Australia’s second national strategy for hepatitis B (1) reiterates the key role of primary care practitioners in the diagnosis, care and management of people living with chronic hepatitis B (CHB). This website provides a comprehensive summary of currently available knowledge and practice. It is intended to be used as an online resource by health professionals who require information to direct management or answer questions from individuals living with CHB.
Practice profiles and the interests of primary care practitioners vary. This guide will be used in a variety of settings, including inner urban and remote rural settings, especially in clinics that serve Aboriginal and Torres Strait Islander people. The editorial team is therefore particularly grateful for input provided by a focus group of primary care practitioners with experience from a wide range of settings.
Updated information on the epidemiology of CHB is provided in Chapter 1: Prevalence and epidemiology of hepatitis B. In 2011, an estimated 218,000 Australians were living with CHB, representing 1% of the population. Most of those affected were born overseas, in the Asia and Pacific regions (particularly China and Vietnam); also disproportionally affected are Aboriginal and Torres Strait Islander people, who make up nearly 10% of people living with CHB. Liver cancer is the most rapidly increasing cause of cancer death and almost half of primary liver cancers diagnosed in Australia today arise in individuals born overseas. Understanding the epidemiology helps the primary care practitioner to target testing to individuals at greater risk of CHB in accordance with the newly released national testing policy (2), which recommends three tests for diagnostic testing: hepatitis B surface antigen (HBsAg), antibodies to core antigen (anti-HBc) and antibodies to surface antigen (anti-HBs) (Chapter 3: Hepatitis B virus testing and interpreting test results). It also allows a focus on prevention, including vaccination of non-immune individuals at risk of infection (Chapter 5: Primary prevention of hepatitis B virus infection).
The understanding of the natural history of CHB is unchanged from the first edition of this guide, with four phases of infection characterised by the immune response to the virus. However, the effect of the treatment in reducing the risk of cancer by up to 75%, reversing severe fibrosis, is better understood (Chapter 4: Natural history of chronic hepatitis B virus infection). The primary care practitioner requires the patient’s viral load, liver function tests and e antigen status to assess the disease phase and arrange appropriate monitoring and referral. In 2011, liver biopsy was removed as a requirement for initiation of antiviral therapy. Non-invasive alternatives to liver biopsy for the assessment of liver fibrosis – including transient elastography (Fibroscan®) – are now increasingly available, and offer a reliable and non- invasive means of fibrosis assessment. In areas where these tools are not available (particularly in remote areas), assessment of synthetic liver function may give an indication as to underlying cirrhosis (Chapter 6: Clinical assessment of patients with hepatitis B virus infection).
Emergence of resistance to older antiviral therapies (Chapter 2: Virology, viral replication and drug resistance) has left treating clinicians with three major therapeutic choices for treatment. Interferon-based therapy is still used in a select group of patients, but in most the mainstay is one of the oral treatments available on the Pharmaceutical Benefits Scheme (PBS), entecavir and tenofovir, which aim to suppress viral replication (Chapter 7: Treatment of chronic hepatitis B virus infection). These therapies are effective, well tolerated and have a barrier to resistance. Primary care practitioners may still see individuals on older combinations of drugs, especially in those who have started treatment overseas, where the cost of therapy limits drug choice.
All patients with advanced liver disease should be considered for antiviral therapy, and should receive shared care with a specialist unit, to prevent and manage complications of advanced disease and to consider whether transplantation is an option (Chapter 8: Managing patients with advanced liver disease).
Standardised incidence rates for primary liver cancer in people born overseas, in areas where hepatitis B virus (HBV) is highly endemic (China and Vietnam, Africa, the Mediterranean region, and the Asia and Pacific regions), are between two and 12 times greater than in the Australian-born population (Chapter 9: Hepatitis B virus related hepatocellular carcinoma). Liver cancer surveillance (6-monthly ultrasound and alpha-fetoprotein [AFP]) improves survival and is recommended in certain groups, based on evidence of cirrhosis, family history, age and country of birth. Aboriginal and Torres Strait Islander people living with CHB are recommended to start surveillance for liver cancer after the age of 50 years.
