Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ACUTE

acute HBV infection

1st line – supportive care

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ACUTE
|
acute HBV infection
1st line – 

supportive care

Acute hepatitis B virus (HBV) infection is defined as the presence of hepatitis B surface antigen (HBsAg) for less than 6 months.[2]

Supportive care is usually all that is needed in most patients with acute infection, provided that there are no signs of synthetic liver function impairment (indicated by rising bilirubin and international normalised ration [INR]). More than 95% of immunocompetent individuals with acute infection will spontaneously achieve seroconversion in the absence of antiviral therapy.[2][29]

Typically, rest, good nutrition, fluids, and avoiding alcohol or hepatotoxic drugs or supplements are enough to treat symptoms.[107] Symptomatic treatment (e.g., analgesic, antipyretic) may be required.

The decision to hospitalise patients is made on a case-by-case basis, depending on the clinical presentation.

Consider – antiviral therapy

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ACUTE
|
acute HBV infection
Consider – 

antiviral therapy

Additional treatment recommended for SOME patients in selected patient group

Consider antiviral therapy in patients with synthetic liver function impairment (indicated by rising bilirubin and international normalised ratio [INR]), to reduce the risk of fulminant liver failure and the need for liver transplantation.[2][29]​ Initiate treatment in patients with acute liver failure or in those who have a severe, protracted course (i.e., total bilirubin level >51.3 micromoles/L (>3 mg/dL), INR >1.5, encephalopathy, or ascites).[2][29]

Entecavir, tenofovir disoproxil, and tenofovir alafenamide are the drugs of choice.[2][29]

Adverse effects may include nephrotoxicity and decreased bone mineral density/osteopenia (tenofovir disoproxil); hypercholesterolaemia and hypertriglyceridaemia (tenofovir alafenamide); potentially fatal lactic acidosis and severe hepatomegaly with steatosis (nucleoside analogues); pancreatitis; and severe acute exacerbations of hepatitis (after discontinuation).

Monitor renal function regularly during treatment. Dose adjustments of tenofovir disoproxil and entecavir may be required in patients with renal impairment. Tenofovir alafenamide is not recommended in patients with an eGFR <15 mL/min/1.72 m². If renal function decreases, or hypophosphataemia or osteoporosis occurs, during treatment with tenofovir disoproxil, switch to tenofovir alafenamide or entecavir.[29] 

Monitor lipid levels regularly during treatment with tenofovir alafenamide, particularly in those at high cardiovascular risk.[125][126]​

Continue treatment until hepatitis B surface antigen (HBsAg) clearance is confirmed, or indefinitely in patients who end up undergoing liver transplantation.[2][29]

Primary options

entecavir: children: consult specialist for guidance on dose; adults: 0.5 mg orally once daily

OR

tenofovir disoproxil: children: consult specialist for guidance on dose; adults: 300 mg orally once daily

More

OR

tenofovir alafenamide: children: consult specialist for guidance on dose; adults: 25 mg orally once daily

Consider – assess for liver transplantation

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ACUTE
|
acute HBV infection
Consider – 

assess for liver transplantation

Additional treatment recommended for SOME patients in selected patient group

Simultaneously assess the patient for liver transplantation when starting antiviral therapy. There is a high risk of mortality in patients with liver failure who do not undergo transplantation.[2][29]

ONGOING

chronic HBV infection and indication for treatment: non-pregnant adult without co-infection or cirrhosis or hepatocellular carcinoma

1st line – nucleoside/nucleotide analogue

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ONGOING
|
chronic HBV infection and indication for treatment: non-pregnant adult without co-infection or cirrhosis or hepatocellular carcinoma
1st line – 

nucleoside/nucleotide analogue

Chronic hepatitis B virus (HBV) infection is defined as the presence of hepatitis B surface antigen (HBsAg) for at least 6 months.[2]

Antiviral therapy is recommended for patients with indications for treatment. Indications for starting antiviral therapy vary across major society guidelines.[2][29][75][112]​​ The recommendations below are from European Association for the Study of the Liver (EASL) guidelines, published in 2025.[29] 

Start treatment in the following individuals: HBV DNA level is ≥2000 IU/mL and ALT level is above the upper limit of normal (ULN) and/or significant fibrosis is present (regardless of hepatitis B e antigen [HBeAg] status); or HBV DNA level is detectable in the presence of cirrhosis (regardless of level of viraemia and serum ALT level).[29]

