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Hepatitis B FAQs
Redefining Success in Hepatitis B Care: FAQs

Released: June 10, 2025

Expiration: June 09, 2026

Jordan J. Feld
Jordan J. Feld, MD, MPH
Norah Terrault
Norah Terrault, MD, MPH
Su Wang
Su Wang, MD, MPH, FACP
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Key Takeaways
  • HBV screening is particularly important for patients who are at increased risk of reactivation and of developing hepatocellular carcinoma.
  • Adding a second antiviral agent may be appropriate for people who are taking their medication as advised but still have persistent HBV viral loads.
  • HDV screening is moving toward being recommended for all people with positive HBsAg, regardless of risk factors.

This commentary includes discussion from the Q&A session at our live symposium at Digestive Disease Week 2025 regarding the current state of hepatitis B virus (HBV) treatment and monitoring, including the shift toward earlier simplified treatment, functional cure, considerations for quantitative hepatitis B surface antigen (HBsAg) monitoring, and HBV therapies in late stages.

How do you address HBV screening for African-born patients, who may have increased risk of hepatocellular carcinoma (HCC)? 

Norah Terrault, MD, MPH:
The current American Association for the Study of Live Diseases (AASLD) liver cancer guidelines indicate that African-born individuals have a higher likelihood of HCC at a younger age, and they recommend that healthcare professionals (HCPs) consider screening these individuals at a younger age. However, the guidelines do not specify what that age is. In my practice, I start screening when I meet them.

Is there a role for HBV genotyping in treatment and monitoring?

Jordan J. Feld, MD, MPH:
I would say that HBV genotype is an important determinant of disease progression and risk of developing HCC. For example, we know that people with genotype C have a much higher risk of cancer than people with genotype B.

However, viral genotyping does not affect our decisions on whether to start therapy. It might be more relevant for future therapies, but before its role in HBV treatment and monitoring can be determined, additional data are needed on its relationship with patients’ race or ethnicity, timing of infection, and other patient factors.

The population of patients on immunosuppressive treatments for autoimmune or oncologic diseases is continuously growing. How do you think we should address gaps in HBV testing in this setting?

Su Wang, MD, MPH, FACP:
When I have individuals who are core antibody positive and surface antigen negative, I make sure that they know that they do not have HBV infection, but that there is a risk of reactivation like there is with chicken pox. I emphasize that they need to be proactive with HBV testing and advocate for themselves in case they ever require immunosuppressive therapy. This also highlights the importance of involving primary care providers in HBV screening for this patient population.

The American Gastroenterology Association also just came out with a new treatment guideline for managing HBV reactivation that includes a nice list of immunosuppressive therapies, classifying them according to reactivation risk. This will be very useful for assessing risk of reactivation and managing that risk.

Is there a role for HBV core-related antigen testing in monitoring and management of chronic HBV infection? If so, in whom, when, and how often?

Jordan J. Feld, MD, MPH:
HBV core-related antigen is a biomarker for infection, but this testing is not clinically available yet. However, since this biomarker correlates with serum HBV DNA and intrahepatic covalently closed circular DNA, testing for it could certainly hold some value in the future.

I have been struggling to get a patient's HBV viral load to undetectable level for 2 years. It is hovering around 100 IU/mL. What is the next step?

Su Wang, MD, MPH, FACP:
In this situation, I would first make sure that the patient is taking medication as advised. In my experience with cases like this, I often find that patients are not taking their medications every day. However, if they are adherent to treatment, I think adding a second antiviral agent is reasonable.

Norah Terrault, MD, MPH:
I would also advise reminding patients to take their medications the right way, in addition to being adherent. For example, people often forget that the entecavir is supposed to be taken on an empty stomach.

I agree that if patients are taking their medications as directed and with good adherence, it is time to consider adding a second drug.

Jordan J. Feld, MD, MPH:
In addition, I think it is also important to factor in where the patient started. For example, if someone started at a baseline viral load of 910-1010 IU/mL, getting down to 100 IU/mL is still a major suppression of viral replication. Ultimately, I think that how I would measure treatment success depends a little bit on the details there.

Given that not all patients with chronic HBV infection have access to tenofovir alafenamide (TAF), how can HCPs address the clinical concern that long-term use of tenofovir disoproxil fumarate (TDF) might lead to bone mineral density loss and renal impairment?

Norah Terrault, MD, MPH:
There are 3 preferred therapies for HBV, and what is best for a patient will depend on individual circumstances. For example, if I have a patient who is older than 60 years of age and who has renal or bone disease or is at risk for those conditions, I would avoid starting on TDF. I would prescribe either entecavir or TAF. I think TDF is still a good drug, and I still use it, but I avoid it for individuals who are older with those comorbidities. 

Will the 2025 AASLD guidelines recommend screening for hepatitis delta virus (HDV) in all patients with positive HBsAg?

Norah Terrault, MD, MPH:
The new AASLD  guidelines are not addressing HDV screening; rather it is the WHO moving toward universal screening for HDV in all individuals with positive HBsAg. However, I think the consensus in the field is that we should not continue to use risk-based testing for HDV.  

HDV reflex testing for individuals with HBsAg has not been widely adopted, but I think it would be a really important way for HCPs to ensure that people get the right testing and to reduce missed opportunities for diagnosis. The ideal situation would be performing the HBV screening triplet, such as testing for HBsAg, antibodies to hepatitis B core antigen, and HBsAg, and then automatically initiating screening for HDV among people with HBsAg. The field is not yet there, but stay tuned.

Your Thoughts
Do you have questions regarding HBV screening that were not addressed above? Leave a comment to let us know!