Simplifying Hepatitis B Guidelines for Primary Care, With Su Wang, MD, MPH

Chronic hepatitis B remains a major global public health challenge, affecting hundreds of millions of people worldwide and contributing substantially to the burden of cirrhosis and hepatocellular carcinoma (HCC).

In the United States, efforts to expand screening and treatment have increasingly emphasized the role of primary care clinicians, who often serve as the first point of contact for patients living with or at risk for hepatitis B infection.

Yet many providers perceive hepatitis B management as complex and highly specialized, in part due to the number of clinical guidelines and the nuanced laboratory interpretation traditionally associated with treatment decisions.

Over the past several years, experts and guideline groups have begun exploring ways to simplify hepatitis B management algorithms, particularly for clinicians outside hepatology or infectious disease. These efforts aim to provide clearer treatment triggers and reduce reliance on complicated staging systems or laboratory combinations that can discourage front-line clinicians from initiating care.

In a recent episode of Liver Lineup: Updates & Unfiltered Insights, Su Wang, MD, medical Director of the Viral Hepatitis Programs and the Center for Asian Health at Cooperman Barnabas Medical Center, discussed how clinicians can navigate the growing number of hepatitis B guidelines and highlighted emerging tools designed to help primary care providers identify patients who may benefit from treatment or referral.

Supporting these efforts is a broader push within the hepatology community to expand screening, vaccination, and treatment access as part of global viral hepatitis elimination goals. Many patients with hepatitis B remain undiagnosed or untreated, and specialists alone are unlikely to meet the scale of care required to reduce disease burden. Simplified clinical pathways and decision-support tools are therefore increasingly viewed as essential components of hepatitis B elimination strategies.

For more on the topic, check out our Q&A from the podcast episode or head to our sister publication, HCPLive, for the full episode.

Managing HBV in Primary Care, With Su Wang, MD, MPH

Patient Care Online: How do you, as a hepatitis B expert, use all these different guidelines in practice—and how can that be simplified for non-specialists?

Su Wang, MD, MPH: Yeah, I think for a lot of us in this space—speaking for myself, and having spoken to a lot of people who do a lot of hep B care—we’re able to pull from a lot of the guidelines and pick out the best parts for what works in our setting, right? I definitely use the AASLD guidance, but also a lot from the primary care guidance. I was also part of another set of recommendations—a simplified algorithm—which they sometimes call the SABA guidelines, using age 30 and abnormal ALT and 2000, and you start seeing a lot of these commonalities, right?

A lot of the guidelines use 2000 and any abnormal ALT to simplify treatment. For primary care providers, it definitely simplifies treatment if we don’t incorporate e-antigen and e-antibody. I still test for them because I want to know what phase people are in, but a lot of people are saying that understanding phase is not necessarily a requirement for treating. So if we can separate some of those pieces and give primary care, and other people who aren’t seeing hep B all the time, some quick triggers for treatment—if the ALT is abnormal and you’re pretty sure it’s not something else… and this is the complexity we have now with MASLD, right, like what are the other causes for abnormal ALT—or the viral load is high, or there are other risk factors like age or family history—then it doesn’t matter. You don’t have to do that whole litany of tests. If you’ve got one or two triggers suggesting someone is more at risk of HCC, that can be enough.

I like what EASL did with their guidelines. They have a whole table of HCC risk factors, and that’s a nice reference where you can say, “Oh, that would be a reason to start treatment early, because that person’s at risk for HCC.”

Those of us in the field kind of have this library of resources now—maybe not sitting in one place, but mentally we can say, “This fits into this, this fits into that.” The AASLD guidelines were focused on six PICO questions, so it’s not comprehensive. For example, it doesn’t address quantitative surface antigen use, which a lot of us are finding really useful as a tool. And I’m sure you guys are ordering it more now too. There aren’t clear guidelines on that yet, but a lot of us are starting to use it because it’s practical.

So, yeah, I’d love to hear how you guys approach it with all your patients, because you have an interesting background too.

Patient Care Online: The hepatology guidelines may be too complex for busy clinicians. What tools make this easier for primary care?

Su Wang, MD, MPH: Yeah, I think people have this trauma from med school where they see the squiggly lines—the viral load, the ALT—and then they’re just like, “Oh, this is specialist matter.” And we’re trying to explain, no—we need you to step in, otherwise we’re never going to get to viral hepatitis elimination if we only think of this as a specialist disease, because it’s so common. A lot of people can’t make it to see hepatologists, and we need people on the front line to start the screening and vaccination, and at least some of the initial testing.

I agree the hepatology guidelines are a lot for physicians to digest, and there are a lot of nuances. The primary care guidance—hosted on the University of Washington website—is great. My favorite product out of the whole thing is a one-pager that we developed, and Nancy’s seen it. That’s something you can print out, post somewhere, or keep a screenshot of. It lays out the screening tests, because we know there’s often confusion—like, do I need to do e-antigen for screening? You do not. There’s also confusion around the core antibody test. Unfortunately, test panels often include IgM, when really you just need IgG or total core antibody for screening for chronic hep B.

It also has a table of interpretation, so you don’t have to Google it every time, and then a summary of the vaccines—recommendations, spacing, and what’s out there—plus initial tests to order. Then it lists treatment indications and breaks it down into four indications.

