primary non-response or partial response to HBV-active antivirals, or where there is virological breakthrough (1C).  43. We recommend against a change in HBV-specific therapy in those whose viraemia continues to show improving response to treatment after 48 weeks (1C).  44. We recommend against testing for HBV genotype as an investigation to determine initial treatment (1C). 6.2.2 Good practice point  45. We recommend adherence is discussed with all patients with HBV viraemia receiving antivirals. 6.3 Thresholds selleck chemical for ART treatment 6.3.1 Recommendations  46. We recommend all those with an HBV DNA ≥2000 IU/mL should be treated, regardless of fibrosis score (1C).  47. We recommend

all those with more than minimal fibrosis on liver biopsy (Metavir ≥F2 or Ishak ≥S2) dipyridamole or indicative of ≥F2 by TE (FibroScan ≥9.0 kPa) should be treated, regardless of HBV DNA

level (1C) (see Section 4).  48. We suggest those with a CD4 ≥500 cells/μL, an HBV DNA of <2000 IU/mL, minimal or no evidence of fibrosis (Metavir ≤F1 or Ishak ≤S1 or FibroScan <6.0 kPa) and a repeatedly normal ALT should be given the option to commence treatment or to be monitored not less than 6-monthly with HBV DNA and ALT and at least yearly for evidence of fibrosis (2C).  49. We recommend all patients with a CD4 <500 cells/μL are treated with fully suppressive ART inclusive of anti-HBV-active antivirals (1B). 6.3.2 Good practice points  50. We recommend at least two baseline HBV DNA measurements are obtained 3 to 6 months apart to guide initiation of therapy.  51. We recommend 6-monthly HBV DNA measurements for routine monitoring of therapy.  52. We recommend that an ALT level below the upper limit of normal should not be used to exclude fibrosis or as a reason to defer HBV therapy. Normal levels of ALT should be considered as 30 IU/L for men and 19 IU/L for women. 6.3.3 Auditable outcome Proportion of patients with a CD4 ≥500 cells/μL and an HBV DNA ≥2000 IU/mL and/or evidence of more than minimal fibrosis (Metavir ≥F2, Ishak ≥S2, or TE ≥9.0 kPa) commencing ART inclusive of anti-HBV antivirals 6.4 Antiviral treatment: CD4 count ≥500 cells/μL (Algorithm 1) 6.4.