Hepatitis B, Chronic (non-HIV coinfection)

B18.0-2/B18.8-9

Consult the most recent Hepatitis Guidelines from the National Department of Health for comprehensive monitoring recommendations.

DESCRIPTION

HBV is most commonly transmitted horizontally, in children <5 years of age. Vertical mother to child transmission and adult transmission, sexually or through a parenteral route, can also occur.
Acute infection may be asymptomatic or present as acute hepatitis.
A proportion of patients develop chronic hepatitis (defined as abnormalities listed in the table below persisting for >6 months), which can result in cirrhosis and hepatocellular carcinoma.
It is essential to know the HIV status of all patients with chronic hepatitis B before considering therapy.
Antiviral therapy is not indicated for acute hepatitis B infection.
There are 5 potential phases of chronic hepatitis B infection which determine the need for treatment:

Phase Serology Viral
load
(HBV
DNA)
IU/mL 		ALT Management
1.  HBeAg-positive chronic HBV infection
(Immune
     Tolerant)
  • HBsAg positive
  • HBeAg positive
    		•  >20000 (usually >200000) Normal
  • Treatment not
    routinely needed,
    but should be
    followed up.
  • Treat only if on
    immunosuppressive
    therapy to prevent
    hepatitis B flares.
    		•
    2.  HBeAg-positive chronic hepatitis B (Immune 
        
    Clearance)
  • HBsAg positive
  • HBeAg positive
    		•  >20000 Elevated
  • Treatment required.
    		•
    3.  HBeAg-negative chronic HBV infection
    (Immune
        
    Control)
  • HBsAg positive
  • HBeAg negative
    		•  <2000 Normal
  • Treatment not
    routinely needed,
    but should be
    followed up.
  • Treat only if on
    immunosuppressive
    therapy to
    prevent hepatitis
    B flares.
    		•
    4.  HBeAg-negative chronic hepatitis B (Immune Escape)
  • HBsAg positive
  • HBeAg negative
    		•  >2000 Elevated
  • Treatment required.
    		•
    5.  Occult hepatitis B
  • HBsAg negative
  • HBsAb negative
  • HB IgG core Ab
    positive
    		•  <200 -
  • No follow-up
    required.
  • Treat only if on
    immunosuppressive
    therapy to prevent
    hepatitis B flares.
    		•

    LoEIII [20]

    HBsAg: hepatitis B surface antigen; HBsAb: hepatitis B surface antibody; HBIG: hepatitis B immunoglobulin

    Treat all patients with cirrhosis regardless of ALT level, HBeAg status and DNA level, to prevent hepatitis B flares that will lead to decompensation.

    MEDICINE TREATMENT

    • Tenofovir, oral, 300 mg daily, if estimated CrCl >50 mL/minute.

    LoEIII [21]

    AIMS OF TREATMENT

    HBeAg-positive disease

    • Sustained HBsAg loss off therapy, with/without the development of anti-HBs, and
    • Suppression of HBV DNA to undetectable or low (<2000 IU/mL) levels, and
    • Normalisation of ALT, and
    • Sustained HBeAg loss and seroconversion to anti-HBe.

    HBeAg-negative disease

    • Sustained HBsAg loss off therapy, with/without the development of anti-HBs, and
    • Suppression of HBV DNA to undetectable or low (<2000 IU/mL), and
    • Normalisation of ALT.

    MONITORING WHILST ON TENOFOVIR

    Baseline FBC+diff, ALT,
    INR, urine protein, serum phosphate and serum creatinine
    Week 4 and
    every 12 weeks     		FBC+diff, ALT
    Week 4 INR
    Week 4, then
    at 3, 6 and 12 months after initiation and every 12 months thereafter if on
    TDF     		Serum
    creatinine
    Every 6 months HBeAg-positive
    patients:
    HbsAg after
    anti-HBe seroconversion
     
    HBeAg-negative
    patients:     HBsAg with
    persistently undetectable HBV DNA
    Every 12
    months     		HBeAg-positive
    patients:     HBeAg, anti HBe
    HBeAg-positive
    patients:     12 months after
    HBeAg seroconversion     		HBV DNA levels

    Adapted from: National Department of Health, National guidelines for the management of viral hepatitis, 2018. Available at www.health.gov.za

    DISCONTINUE TREATMENT WITH TENOFOVIR WHEN:

    • HBeAg-positive patients: 12 months after HBeAg seroconversion and in association with persistently normal ALT levels and undetectable HBV DNA levels.
    • HBeAg-negative patients: Long-term therapy unless HBsAg seroconversion is achieved.
    • Cirrhotic patients: Lifelong treatment.

    REFERRAL

    Failure of or contraindications to tenofovir.