Consider treatment in the following individuals: HBV DNA level is detectable in the presence of advanced liver disease (i.e., Metavir fibrosis score ≥F3 on liver histology or liver stiffness measurement [LSM] >8.0 kPa), regardless of level of viraemia and serum ALT level; or HBV DNA level is persistently low (i.e., <2000 IU/mL) and ALT level is persistently elevated. However, it is important to investigate other potential causes of liver dysfunction.[29]

Consider a personalised assessment to determine whether treatment is required in individuals with HBeAg-positive or HBeAg-negative chronic infection. Treatment is recommended in patients with the following: an increased or high risk for hepatocellular carcinoma (HCC); HBV-related extrahepatic manifestations; those being considered for immunosuppressive therapy or who are immunocompromised (to prevent HBV reactivation or hepatitis). Select individuals can also be treated to prevent HBV transmission.[29] 

Nucleoside/nucleotide analogues are a first-line option. They have predictable, long-term efficacy and a favourable safety profile. However, functional cure is rare. They are administered orally daily, have few contraindications and cautions and a low risk of adverse effects, but typically need to be given long term. In general, these drugs are better at normalising alanine aminotransferase (ALT) level and making HBV DNA undetectable compared with peginterferon alfa. Take patient-specific factors (e.g., patient preferences, comorbidities, previous treatments, age, pregnancy) and treatment-specific factors into account when deciding on the best treatment.[2][29]​​

Drugs with a high genetic barrier to drug resistance are the preferred options (i.e., entecavir, tenofovir disoproxil, tenofovir alafenamide). Entecavir and tenofovir alafenamide are the preferred options in patients with a history of renal impairment and/or osteoporosis.[2][29][75] ​

Adverse effects may include nephrotoxicity and decreased bone mineral density/osteopenia (tenofovir disoproxil); hypercholesterolaemia and hypertriglyceridaemia (tenofovir alafenamide); potentially fatal lactic acidosis and severe hepatomegaly with steatosis (nucleoside analogues); pancreatitis; and severe acute exacerbations of hepatitis (after discontinuation).

Monitor renal function regularly during treatment. Dose adjustments of tenofovir disoproxil and entecavir may be required in patients with renal impairment. Tenofovir alafenamide is not recommended in patients with an eGFR <15 mL/min/1.72 m². If renal function decreases, or hypophosphataemia or osteoporosis occurs, during treatment with tenofovir disoproxil, switch to tenofovir alafenamide or entecavir.[29] 

Monitor lipid levels regularly during treatment with tenofovir alafenamide, particularly in those at high cardiovascular risk.[125][126]​ 

Monitor patients during treatment to assess response. Adjustments to treatment (e.g., switching to another drug within this class, adding on another drug) may be required.[2][29]​

Nucleoside/nucleoside analogues are typically continued for many years, or possibly lifelong, as HBsAg seroclearance rate is low, ranging from 1% to 5% in 1 year.[84] Only consider discontinuation after consultation with a specialist experienced in treating chronic infection, as severe hepatitis flares may occur following discontinuation.[2][29]

Primary options

entecavir: 0.5 mg orally once daily

More

OR

tenofovir disoproxil: 300 mg orally once daily

More

OR

tenofovir alafenamide: 25 mg orally once daily

1st line – peginterferon alfa

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ONGOING
|
chronic HBV infection and indication for treatment: non-pregnant adult without co-infection or cirrhosis or hepatocellular carcinoma
1st line – 

peginterferon alfa

Chronic hepatitis B virus (HBV) infection is defined as the presence of hepatitis B surface antigen (HBsAg) for at least 6 months.[2]

Antiviral therapy is recommended for patients with indications for treatment. Indications for starting antiviral therapy vary across major society guidelines.[2][29][75][112]​ The recommendations below are from European Association for the Study of the Liver (EASL) guidelines, published in 2025.[29]

Start treatment in the following individuals: HBV DNA level is ≥2000 IU/mL and alanine aminotransferase (ALT) level is above the upper limit of normal (ULN) and/or significant fibrosis is present (regardless of hepatitis B e antigen [HBeAg] status); or HBV DNA level is detectable in the presence of cirrhosis (regardless of level of viraemia and serum ALT level).[29]

