Are We Making Hepatitis B Treatment Too Complicated?

In this segment from a new episode of Liver Lineup, hosts Kimberly Brown, MD, and Nancy Reau, MD, continue their conversation with Su Wang, MD, MPH, exploring an uncomfortable but important question about hepatitis B care: have complex guidelines unintentionally discouraged clinicians from treating the disease?

Brown frames the issue through the lens of paternalism. While medicine has increasingly recognized the need to move away from paternalistic relationships with patients, she suggests the hepatology community may have created a different form of paternalism, one aimed toward other clinicians. The complexity of hepatitis B algorithms and treatment thresholds, she argues, may have inadvertently signaled to frontline providers that they should defer care to specialists for fear of doing something wrong.

Wang agrees the concern is real and points to the restrictive nature of many historical treatment criteria. From the patient perspective, she says, those restrictions can feel confusing and even unfair. Patients often ask why treatment is withheld if medications are safe, effective, and increasingly affordable. The traditional explanation that therapy may be lifelong or that flares could occur if treatment stops does not always resonate with patients weighing the potential benefits of earlier intervention.

Wang also shares her own experience navigating the treatment decision as someone living with chronic hepatitis B. When she sought advice from specialists, she found many clinicians uncomfortable discussing treatment options outside strict guideline thresholds. Yet some privately acknowledged they would choose therapy themselves under the same circumstances. That disconnect, Wang notes, highlights an important tension between guideline-based medicine and evolving scientific understanding of hepatitis B biology.

Emerging research, including insights into viral DNA integration, immune exhaustion, and long-term oncogenic risk, continues to reshape how experts think about disease progression. However, the group says that much of that mechanistic science does not easily translate into the evidence frameworks used to generate formal guideline recommendations.

The result, Wang suggests, may be a gap between how experts think about hepatitis B risk and how treatment decisions are communicated in practice. She emphasizes that empowering clinicians, especially those in primary care, to feel comfortable initiating treatment will be essential to expanding access.

For Wang, the ultimate goal is clear: hepatitis B care should not remain confined to specialists. As this Liver Lineup discussion highlights, addressing guideline complexity and clinician hesitation may be a crucial step toward improving care for the millions of people living with hepatitis B worldwide.

Editor’s note: Relevant disclosures for Reau include AbbVie, Gilead, Salix, Arbutus, and VIR. Relevant disclosures for Brown include Mallinckrodt Pharmaceuticals, Gilead, Salix, Intercept, Ipsen, and Madrigal. Relevant disclosures for Wang include Gilead Sciences.

References

1. Ghany MG, Pan CQ, Lok AS, et al. AASLD ISDA Practice Guideline on treatment of chronic hepatitis B. Hepatology ():10.1097/HEP.0000000000001549, November 4, 2025. | DOI: 10.1097/HEP.0000000000001549

2. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on the management of hepatitis B virus infection. J Hepatol. 2025;83(2):502-583. doi:10.1016/j.jhep.2025.03.018

3. You H, Wang F, Li T, et al. Guidelines for the Prevention and Treatment of Chronic Hepatitis B (version 2022). J Clin Transl Hepatol. 2023;11(6):1425-1442. doi:10.14218/JCTH.2023.00320