A Review of the Systemic Manifestations of HBV Infection, Hepatitis D Virus, Hepatocellular Carcinoma, and Emerging Therapies

Chronic hepatitis B virus infection affects about 262 million people worldwide, leading to over 820,000 deaths each year primarily due to cirrhosis and hepatocellular carcinoma. The World Health Organization (WHO) has pledged to eliminate hepatitis B virus (HBV) as a health threat by 2030, but currently, no countries are on track to achieve this goal. One of the barriers to HBV elimination is stigma, causing shame, denial, self-isolation, self-rejection, and depression leading to those with chronic HBV less likely to get tested or seek treatment and more likely to conceal their infection. Other barriers include limited access to care and complicated and restrictive clinical practice guidelines. Increasing public and political efforts are necessary to raise awareness, increase access to care, and change screening and treatment guidelines. The current guidance of the American Association for the Study of Liver Diseases (AASLD) recommends testing only if patients are considered at risk, but this has proven to be ineffective. We propose a simplified “test all and treat all” approach with a 5-line guideline for HBV infection. Universal screening and treatment of adults is cost effective and can prevent transmission by effectively managing chronic HBV. All patients who are HBsAg-positive with detectable HBV-DNA should receive treatment until HBsAg is undetectable for 12 months, as HBV-DNA transmission via blood transfusion can occur even at low viral loads of 16 copies/mL, and mother-to-child transmission is still a risk even with passive-active immunoprophylaxis. Furthermore, clinical outcomes after HBsAg clearance are significantly better than those who remain HBsAg-positive.