Consider treatment in the following individuals: HBV DNA level is detectable in the presence of advanced liver disease (i.e., Metavir fibrosis score ≥F3 on liver histology or liver stiffness measurement [LSM] >8.0 kPa), regardless of level of viraemia and serum ALT level; or HBV DNA level is persistently low (i.e., <2000 IU/mL) and ALT level is persistently elevated. However, it is important to investigate other potential causes of liver dysfunction.[29]

Consider a personalised assessment to determine whether treatment is required in individuals with HBeAg-positive or HBeAg-negative chronic infection. Treatment is recommended in patients with the following: an increased or high risk for hepatocellular carcinoma (HCC); HBV-related extrahepatic manifestations; those being considered for immunosuppressive therapy or who are immunocompromised (to prevent HBV reactivation or hepatitis). Select individuals can also be treated to prevent HBV transmission.[29]

Peginterferon alfa is an alternative first-line option to nucleoside/nucleotide analogues. It is administered subcutaneously weekly, has numerous contraindications and cautions and a high risk of adverse effects, and is given for a finite period. Variable response rates and an unfavourable safety profile limit its use. In general, peginterferon alfa increases the chance of HBsAg seroconversion compared with nucleoside/nucleotide analogues (although not significantly), and is not associated with disease flare when treatment is stopped. Take patient-specific factors (e.g., patient preferences, comorbidities, previous treatments, age, pregnancy) and treatment-specific factors into account when deciding on the best treatment.[2][29]

Peginteferon alfa can cause or aggravate life-threatening or fatal neuropsychiatric, autoimmune, infectious, and ischaemic disorders. It is contraindicated in autoimmune hepatitis and hepatic decompensation. Use with caution in patients with autoimmune disease, psychiatric disorders, cardiovascular disease, diabetes, infectious diseases, ischaemic disorders, seizure disorders, thyroid disorders, and renal impairment. Close monitoring is required during and after treatment.[2][29]

Adverse effects may include: flu-like symptoms; bone marrow suppression; CNS depression; severe dermatologic effects; gastrointestinal issues; hypersensitivity reactions; neuropsychiatric disorders; ophthalmic or pulmonary disorders; and pancreatitis.[2][29]

Monitor patients during treatment to assess response. Seroconversion rates appear to be more sustained after treatment discontinuation compared with nucleoside/nucleotide analogues. However, while HBsAg loss rates are higher, the overall rate of HBsAg loss is still considered to be low.[2][29]

Typically given for a finite period of 48 weeks. However, stopping rules can be considered based on the quantitative determinations of HBV DNA and HBsAg at weeks 12 and 24 of treatment. Consider stopping treatment in patients with negative predictors of treatment response.[2][29]

Primary options

peginterferon alfa 2a: 180 micrograms subcutaneously once weekly for 48 weeks

chronic HBV infection: non-pregnant adult with cirrhosis

1st line – nucleoside/nucleotide analogue

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ONGOING
|
chronic HBV infection: non-pregnant adult with cirrhosis
|
compensated cirrhosis
1st line – 

nucleoside/nucleotide analogue

Chronic hepatitis B virus (HBV) infection is defined as the presence of hepatitis B surface antigen (HBsAg) for at least 6 months.[2]

All patients with compensated cirrhosis require treatment. Initiate treatment in patients with low-level viraemia (i.e., hepatitis B virus [HBV] DNA level <2000 IU/mL), regardless of alanine aminotransferase (ALT) level.​​ If treatment is not started, patients must be monitored closely every 3-6 months for an increase in HBV DNA level and/or clinical decompensation, with treatment started if either occurs.[2][29]

Nucleoside/nucleotide analogues are the first-line option. They are considered safer than peginterferon alfa in patients with compensated cirrhosis. Entecavir, tenofovir disoproxil, and tenofovir alafenamide are the recommended options.[2][29]​​​

Adverse effects may include nephrotoxicity and decreased bone mineral density/osteopenia (tenofovir disoproxil); hypercholesterolaemia and hypertriglyceridaemia (tenofovir alafenamide); potentially fatal lactic acidosis and severe hepatomegaly with steatosis (nucleoside analogues); pancreatitis; and severe acute exacerbations of hepatitis (after discontinuation).

