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Joy

Meet Joy . . .

  • She is a high school teacher
  • She is married with two children
  • She is busy juggling work and her children’s extracurricular activities

Patient demographics and diagnosis

Sex: Female
Age: 38 years
Race/Ethnicity: Filipino

  • She was diagnosed with chronic HBV infection in her 20s
  • She regularly follows up with her hepatologist
  • She has not required antiviral treatment for hepatitis B

Follow-up visit with hepatologist

Past medical history: Unremarkable. No history of hepatic decompensation; no coinfection with hepatitis C virus, hepatitis D virus, or HIV
Medications: None
Past surgical history: C-section at age 32 years

    • Born in the Philippines and immigrated to the US with her parents at age 14
    • Lives at home with her husband (age 38) and two children (ages 10 and 12)
    • Husband and children are fully vaccinated against HBV with documented serologic immunity
    • Has 1–2 servings of alcohol monthly
    • Has never smoked tobacco or used recreational drugs

  • Her mother has chronic hepatitis B. She is not receiving antiviral treatment. She does not have a history of cirrhosis or hepatocellular carcinoma

    • BP: 110/80 mmHg, HR: 84 bpm, RR: 12/min
    • BMI: 22.5 kg/m2
    • No jaundice or scleral icterus
    • No abdominal distention
    • No lower extremity edema

    • HBsAg (+), anti-HBs (–), anti-HBc total (+), HBeAg (–), anti-HBe (+)
    • HBV DNA: 3500 IU/mL
    • ALT: 22 U/L (ULN: 25 U/L)1
    • Basal core promoter mutation: Negative
    • AFP: 3.1 ng/mL (normal: <10 mg/mL)2
    1. Terrault NA, et al. Hepatology. 2018;67(4):1560-1599. 2. Ball D, et al Am J Med Sci. 1992;303(3):157-159.

  • RUQ ultrasound

    • Normal liver ultrasound
    • No focal liver lesion or biliary ductal dilatation
    • Patent portal vein with normal hepatopetal flow

  • Vibration-controlled transient elastography

    • 5.0 kPa (significant fibrosis cutoff, >7.0 kPa)1

    Controlled attenuation parameter

    • 220 dB/min (steatosis cutoff, ≥288 dB/min)2
    1. European Association for the Study of the Liver. J Hepatol. 2025;83(2):502-583. 2. Terrault NA, et al. Hepatology. 2018;67(4):1560-1599.

Joy asks if she should start antiviral treatment for hepatitis B.

What next step do you agree on?

  • What factors favored starting antiviral treatment?

    • Joy is in the indeterminate phase ("gray zone") of chronic HBV infection. The indeterminate phase of CHB refers to patients whose lab results do not neatly fit into the classic phases of infection1,2
    • Patients in the indeterminate phase have higher risk of HCC and liver disease progression than patients with HBeAg-negative chronic infection (inactive HBV)3,4
    • Joy's hepatologist obtained quantitative HBsAg (qHBsAg) testing, which showed 1800 IU/mL. In HBeAg-negative patients, qHBsAg >1000 IU/mL is associated with increased risk of HCC and liver disease progression and may help distinguish chronic infection (inactive HBV) from chronic hepatitis B (immune-active)1,2,5
    1. Terrault NA, et al. Hepatology. 2018;67(4):1560-1599. 2. European Association for the Study of the Liver. J Hepatol. 2025;83(2):502-583. 3. Hui VW, et al. Hepatology. Published online April 21, 2025. doi:10.1097/HEP.0000000000001354. 4. Jiang H, et al. J Gastroenterol Hepatol. 2025;40(3):720-730. 5. Lee MH, et al. Hepatology. 2013;58(2):546-554.

    What should Joy expect with antiviral treatment?

    • Nucleos(t)ide analogs (NAs) are recommended first-line therapy for CHB1
    • NAs are oral medicines taken once a day and are generally well tolerated2
    • NAs effectively suppress HBV DNA. Antiviral treatment is associated with reduced risk of HCC in patients with indeterminate phase CHB3
    • NA therapy is long-term and potentially lifelong. NA therapy may be stopped after loss of HBsAg, or functional cure, but this is rare.1 Her hepatologist explains that HBsAg loss is associated with a further reduction in risk of HCC4
    1. European Association for the Study of the Liver. J Hepatol. 2025;83(2):502-583. 2. Terrault NA, et al. Hepatology. 2018;67(4):1560-1599. 3. Lai J, et al. J Hepatol. 2025;82(6):992-1030. 4. Yip TC, et al. J Hepatol. 2019;70(3):361-370.

  • What factors were considered in the decision not to start antiviral treatment?

    • Joy is in the indeterminate phase ("gray zone") of chronic HBV infection. The indeterminate phase of CHB refers to patients whose lab results do not neatly fit into the classic phases of infection1,2
    • Joy does not have significant hepatic fibrosis or extrahepatic manifestations of chronic HBV infection, which are indications for treatment.2 Her age of >35 years may confer increased risk of HCC, but she does not have other risk factors (eg, family history of HCC, male sex)2
    • Her hepatologist obtained quantitative HBsAg (qHBsAg) testing, which showed 300 IU/mL. In HBeAg-negative patients, qHBsAg <1000 IU/mL is associated with having chronic infection (inactive HBV) rather than hepatitis (immune-active)3
    • Joy has only taken over-the-counter medicines as needed for fever and body aches. She feels anxious about the stigma of taking a daily medicine for a chronic illness. Between her work as a teacher and her duties as a mom, she is worried about frequently missing doses
    1. Terrault NA, et al. Hepatology. 2018;67(4):1560-1599. 2. European Association for the Study of the Liver. J Hepatol. 2025;83(2):502-583. 3. Liu J, et al. Hepatology. 2016;64(2):381-389.

    What are the next steps for Joy?

    • Joy and her hepatologist agree on continuing close monitoring of her labs so they can keep a close eye if Joy is experiencing liver disease progression or transition to the chronic hepatitis (immune-active) phase of HBV infection
    • They agree to monitor Joy’s ALT and HBV DNA levels every 6 months, evaluate quantitative HBsAg every 12 months, and assess fibrosis using vibration-controlled transient elastography every 1 to 2 years1
    • In the future, Joy will also have an ultrasound and serum AFP testing every 6 months to screen for HCC2
    1. European Association for the Study of the Liver. J Hepatol. 2025;83(2):502-583. 2. Terrault NA, et al. Hepatology. 2018;67(4):1560-1599.

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