Challenges and Controversies

This young individual is in the immune-tolerant phase with a high viral load but very normal liver function tests. In general, in this phase of HBV there is high replication of virus but low inflammation and minimal progression of disease. This phase has a variable duration. As people age there is an increased likelihood that they could convert to an immune active state, at which time they may require antiviral therapy.

I would choose to do a FibroScan on this patient to confirm the fibrosis stage. If their fibrosis stage was F2 or less, then I would not start antiviral therapy but continue to follow. If their fibrosis stage was >F2, I would have a discussion with the patient about starting antiviral therapy.

This young man's high viral load puts him at high risk for HBV transmission to others who may not have HBV immunity from vaccination. I would assess his risk for HBV transmission to household and sexual contacts with unknown immunity/vaccination status. If he has multiple sexual contacts with unknown HBV immunity status or household/close contact with individuals who are incompletely vaccinated (e.g. young infants) or unable to mount a sufficient immune response to vaccine (e.g. some patients with immunosuppression, end stage renal disease), then he may want to consider going on antiviral therapy.

If he has a stable sexual partner and/or immunocompetent household contacts, I would advise that he ensure they get tested and vaccinated, if HBV susceptible, with post-vaccination serology testing to confirm antibody immunity and long-term protection from HBV transmission. In this case, his risk of transmitting HBV to others is low and thus antiviral would not be needed for this indication alone.

Some guidelines recommend antiviral treatment for patients who are HBV immune tolerant and over the age of 40 years due to an assumption that failure to naturally seroconvert from HBeAg positive to negative by then results in decades of high viral load exposure and increased risk for HCC. This patient is still at an age where he could potentially convert on his own without antiviral, and hopefully into an inactive chronic hepatitis B phase with low viral load and normal ALT.

I recommend that all patients with chronic hepatitis B get a FibroScan or other non-invasive fibrosis assessment to evaluate for significant fibrosis as an indication for antiviral treatment. If F2 moderate fibrosis or higher, I would automatically recommend treatment, as recommended by the 2024 WHO HBV treatment guidelines.

Ultimately the decision to treat should be a shared-decision making process, taking into account the patient's values, preferences, and ability to take treatment consistently. If he wants to initiate treatment, I would make sure that he understands that treatment is long-term and that there is risk for hepatitis flare if he self-discontinues medication prematurely.