Monitor renal function regularly during treatment. Dose adjustments of tenofovir disoproxil and entecavir may be required in patients with renal impairment. Tenofovir alafenamide is not recommended in patients with an eGFR <15 mL/min/1.72 m². If renal function decreases, or hypophosphataemia or osteoporosis occurs, during treatment with tenofovir disoproxil, switch to tenofovir alafenamide or entecavir.​[29]​​​

Monitor lipid levels regularly during treatment with tenofovir alafenamide, particularly in those at high cardiovascular risk.[125][126] 

Discontinuation of antiviral therapy in patients with compensated cirrhosis was associated with a high risk of relapse (virological relapse 55%, clinical relapse 44%), but the incidence of adverse events was generally low and controlled. The rate of hepatocellular carcinoma (HCC) after discontinuation of antiviral therapy was 9%.[133] Therefore, discontinuation of nucleoside/nucleotide analogues is only recommended after confirmed seroconversion to antibody to hepatitis B surface antigen (anti-HBs) or following HBsAg loss after at least 12 months of consolidation therapy (i.e., 12 months of persistently normal ALT level and undetectable serum HBV DNA).[2][29]​​​

There is no optimal length of treatment. Monitor patients at least every 3 months for 1 year after stopping therapy to check for viral rebound that could lead to decompensation.[2]​​​​

Primary options

entecavir: 0.5 mg orally once daily

More

OR

tenofovir disoproxil: 300 mg orally once daily

More

OR

tenofovir alafenamide: 25 mg orally once daily

2nd line – peginterferon alfa

Back
ONGOING
|
chronic HBV infection: non-pregnant adult with cirrhosis
|
compensated cirrhosis
2nd line – 

peginterferon alfa

All patients with compensated cirrhosis require treatment. Initiate treatment in patients with low-level viraemia (i.e., hepatitis B virus [HBV] DNA level <2000 IU/mL), regardless of alanine aminotransferase (ALT) level. If treatment is not started, patients must be monitored closely every 3-6 months for an increase in HBV DNA level and/or clinical decompensation, with treatment started if either occurs.[2][29]

Peginterferon alfa may be considered a second-line alternative to nucleoside/nucleotide analogues in patients with compensated cirrhosis, provided they do not have portal hypertension. Nucleoside/nucleotide analogues are considered safer in these patients.[2][132] 

Peginteferon alfa can cause or aggravate life-threatening or fatal neuropsychiatric, autoimmune, infectious, and ischaemic disorders. It is contraindicated in autoimmune hepatitis and hepatic decompensation. Use with caution in patients with autoimmune disease, psychiatric disorders, cardiovascular disease, diabetes, infectious diseases, ischaemic disorders, seizure disorders, thyroid disorders, and renal impairment. Close monitoring is required during and after treatment.[2][29]

Adverse effects may include flu-like symptoms; bone marrow suppression; CNS depression; severe dermatological effects; gastrointestinal issues; hypersensitivity reactions; neuropsychiatric disorders; ophthalmic or pulmonary disorders; and pancreatitis.[2][29]

Typically given for a finite period of 48 weeks. There is no optimal length of treatment. Monitor patients at least every 3 months for 1 year after stopping therapy to check for viral rebound that could lead to decompensation.[2]

Primary options

peginterferon alfa 2a: 180 micrograms subcutaneously once weekly for 48 weeks

1st line – nucleoside/nucleotide analogue

Back
ONGOING
|
chronic HBV infection: non-pregnant adult with cirrhosis
|
decompensated cirrhosis or acute-on-chronic liver failure
1st line – 

nucleoside/nucleotide analogue

Chronic hepatitis B virus (HBV) infection is defined as the presence of hepatitis B surface antigen (HBsAg) for at least 6 months.[2]

The decision to hospitalise patients is made on a case-by-case basis, depending on the clinical presentation (e.g., complications are present).

All patients with decompensated cirrhosis or acute-on-chronic liver failure require treatment. Initiate antiviral therapy as soon as possible. There is some debate about whether individuals with an undetectable HBV DNA level require treatment. However, do not delay treatment if results are not immediately available, or it is not possible to closely monitor HBV DNA level.[2][29]

Entevacir, tenofovir disoproxil, and tenofovir alafenamide are first-line options. Nucleoside/nucleotide analogues have been shown to improve outcomes (e.g., improved liver function, reduced risk of hepatocellular carcinoma [HCC], increased survival, and increased transplant-free survival) in patients with decompensated cirrhosis or acute-on-chronic liver failure, especially with early treatment.[2][29]​ Tenofovir disoproxil and entecavir are equally effective in improving virological response, liver function, and survival among patients with acute-on-chronic liver failure.[134]

