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Hepatitis B virus infection

What's new

The American Gastroenterological Association (AGA) has updated guidelines for preventing hepatitis B virus reactivation (HBVr) in at-risk patients, including those undergoing immunosuppressive treatment or transcatheter arterial chemoembolization (TACE). Antiviral prophylaxis is recommended for high-risk patients and suggested for moderate-risk patients, while clinical monitoring alone is suggested for low-risk patients. A clinical decision support tool has been proposed for risk stratification. .

Guidelines

Key sources

The following summarized guidelines for the evaluation and management of hepatitis B virus infection are prepared by our editorial team based on guidelines from the American Association for the Study of Liver Diseases (AASLD 2025,2021,2018,2014), the American Gastroenterological Association (AGA 2025,2015), the U.S. Department of Health and Human Services (DHHS 2025), the American Academy of Family Physicians (AAFP 2024), the ...
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Screening and diagnosis

Indications for screening, general population
As per WHO 2024 guidelines:
Ensure routine access to and offer HBsAg serological testing (with linkage to prevention, care, and treatment services) for all adults in settings with a HBsAg seroprevalence of ≥ 2% or ≥ 5% in the general population. Utilize existing community- or health facility-based testing opportunities or programs, such as antenatal clinics, HIV, or tuberculosis clinics.
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Screen blood donors (with linkage to care, counseling, and treatment) in all settings.
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  • Indications for screening (population at risk)

  • Indications for screening (pregnancy)

  • Indications for screening (before anticancer therapy)

Diagnostic investigations

Serologic testing: as per WHO 2024 guidelines, obtain a serological assay, either rapid diagnostic test or laboratory-based immunoassay, meeting minimum quality, safety and performance standards (with regard to both analytical and clinical sensitivity and specificity) to detect HBsAg for the diagnosis of chronic hepatitis B in adult, adolescent, and pediatric (aged > 12 months) patients. Obtain laboratory-based immunoassays as the preferred assay format in settings where existing laboratory testing is already available and accessible. Obtain rapid diagnostic tests to improve access in settings where there is limited access to laboratory testing and/or in populations where access to rapid testing would facilitate linkage to care and treatment.
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  • HBV DNA

  • Evaluation of renal function

  • Evaluation for liver fibrosis (imaging-based)

  • Evaluation for liver fibrosis (blood-based)

Medical management

Management of acute HBV infection
As per EASL 2017 guidelines:
Do not initiate specific treatment in most (> 95%) adult patients with acute HBV because they will fully recover spontaneously.
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Initiate nucleoside/nucleotide analogs only in patients with severe acute hepatitis B, characterized by coagulopathy or protracted course, and assess for liver transplantation.
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  • Indications for antiviral therapy

  • Goals of antiviral therapy

  • Choice of antiviral regimens

  • Maintenance therapy

  • Management of treatment failure

  • Management of relapse

Surgical interventions

Liver transplantation, pre-transplant antiviral therapy: as per EASL 2017 guidelines, initiate nucleoside/nucleotide analogs in all patients with HBV-related liver disease on the transplant waiting list.
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  • Liver transplantation (post-transplant antiviral prophylaxis)

Specific circumstances

Pregnant patients, indications for screening: as per SMFM 2024 guidelines, obtain triple panel testing (HBsAg, HBsAb, and total HBcAb) at the initial prenatal visit if not previously documented or known to have been obtained.
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  • Pregnant patients (immunization of the mother)

  • Pregnant patients (indications for testing)

  • Pregnant patients (laboratory testing)

  • Pregnant patients (liver imaging)

  • Pregnant patients (hepatitis B immunoglobulin)

  • Pregnant patients (antiviral therapy)

  • Pregnant patients (counseling)

  • Pregnant patients (fetal evaluation)

  • Pregnant patients (delivery)

  • Pregnant patients (immunization of the infant)

  • Pregnant patients (breastfeeding)

  • Pediatric patients (screening)

  • Pediatric patients (antiviral therapy)

  • Pediatric patients (monitoring)

  • Pediatric patients (patients with HIV co-infection)

  • Pediatric patients (patients on immunosuppressive therapy)

  • Pediatric patients (liver transplant recipients)

  • Pediatric patients (non-liver transplant recipients)

  • Pediatric patients (hematologic stem cell transplant recipients)

  • Patients with renal impairment

  • Patients with malignancy

  • Patients with HDV co-infection

  • Patients with HCV co-infection

  • Patients with HIV co-infection

  • Patients on immunosuppressive therapy

  • Patients with extrahepatic manifestations

Preventative measures

Immunizations, infants: as per BSG 2024 guidelines, administer vaccination against HBV in all infants as part of the childhood immunization program, including infants born to HBV-positive mothers.
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  • Immunizations (adults)

  • Prevention of HBV reactivation

Follow-up and surveillance

Monitoring of untreated patients: as per WHO 2024 guidelines, consider obtaining annual monitoring for disease progression and ALT and HBV DNA levels (if available) in patients not currently meeting the criteria for antiviral therapy, as defined by persistently normal serum aminotransferase results and HBV DNA levels < 2,000 IU/mL (if available) or expressing a desire to defer treatment.
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  • Monitoring of treatment response

  • Monitoring of treatment adverse effects

  • Surveillance for HCC

Quality improvement

Healthcare workers
As per EASL 2017 guidelines:
Do not disqualify persons from the practice or study of surgery, dentistry, medicine, or allied health fields based on HBV infection alone.
D
Consider initiating nucleoside/nucleotide analogs to reduce transmission risk in healthcare workers performing exposure-prone procedures with serum HBV DNA > 200 IU/mL.
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