One of them is labs: abnormal ALT and viral load over 2000, plus fibrosis. So looking at someone with significant fibrosis. We have options like elastography, APRI, or FIB-4. The third is comorbidities—someone with HIV, although we would send them to infectious disease—but also other factors like family history. And we incorporated pregnancy: someone who’s pregnant with a high viral load, over 200,000, because of transmission risk, which is new in the AASLD guidance, as you guys know.

And then lastly—which I think is important—is an option that if a patient prefers treatment over monitoring, that alone can be a reason. There’s been a lot of discussion about this in this AASLD guidance. I don’t know that it’s obvious when you read it, but if you’ve heard people like Nora, and even Mark, present about it, one of the things we really wanted to shift from the previous guidance is that nowhere does it say there’s a group you cannot treat. We’re trying to make it so that potentially anybody with hepatitis B could be treated. And EASL is very clear about that. It says, in theory, anybody who’s surface antigen–positive with viremia is a candidate for treatment. Obviously, the risks and benefits depend a lot on viral load and ALT, and other risk factors, but I love that shift.

That’s also where shared decision-making comes in. I know the term gets thrown around a lot right now, and sometimes not in a good way—especially in vaccination discussions—where it can be framed as if risks and benefits are equivalent. For hep B vaccination, most of us would say the benefit clearly outweighs the risk. But for hepatitis B treatment, AASLD used shared decision-making for certain scenarios—indeterminate cases, horizontal transmission risk, e-antigen–positive cases—where it’s not clear, but you can still offer it and discuss with patients.

From the affected community, there was a really good survey done before the WHO guidance—about 500 people with hep B—and it was eye-opening. About half of the respondents said their doctors never even mentioned that there was something they could take for hepatitis B. That’s a failure on us. We’ve already made the decision for the patient. We told them they don’t need it, or we didn’t even offer it, so they’re not aware.

We need to at least inform patients there are medications that can treat hepatitis B, then explain why my recommendation is what it is, based on guidance, and then actually elicit patient preferences and values. Do you want to be proactive and take medication? Because what we see a lot is when the doctor says there’s nothing for you, patients go out and buy herbal medicines—things we know don’t work. Logically, it doesn’t make sense to let patients spend money on something ineffective when they could take something that works well and is affordable now because it’s generic.

Some patients, as you know, don’t want to be on medication unless they absolutely have to. So it’s helpful to ask what they prefer. I think many of us feel like we’re already doing that, but we’re not explicit enough.

Patient Care Online: What does your “Be Smart” shared decision-making tool look like in practice?

Su Wang, MD, MPH: I think tools will be important. Beyond guidelines, what else can we do to facilitate this? It is time-consuming. We’re hearing about tools—Patrick Kennedy developed an app called Hep B and Me that patients can use to walk through steps and see where they fall in terms of risks.

Education is key. Educated patients are really helpful in the partnership because they understand what we’re talking about when we discuss risk factors.

In my clinic, we’re piloting a shared decision-making survey—we’re calling it “Be Smart.” I’m hoping once we get through the pilot phase, we can release it more widely. It looks at PROs—patient-reported outcomes—and asks how hep B impacts your life: is it nothing, or is it a lot? What symptoms do you feel?

Traditionally, we’ve thought that unless you’re cirrhotic, hep B is silent—asymptomatic. But when you look at years of studies and patient surveys, fatigue is one of the things people report even when they’re not cirrhotic. There’s more recognition of PROs across liver diseases, and we have to listen to patients. PROs are supposed to be unfiltered—what is the patient’s experience?

The Hep B Foundation has done great work here, and certain domains come up consistently: fatigue, worry and anxiety, and psychosocial impact. It’s the worry and stress of having something you could die early from—like liver cancer. There’s self-stigma—feeling infectious, feeling like you need to stay away from people. We see people isolate themselves. There’s depression, and reports of suicidality. It can completely change someone’s future—whether they pursue certain careers or go to school. These are things we need to recognize, and not only focus on the liver, but focus on the whole person.

So our survey asks how much it affects someone’s life, then walks through what’s important to them: is it important to reduce risk of liver cancer and cirrhosis as much as possible, or is it important not to take medicine because you worry about side effects? Is it important to be proactive? We have them rank these.

We learned from a Hep C PCORI study that ranking can be really informative. People were concerned about liver cancer, but also about medication cost—because that’s the day-to-day issue right away, compared to something that could happen decades down.

Then we have a table where we go through their labs together. It’s broken down simply—normal vs abnormal, normal vs high—so they can visually see where they fall. And we give it to the patient before the doctor even sees them, so you’re not sitting in the room waiting for them to fill it out.

References:

1. Terrault NA, Lok ASF, McMahon BJ, et al. Update on prevention, diagnosis, and treatment of chronic hepatitis B: AASLD 2018 hepatitis B guidance. Hepatology. 2018;67(4):1560-1599. doi:10.1002/hep.29800

2. European Association for the Study of the Liver. EASL 2017 clinical practice guidelines on the management of hepatitis B virus infection. J Hepatol. 2017;67(2):370-398. doi:10.1016/j.jhep.2017.03.021

3. World Health Organization. Global Hepatitis Report 2024. Geneva, Switzerland: World Health Organization; 2024.