Adverse effects may include: nephrotoxicity and decreased bone mineral density/osteopenia (tenofovir disoproxil); hypercholesterolaemia and hypertriglyceridaemia (tenofovir alafenamide); potentially fatal lactic acidosis and severe hepatomegaly with steatosis (nucleoside analogues); pancreatitis; and severe acute exacerbations of hepatitis (after discontinuation). The risk of lactic acidosis is increased in patients with decompensated cirrhosis.[127]

Monitor renal function regularly during treatment. Dose adjustments of tenofovir disoproxil and entecavir may be required in patients with renal impairment. Tenofovir alafenamide is not recommended in patients with an eGFR <15 mL/min/1.72 m². If renal function decreases, or hypophosphataemia or osteoporosis occurs, during treatment with tenofovir disoproxil, switch to tenofovir alafenamide or entecavir.​[29]

Monitor lipid levels regularly during treatment with tenofovir alafenamide, particularly in those at high cardiovascular risk.[125][126]

Lifelong treatment is recommended, regardless of alanine aminotransferase (ALT) or HBV DNA levels, or hepatitis B e antigen (HBeAg) status. The goal is to achieve an undetectable HBV DNA level, ideally within 12 months of treatment. Adjustments to treatment may be considered if this is not achieved.[2]

Primary options

entecavir: 1 mg orally once daily

More

OR

tenofovir disoproxil: 300 mg orally once daily

More

OR

tenofovir alafenamide: 25 mg orally once daily

Plus – assess for liver transplantation

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ONGOING
|
chronic HBV infection: non-pregnant adult with cirrhosis
|
decompensated cirrhosis or acute-on-chronic liver failure
Plus – 

assess for liver transplantation

Treatment recommended for ALL patients in selected patient group

Simultaneously assess the patient for liver transplantation when starting antiviral therapy.[2][29]

Antiviral prophylaxis (e.g., a nucleoside/nucleotide analogue plus hepatitis B immunoglobulin [HBIG]) is recommended in patients who undergo liver transplantation to prevent recurrence. HBIG may be discontinued after transplantation under certain circumstances. Consult a specialist for guidance on the most appropriate regimen.[29] Similar recurrence and overall survival rates have been reported in patients on a nucleoside/nucleotide analogue alone compared with those on a nucleoside/nucleotide analogue plus HBIG.[136]

chronic HBV infection: non-pregnant adult with hepatocellular carcinoma

1st line – tumour management plus antiviral therapy

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ONGOING
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chronic HBV infection: non-pregnant adult with hepatocellular carcinoma
1st line – 

tumour management plus antiviral therapy

Chronic hepatitis B virus (HBV) infection is defined as the presence of hepatitis B surface antigen (HBsAg) for at least 6 months.[2]

Initiate antiviral therapy in patients with hepatocellular carcinoma (HCC), regardless of HBV DNA level. Tenofovir disoproxil is the recommended treatment for tertiary prophylaxis after curative treatment for HCC (e.g., surgery, locoablative therapy).[29] 

See Hepatocellular carcinoma.

chronic HBV infection: non-pregnant adult with HIV co-infection

1st line – antiretroviral therapy (ART) incorporating hepatitis B virus (HBV)-specific antivirals

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ONGOING
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chronic HBV infection: non-pregnant adult with HIV co-infection
1st line – 

antiretroviral therapy (ART) incorporating hepatitis B virus (HBV)-specific antivirals

Chronic HBV infection is defined as the presence of hepatitis B surface antigen (HBsAg) for at least 6 months.[2]

All patients who are HBsAg-positive and living with HIV should receive HBV-specific antivirals incorporated into their ART regimen, regardless of HBV DNA level, alanine aminotransferase (ALT) level, or CD4 cell count.[2][29][138]

Initiate ART, regardless of CD4 cell count, according to current local HIV guidelines and under specialist guidance. Make sure that the ART regimen includes drugs that are active against both viruses, including two drugs with activity against HBV. The preferred regimen includes tenofovir disoproxil or tenofovir alafenamide plus emtricitabine or lamivudine as the backbone. In patients already on ART, review the regimen to make sure it includes drugs with HBV activity. Do not discontinue ART. Treatment monitoring is the same as for patients who are not living with HIV.[2][29][138]

