The World Health Organization (WHO) launched new guidelines for chronic hepatitis B at the 2024 Asian Pacific Conference for the Study of Liver Disease (APASL) in Kyoto, Japan. The new guidelines aim to reduce harm from the virus, by helping more people to be tested, diagnosed and treated.
Hepatitis B is a bloodborne virus that infects the liver. Long term infections, called chronic hepatitis B, can lead to liver damage, cirrhosis or liver cancer. But most people with chronic hepatitis B stay healthy. Chronic hepatitis B is complicated to treat, and at the moment it is managed rather than cured.
The new guidelines aim to increase the number of people being tested and treated for hepatitis B and to improve patient choice. They now also cover teenagers as well as adults. The new guidelines advise treatment if any of these are true:
- You have moderate liver scarring, medically known as F2 fibrosis or higher (previously only people with cirrhosis which is F4 fibrosis).
- You have a viral load (viral DNA level) of 2,000 or more (previously 20,000 or more).
- You have another condition or infection, such as fatty liver disease or hepatitis C, a suppressed immune system, or hepatitis B is affecting you in other ways such as glomerulonephritis or vasculitis (not previously included).
- You are pregnant and have a viral load of 200,000 or more, or you test positive for hepatitis B envelope antigen, to stop the virus being passed on to your child (no change).
- In places where DNA testing isn’t available, you have a raised ALT at least twice in a 6 to 12 month period (not previously included).
The guidelines also make recommendations about testing, including suggesting countries consider introducing automatic testing for hepatitis D if someone has hepatitis B. Hepatitis D only affects people with hepatitis B. It is linked with higher levels of liver damage, so it is important to find out if someone is affected.
Ahmed Elsharkawy, Consultant Hepatologist at University Hospitals Birmingham NHS Foundation Trust, said “The overall direction is to simplify a quite complex set of rules doctors have traditionally followed to decide if people should get treatment to suppress the virus. The suggested level of virus goes from 20,000 to 2,000. And patient choice is used more and more to inform treatment decisions.
“There’s also a focus on places globally with limited resources, where lack of blood tests has meant people can’t be treated. There are now options that mean long term treatment can be started without a test for the level of virus.”
These guidelines could make a huge difference to the picture on hepatitis B – around the world and here in the UK. But the guidelines are just that, a guide. They aren’t compulsory. What happens next will be a ripple effect of guideline updates.
Clinicians in the UK will likely wait to see what the new European Association for Study of the Liver (EASL) guidelines say. And in turn that will influence updated guidelines from the British Association for Study of the Liver (BASL). This process helps make sure guidelines are relevant to the UK and can be put into practice by doctors here.
Dr Elsharkawy added “the new European guidelines are expected to be similar to the WHO guidelines. So doctors will be able to say to more of their patients ‘we’d like to start you on treatment to suppress the virus.’ If you’re unsure what this might mean for you, speak to your hepatitis B specialist.”
EASL and BASL knew this announcement was coming and had update plans in place so they could react quickly to the WHO announcement. Realistically, we are likely to see new UK guidelines announced in 2025.
In the meantime, doctors are increasingly aware that people living with hepatitis B may prefer to be treated, for example to reduce the chance of the virus getting passed on. So it’s a good idea to talk to your doctor about treatment, what you would like to happen, and any questions or worries.
