Chronic hepatitis B (CHB) remains a significant public health issue, particularly in China, where the disease is prevalent. In response, the 2022 Chinese guidelines for the prevention and treatment of CHB have adopted a more aggressive stance, broadening treatment criteria and simplifying management protocols to improve overall disease control. This essay elaborates on Mengyang Zhang et al.’s study, published in the Journal of Clinical and Translational Hepatology, which assesses these new guidelines and evaluates the impact of a “Treat-all” strategy in managing CHB. The review begins by emphasising the substantial health burden of untreated CHB, which can progress to severe liver diseases like cirrhosis and hepatocellular carcinoma (HCC), particularly underlining the situation in China, where HBV is a major cause of liver-related death.
The “Treat-all” strategy outlined in the guidelines advocates for initiating treatment in all individuals with detectable HBV DNA or positive HBsAg, aiming to reduce the disease burden by preventing the progression to more severe liver conditions. The rationale is that early treatment can enhance quality of life, minimise infectivity, and manage comorbidities such as fatty liver disease and HBV reactivation in the context of immunosuppressive therapies. This approach supports evidence that early antiviral treatment can prevent the progression of liver disease and reduce the incidence of HCC, suggesting a significant shift towards proactive disease management.
The expanded criteria in the 2022 guidelines now recommend treatment for nearly all patients with detectable HBV DNA, mainly targeting those at higher risk of disease progression. This includes adults over 30, due to the increased risk of disease progression and HCC, and children aged 1-7, who have a higher chance of achieving a functional cure and present significant liver damage. Furthermore, treatment is advised for at-risk adults exhibiting symptoms like elevated ALT, cirrhosis, considerable fibrosis, extrahepatic manifestations, or a family history of HCC.
A central discussion point in the review is the treatment of patients with HBeAg-positive chronic HBV infection, which traditionally was not immediately treated due to perceived minimal liver damage. Recent studies challenge this view, showing significant histological damage even in this phase and suggesting that early antiviral treatment can prevent disease progression and reduce HCC risk. The article also stresses the cost-effectiveness of early treatment initiation, utilising decision-tree Markov models to demonstrate that expanding antiviral treatment to all HBsAg-positive patients could drastically reduce liver-related events and overall healthcare costs, aligning with WHO’s goals to decrease HBV-related mortality by 65%.
Despite the promising prospects of the “Treat-all” strategy, it also presents challenges such as the potential for overtreatment, the necessity for sustained adherence to antiviral therapy, and managing the risks associated with treatment withdrawal, like viral relapse and liver failure. The review calls for continued research and adaptation of treatment strategies to address these challenges and improve patient outcomes effectively.
The 2022 Chinese guidelines for CHB mark a significant advancement in the proactive management of chronic hepatitis B. By advocating a “Treat-all” approach, despite its associated challenges, there is a substantial potential to reduce the burden of HBV-related liver diseases and contribute to the elimination of hepatitis B as a public health threat by 2030. The insights provided by Mengyang Zhang et al. are crucial. They emphasise the importance of early treatment and explore both the benefits and challenges of a more inclusive antiviral treatment approach in the context of global health strategies.
More information: Mengyang Zhang et al, “Treat-all” Strategy for Patients with Chronic Hepatitis B Virus Infection in China: Are We There Yet? Journal of Clinical and Translational Hepatology. DOI: 10.14218/JCTH.2024.00091
Journal information: Journal of Clinical and Translational Hepatology Provided by Xia & He Publishing Inc.
