Childhood Hepatitis B Vaccination Tied to Lower Coinfection in Patients With HIV

People with HIV (PWH) born after 1980, who were the first birth cohort broadly eligible for childhood hepatitis B virus (HBV) vaccination recommendations, had an 81% lower risk of active HBV coinfection than those born earlier, according to findings published in Open Forum Infectious Diseases, providing some of the first US-based evidence linking widespread HBV vaccination with lower coinfection risk decades later.¹

Assessing the Long-Term Impact of HBV Vaccination Among PWH

Chronic HBV infection remains a major global health concern, affecting an estimated 254 million people worldwide and contributing to 1.1 million deaths in 2022, largely through complications such as cirrhosis and hepatocellular carcinoma. Despite an effective vaccine being available since 1982, HBV remains prevalent in the US, with infections primarily associated with injection drug use (IDU) and high-risk sexual behaviors.

PWH face a higher burden of HBV infection due to shared transmission routes; HBV coinfection occurs in an estimated 5% to 11% of this subgroup, compared with 0.3% of the general US population. PWH are also less likely to clear acute HBV infections without antiretroviral therapy, increasing the risk of chronic infection and related complications.

Given this elevated burden among PWH, the impact of HBV vaccination policy on this population is of particular interest. Following the introduction of HBV vaccination recommendations for high-risk groups in 1982 and subsequent universal infant and childhood vaccination policies in the 1990s, HBV incidence declined across the US population. However, the impact of these policies across different birth cohorts remains unclear. Because of this, investigators examined hepatitis B surface antigen (HBsAg) seroprevalence among PWH born between 1940 and 1999 to assess how changes in HBV vaccination availability and recommendations influenced HIV-HBV coinfection rates over time.

Post-1980 Birth Cohort Had Significantly Lower HBV Coinfection Risk

They analyzed data from the Johns Hopkins HIV Clinical Cohort, an observational cohort of PWH enrolled in care at a Baltimore infectious disease clinic between 1989 and 2023. Patients were categorized into birth-year cohorts (1940–1959, 1960–1979, or 1980–1999) and then further dichotomized into pre- and post-1980 birth-year cohorts.

The researchers identified 5598 participants with documented HBsAg testing at cohort entry, most being men (67%) and Black (77%), with a mean age of 39.7 years. Of the population, 42% (n = 2347) were in the 1940-1959 cohort, 50% (n = 2789) in 1960-1979, and 8% (n = 462) in 1980-1999. Among the cohorts, the 1980-1999 cohort had a higher proportion of men who have sex with men (MSM; 66%) than the 1940-1959 (22%) and 1960-1979 (30%) cohorts. By contrast, history of IDU decreased with each subsequent birth-year cohort, with 54% for 1940-1959, 32% for 1960-1979, and 7% for 1980-1999.

Consistent with previously reported coinfection rates of 5% to 11% among PWH, overall HBV prevalence was 6.7% (95% CI, 6.0%-7.4%). However, prevalence sharply diverged by birth-year cohort: 6.2% (95% CI, 5.3%–7.2%) among those born 1940-1959, 7.9% (95% CI, 6.8%–9.0%) for those born 1960-1979, and 2.6% (95% CI, 1.4%–4.7%) for those born 1980-1999. After adjusting for race/ethnicity, HIV risk factors, CD4+ cell count, viral load, HBV-active therapy, and age and year at cohort entry, the post-1980 cohort had a significantly lower risk of HBV coinfection than the pre-1980 cohort (adjusted prevalence ratio [PR], 0.19; 95% CI, 0.09-0.42), corresponding to about 6 fewer infections per 100 individuals.

The post-1980 cohort would have been the first eligible for the Advisory Committee on Immunization Practices' (ACIP) sequence of childhood HBV vaccination recommendations, as risk-based vaccination was established in 1982, universal infant vaccination in 1991, and catch-up vaccination of previously unvaccinated adolescents and children through 1999. By contrast, the pre-1980 cohort was subject only to the narrower 1982 risk-based recommendation, which suffered from poor uptake and early, unfounded fears linking the vaccine to HIV transmission.

HBV Coinfection Declines Varied by MSM, IDU Status

The protective association was not uniform across risk groups. Among participants who identified as MSM, HBV prevalence dropped from 11.4% (95/831) in the pre-1980 cohorts to 2.9% (9/307) in the post-1980 cohort, which, the researchers noted, was a significant reduction (PR, 0.17; 95% CI, 0.07-0.43). By contrast, the decline was not statistically significant among non-MSM participants (PR, 0.34; 95% CI, 0.10-1.13).

A similar pattern emerged by IDU status: among participants without a history of IDU, the post-1980 cohort was less likely to have HBV coinfections than the pre-1980 cohort (PR, 0.19; 95% CI, 0.09-0.44). However, among those with a history of IDU, the likelihood of HBV coinfection in the post-1980 vs pre-1980 cohorts was not statistically significant (PR, 0.41; 95% CI, 0.06–2.95).

Even at its lowest point, the 2.6% HBV prevalence in the post-1980 PWH cohort remained well above the near-undetectable rates reported in the general US population born after 1980. Part of that persistent gap may be biological rather than purely a matter of vaccine access, the researchers noted.

HIV disrupts several immune steps required for durable antibody production after HBV vaccination, including depletion of CD4+ helper T cells and expansion of exhausted B-cell subsets, leaving standard vaccination less effective in PWH than in the general population, even when doses are received on schedule.² That immunological gap helps explain why catch-up and revaccination efforts matter as much as the timing of the original series, the authors noted.¹

Findings Reinforce Importance of Universal HBV Vaccination Amid Policy Changes

The findings arrive as US hepatitis B vaccination policy is in flux. In December 2025, the ACIP voted to shift the newborn HBV birth dose from a universal recommendation to shared clinical decision-making between provider and parent, a change the CDC formally adopted that same month.³ Public health researchers have warned that vaccines moved from universal to optional recommendations often see coverage declines that are difficult to reverse, threatening the same childhood immunization infrastructure the current cohort study credits with reducing HBV coinfection in PWH decades later.¹

As evolving federal guidance introduces new uncertainty into the vaccination pipeline that payers rely on when setting coverage policy, the authors called for continued public awareness efforts and clinician engagement.

At the same time, they acknowledged their study’s limitations, including the use of a convenience sample lacking data on resolved HBV infections and immigration status. Similarly, the smaller size of the post-1980 cohort limits precision. Still, the researchers argued the results support continued investment in universal childhood HBV vaccination.

“These findings highlight the importance of HBV vaccination in preventing HBV infection before individuals engage in high-risk activities,” they concluded. “Increasing public awareness of the importance of HBV vaccination and clinicians’ enthusiasm for its importance is essential in ensuring that all individuals have the benefit of HBV prevention.”

References

1. Lee SJ, Verinumbe T, Lesko CR, et al. Prevalence of hepatitis B coinfection in people with HIV by birth-year cohort. Open Forum Infect Dis. Published online July 8, 2026. doi:10.1093/ofid/ofag400
2. Shaw ML. Hepatitis B virus vaccines underperform in people living with HIV. AJMC. July 29, 2026. https://www.ajmc.com/view/hepatitis-b-virus-vaccines-underperform-in-people-living-with-hiv
3. Joszt L. Misinformation, access gaps threaten hepatitis B elimination goals. AJMC. June 18, 2026. Accessed July 31, 2026. https://www.ajmc.com/view/misinformation-access-gaps-threaten-hepatitis-b-elimination-goals