See HIV infection.

chronic HBV infection: non-pregnant adult with hepatitis C co-infection

1st line – hepatitis B virus (HBV) antiviral therapy plus hepatitis C virus (HCV)-specific antiviral therapy

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ONGOING
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chronic HBV infection: non-pregnant adult with hepatitis C co-infection
1st line – 

hepatitis B virus (HBV) antiviral therapy plus hepatitis C virus (HCV)-specific antiviral therapy

Chronic HBV infection is defined as the presence of hepatitis B surface antigen (HBsAg) for at least 6 months.[2]​​

In general, the indications for treatment with HBV antiviral therapy are the same as those for chronic HBV monoinfection. However, patients who are HBsAg-positive with chronic HCV co-infection must also be treated with HCV-specific direct-acting antiviral (DAA) therapy according to current local hepatitis C guidelines and under specialist guidance.[2][29]

Nucleoside/nucleotide analogues are also recommended during DAA therapy in patients who are HBsAg-positive with cirrhosis to prevent HBV reactivation. They can also be given to patients who do not meet the indications for treatment for chronic HBV monoinfection in order to prevent HBV reactivation during DAA therapy.​[29]​ The rate of HBV reactivation is higher in patients receiving DAA therapy compared with those receiving peginterferon alfa for the treatment of hepatitis C.[139]

See Hepatitis C.

chronic HBV infection: non-pregnant adult with hepatitis D co-infection

1st line – hepatitis B virus (HBV) antiviral therapy plus hepatitis D virus (HDV)-specific antiviral therapy

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ONGOING
|
chronic HBV infection: non-pregnant adult with hepatitis D co-infection
1st line – 

hepatitis B virus (HBV) antiviral therapy plus hepatitis D virus (HDV)-specific antiviral therapy

Chronic HBV infection is defined as the presence of hepatitis B surface antigen (HBsAg) for at least 6 months.[2]​

Consider HDV-specific antiviral therapy for all patients with chronic HBV infection, regardless of whether they have cirrhosis, according to current local hepatitis D guidelines and under specialist guidance. Treatment options include peginterferon and/or bulevirtide depending on local guidelines and availability of these drugs.​[29]

Nucleoside/nucleotide analogues are recommended in addition to HDV antiviral therapy in patients with compensated or decompensated cirrhosis, or patients without cirrhosis if the HBV DNA level is ≥2000 IU/mL.[2][29]

See Hepatitis D.

chronic HBV infection: pregnant or breastfeeding

1st line – antiviral prophylaxis

Back
ONGOING
|
chronic HBV infection: pregnant or breastfeeding
1st line – 

antiviral prophylaxis

Chronic hepatitis B virus (HBV) infection is defined as the presence of hepatitis B surface antigen (HBsAg) for at least 6 months.[2] 

Antiviral prophylaxis is recommended in all pregnant women who are HBsAg-positive with a HBV DNA level >200,000 IU/mL, or a positive hepatitis B e antigen (HBeAg) status regardless of HBV DNA level (in areas where HBV DNA testing is unavailable), to reduce the risk of perinatal transmission. Prophylaxis is also recommended in pregnant women with chronic hepatitis, in accordance with the recommendations for non-pregnant women.[2][29][75][77]​​​​​​​​​​

Ideally, antiviral prophylaxis should be started before the last trimester, usually in the second trimester or at 28-32 weeks' gestation (depending on guidelines), and discontinued at birth to 3 months postpartum or upon completion of the infant HBV vaccination series.[2][29][75]

Tenofovir disoproxil or tenofovir alafenamide are the preferred first-line options. Evidence shows that tenofovir disoproxil and tenofovir alafenamide significantly reduce the rate of perinatal transmission, are equally effective at reducing perinatal transmission, and are considered safe for the mother and baby.[145]​​[146]​​[147][143][148]

Lamivudine is an alternative option. It can be given during the third trimester of pregnancy and demonstrates safety and reduction in perinatal and intra-uterine transmission of HBV when given with infant hepatitis B vaccination and hepatitis B immunoglobulin (HBIG).[2][149][150][151][152]

Women who become pregnant while receiving tenofovir may continue on this treatment. However, switching to tenofovir is recommended in women who become pregnant while receiving other drugs. Tenofovir can be continued long-term after delivery to maintain viral suppression.[2][29]​ 

