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PCPs in HBV Management
How Primary Care Can Make a Difference in HBV Management

Released: April 30, 2024

Expiration: April 29, 2025

Su Wang
Su Wang, MD, MPH, FACP
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Key Takeaways
  • Primary care providers can have a crucial role in treating, monitoring, and partnering with patients with HBV infection.

If you are a primary care provider, you may have a bigger—and easier—role in hepatitis B virus (HBV) management than you think. That is what I have learned in my years as an internist practicing primary care.

I admit that how to treat people with HBV was not something I learned about much in medical school. But as I worked with people who have done it, and educated myself over time, I can see how it has gotten easier than before.

For one thing, the treatments for HBV are definitely easier than for most of the chronic conditions we manage in primary care, such as diabetes, heart failure, or hypertension. 

And the guidelines for deciding whom to treat and when to treat have also become easier. The WHO, for example, simply recommends treating all adults and adolescents with HBV infection any of the following:

  • Fibrosis or cirrhosis
  • HBV DNA >2000 IU/mL and alanine aminotransferase (ALT) > upper limit of normal
  • Coinfections, history of liver cancer or cirrhosis, immune suppression, comorbidities, extrahepatic manifestations 

In addition to these WHO guidelines, there is a very specific algorithm for primary care physicians posted on the University of Washington website. 

Expanding Engagement
Even before deciding whether to treat HBV, primary care providers have a crucial role in evaluation and monitoring of HBV. If you are not quite comfortable initiating treatment—if you plan to refer to a specialist for treatment—I think primary care providers can easily do some of the initial steps of evaluation.

Quite a lot of people with HBV infection have disease that is not complicated. I often tell providers to just start ordering the viral load—you will find a lot have viral loads <2000 IU/mL or maybe even undetectable. These are people who are easy to continue monitoring, either every 6 months or once per year when they are already coming for medical visits. It is so simple and effective to just watch them until things start changing.

And even if you are not comfortable with that level of monitoring, primary care providers can still have a huge impact with steps as simple as ordering α-fetoprotein or an ultrasound for hepatocellular carcinoma screening.

Partnering With Patients
Working in primary care, I think of my role as partnership, where I work alongside a gastroenterologist or hepatologist or infectious disease specialist. And I think that team-based approach is important, especially because in primary care I am going to see these patients much more often, and they may not need to see the specialist as often. 

This partnership also extends to the patient. I often have patients who are indicated for treatment but who feel they are not quite ready to start. These are the people to whom I say, “Your choice is drug therapy, or we can continue to monitor your viral load and ALT, but you need to be really good at coming back for tests so we can see how your lab results progress.” 

In these conversations, I find it is so important to focus on the patient’s priorities. Are they concerned about liver cancer or transmissibility, or is it that they really do not want to be on medication? How does stigma affect their decision-making?

Patient-reported outcomes is something that we in primary care are well positioned to address. It is not just about liver enzymes; there is so much more that hepatitis B affects in a person's life. We know that early treatment can help prevent cirrhosis, liver cancer, and other end-stage outcomes, but we have to consider the multiple dimensions and where treatment could help in other areas.

Personally, I am excited about this movement—for task shifting, decentralizing, and getting primary care providers to help with getting us to hepatitis elimination. In primary care, we are going to be a key part of reaching the WHO 2030 goals of eliminating hepatitis B and being able to provide the next generation with a hepatitis B–free future.

Your Thoughts?
How do you see primary care providers taking on an expanded role to enhance early engagement in HBV management? What barriers or challenges have you encountered? Join the conversation by posting a comment!