Chronic Hepatitis B Management Updates

Epidemiological Context and Rationale

India harbors approximately 40 to 50 million individuals with Chronic Hepatitis B (CHB).
Perinatal and early childhood transmission accounts for 70% to 80% of chronic cases.
Without intervention, 90% of perinatally infected infants develop chronicity, compared to less than 5% in adults.
Left untreated, 15% to 40% progress to cirrhosis or hepatocellular carcinoma (HCC) by adulthood.

Treatment relies on high-barrier nucleos(t)ide analogues (NAs).
Long-term NA therapy achieves viral suppression exceeding 95%, reduces HCC risk by 50% to 70%, and improves hepatic histology.
Preferred Agents in Pediatrics: Entecavir (ETV) is approved for children $\geq$ 2 years; Tenofovir Alafenamide (TAF) is approved for adolescents $\geq$ 12 years.
TAF demonstrates superiority over Tenofovir Disoproxil Fumarate (TDF) regarding bone mineral density (osteoporosis) and renal safety (chronic kidney disease).

Issuing Body	Key Diagnostic and Treatment Recommendations
WHO 2024	Expanded eligibility for all adolescents $\geq$ 12 years with HBV DNA >2000 IU/mL + ALT >Upper Limit of Normal (ULN) on two occasions, or presence of cirrhosis regardless of ALT/DNA.
AASLD/IDSA 2025	Advocates selective treatment of the immune-tolerant phase. Recommends therapy if age >40 years or significant fibrosis ( $\geq$ F2) or inflammation ( $\geq$ G2). Shared decision-making for <40 years.
EASL 2025	Treat HBeAg+ chronic infection if HCC risk or extrahepatic manifestations exist. Advanced fibrosis (LSM $\geq$ 8 kPa) mandates treatment regardless of ALT/DNA levels.
INASL 2025	Prioritizes TAF/ETV/TDF as first-line. Recommends individualized management and emphasizes long-term adherence in pediatric populations.

Universal Hepatitis B birth dose and subsequent pentavalent vaccine remain the cornerstone of primary prevention.
Maternal prophylaxis using TDF or TAF initiated at 28 weeks of gestation is indicated if maternal HBV DNA exceeds 200,000 IU/mL.
This intervention effectively reduces the risk of vertical transmission to less than 1%.

Invasive liver biopsy has been largely replaced by non-invasive tools such as FibroScan (Vibration-Controlled Transient Elastography), APRI, and FIB-4 scores for fibrosis assessment.
Routine monitoring requires ALT and HBV DNA evaluation every 6 to 12 months.
The National Viral Hepatitis Control Programme (NVHCP) provides free diagnostics, reflex HBV DNA testing, and NA treatment (prioritizing TDF and ETV) at designated centers, aiming for a 90% reduction in new infections by 2030.