Peripartum antiviral prophylaxis has been shown to be highly effective at reducing the risk of perinatal transmission, and considered safe with no increased risk of infant or maternal safety outcomes.[142][143]​ One Cochrane review found no evidence to demonstrate or disprove any benefit for antiviral therapy for the prevention of perinatal transmission in pregnant women with HIV and HBV co-infection.[144]

Encourage breastfeeding of infants born to mothers who are HBsAg-positive, unless there are contraindications, or the mother presents with cracked nipples and/or the infant has oral ulcers and the mother has detectable HBV DNA level.[77][154] Breastfeeding after neonatal immunoprophylaxis does not increase transmission rates compared with not breastfeeding.[157]

Antiviral therapy is not contraindicated during breastfeeding.[2][154] Antivirals are minimally excreted in breast milk and are unlikely to pose a significant risk to the infant. However, the risks associated with low-level exposure are unknown. Tenofovir can be continued safely during breastfeeding.[29][158]

Primary options

tenofovir disoproxil: 300 mg orally once daily

OR

tenofovir alafenamide: 25 mg orally once daily

Secondary options

lamivudine: 100 mg orally once daily

Consider – delivery via caesarean section

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ONGOING
|
chronic HBV infection: pregnant or breastfeeding
Consider – 

delivery via caesarean section

Additional treatment recommended for SOME patients in selected patient group

Caesarean section delivery may be considered in select patients in order to reduce the risk of perinatal transmission.[153] 

The American College of Obstetricians and Gynecologists (ACOG) suggest that caesarean delivery be reserved for obstetric indications for caesarean delivery only.[77] 

European guidelines do not recommend caesarean section to reduce the risk of perinatal transmission in women who are hepatitis B surface antigen (HBsAg)-positive. However, caesarean section may be considered in Asian women who are hepatitis B e antigen (HBeAg)-positive with a high hepatitis B virus (HBV) DNA level who have not received antiviral therapy during pregnancy. Recommendations for patients with hepatitis D virus (HDV) co-infection are the same as those with HBV infection.[154]

chronic HBV infection: children

1st line – supportive care

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ONGOING
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chronic HBV infection: children
1st line – 

supportive care

Chronic hepatitis B virus (HBV) infection is defined as the presence of hepatitis B surface antigen (HBsAg) for at least 6 months.[2] 

A conservative approach to treatment is usually acceptable in children owing to a paucity of clinical data and therapeutic options. Chronic infection typically runs an asymptomatic course in most children. Follow-up of children through to adulthood is important.[2][29] 

Typically, rest, good nutrition, fluids, and avoiding alcohol or hepatotoxic drugs or supplements are enough to treat symptoms.[107] Symptomatic treatment (e.g., analgesic, antipyretic) may be required.

Consider – antiviral therapy

Back
ONGOING
|
chronic HBV infection: children
Consider – 

antiviral therapy

Additional treatment recommended for SOME patients in selected patient group

A provider experienced in treating children must initiate antiviral therapy, if indicated.

Consider antiviral therapy in hepatitis B e antigen (HBeAg)-positive children ages ≥2 years who have an elevated ALT level (>1.3 times the upper limit of normal [ULN] for at least 6 months) and a measurable hepatitis B virus (HBV) DNA level. The HBV DNA level is generally very high in children. Therapy may be deferred until other aetiologies of liver disease and spontaneous HBeAg seroconversion are excluded in patients with a HBV DNA level <10⁴ IU/mL.[2] 

Tenofovir disoproxil, entecavir, and lamivudine are approved in the US for use in children ≥2 years of age. Tenofovir alafenamide is approved for children ≥6 years of age. Peginterferon alfa is approved for use in children ages ≥3 years of age.[2] Approval age cut-offs may vary in other countries.

Duration of nucleoside/nucleotide analogue treatment studied in children is 1-4 years. However, HBeAg seroconversion may be used as a therapeutic endpoint, continuing for a further 12 months of consolidation (as per adults). The treatment course of peginterferon alfa in children is 48 weeks.[2]

Primary options

entecavir: consult specialist for guidance on dose

OR

tenofovir disoproxil: consult specialist for guidance on dose

OR

tenofovir alafenamide: consult specialist for guidance on dose

OR

peginterferon alfa 2a: consult specialist for guidance on dose

Secondary options

lamivudine: consult specialist for guidance on dose

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

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