All pregnant women should be screened for CHB, and primary care practitioners are advised to order three tests (HBsAg, anti-HBc and anti-HBs) for women at risk of infection, rather than testing for HBsAg alone. All pregnant women with CHB need to have a viral load test during pregnancy; women with a viral load greater than 10,000,000 IU/mL should be considered for antiviral therapy during the third trimester, to further reduce the chance of transmission. All infants born to women with CHB should receive immunoglobulin within 12 hours, concurrently with birth dose hepatitis B vaccination (Chapter 10: Managing hepatitis B virus in pregnancy and children).
Transmission continues to occur in priority populations, including men who have sex with men and people living with human immunodeficiency virus (HIV) infection. Co-infection with hepatitis C virus, hepatitis D virus (HDV) and HIV needs special consideration and specialist management, because outcomes may be worse and management more complex in these patients. All patients undergoing significant immunosuppression, including chemotherapy (especially with biological agents), should be screened for infection and started on antiviral therapy if found to have CHB (Chapter 11: Complex situations: Co-infection and immunosuppression).
Universal precautions are the mainstay of infection control and should be understood and adhered to by all health practitioners. Vaccination of all health care professionals is recommended. People living with CHB are able to work in the health profession, but must not perform exposure prone procedures (Chapter 12: Infection control and occupational health and Chapter 13: Privacy, confidentiality and other legal responsibilities).
Irrespective of the stage of disease, many people living with HBV choose to use alternative or complementary medicines at some time during their infection. While there is no current evidence of benefit from complementary medicines in changing disease outcomes, there is evidence of harm with use of certain compounds. Thus, patients need sound advice to make good health choices (Chapter 14: The role of complementary medicine in hepatitis B).
The challenge presented by the need for what is often lifelong management of CHB cannot be overstated. Many people do not have a single health provider, so the key to effective care is not the enthusiasm of a single provider or clinic, but a health system that coordinates care and provides the best possible information for individuals to make informed choices. Community engagement and involvement in decision-making is vital to increasing the numbers diagnosed, and to appropriate management. Individuals living with hepatitis B need to receive clear and culturally appropriate information from primary care practitioners about their CHB.
Many uncertainties still exist, such as which patients will benefit from therapeutic intervention, the optimal time to initiate therapy, and the extent of virological suppression required to reduce disease progression. Our knowledge and understanding of this complex disease have been improved by the greater number of effective agents and the availability of increasingly sensitive tests that monitor the natural history and the therapeutic response. Nevertheless, the appropriate identification, management and referral of people with HBV infection within the primary care setting is key to preventing a greater burden of CHB in Australia in the future.
General practitioners can prescribe maintenance antiviral therapy under the Highly Specialised Drugs programme (under the direction of a treating specialist affiliated with a hospital; or, as part of s100 community prescriber programs in a number of jurisdictions). This is an area that may change in the future. Not all primary care practitioners will be confident in prescribing antiviral therapy; however, as with other models of chronic disease delivery, increased expertise (including prescribing) will be essential for decreasing the incidence of adverse outcomes, including liver cancer.
General Practice – Joslin Clinic, Western Region Health Centre and Victorian Infectious Diseases Reference Laboratory
- Australian Government Department of Health. National Hepatitis B Strategy 2014-2017. Canberra: Commonwealth of Australia, 2014
- Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). B positive - all you wanted to know about hepatitis B: a guide for primary care providers (first edition). Darlinghurst NSW: ASHM, 2008.
- Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Decision-making in HBV. Darlinghurst NSW: ASHM, 2013.
- National HBV Testing Policy Expert Reference Committee. National hepatitis B testing policy. Darlinghurst NSW: Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM), 2012.