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Elimination Starts at the Frontlines: Why Primary Care Must Be at the Forefront of Viral Hepatitis

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Released: September 30, 2026

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Viral hepatitis elimination is fully within our reach, and it is up to primary care providers to initiate the care cascade by implementing universal, one-time HBV and HCV screening for all adults and offering the HBV vaccine to any adult lacking immunity. In this commentary, I discuss how primary care providers can actively halt viral transmission and connect individuals with positive test results to care.

Su Wang
Su Wang, MD, MPH, FACP
Viral Hepatitis in Primary Care

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A Librarian’s Story
He was a retired librarian and an affable, meticulous man with good health insurance who never missed his annual primary care checkups. Years earlier, he had been diagnosed with hepatitis B virus (HBV) infection by a doctor he saw while visiting his daughter. However, because he was feeling fine and was told at the time that he did not need treatment, he received no follow-up care for his HBV. He never saw a specialist and was never monitored with routine HBV DNA testing or surveillance for hepatocellular carcinoma (HCC).

A decade after his diagnosis, he developed abdominal pain, distention, and weight loss, leading him to the emergency room. Imaging revealed a 12 cm HCC that was far beyond the criteria for resection or liver transplantation. The oncology team told him he had roughly 6 months to live.

He was sent to me to treat his HBV, but I explained that although antivirals treat the virus to prevent cancer, they cannot reverse established cancer. Heartbroken and bewildered, he asked me a question that haunts me to this day: “I saw my doctor every year. How could this have happened?”

Choosing not to pursue aggressive therapies, he spent his remaining 6 months writing his autobiography. In our conversations, he pleaded that no one else should suffer his preventable fate. He urged people to get tested and cared for, and he asked me to tell his story so others would learn.

How Elimination Happens
In order to eliminate viral hepatitis by the global goal of 2030, we must change where this battle is fought. Mortality and liver cancer rates caused by HBV and hepatitis C virus (HCV) continue to rise, underscoring an urgent, expanding public health crisis. We cannot hope to reverse this trend without actively “finding the missing millions” who remain undiagnosed and re-engaging those in care who were diagnosed but lost to follow-up.

As frontline primary care providers (PCPs), we must initiate the care cascade. We must implement CDC recommendations for universal, one-time HBV and HCV screening for all adults. We must pair this universal screening with active prevention by offering the HBV vaccine to all adults lacking immunity. By actively screening and vaccinating, we can halt viral transmission and connect individuals with positive test results to care.

As a PCP and a member of the hepatitis B-affected community, I know firsthand that we cannot achieve elimination—in HBV or in HCV—by relying solely on specialist referrals. Once people are diagnosed, their care must involve their frontline providers.

Prove It
For too long, the clinical paradigm for HBV treatment has been: “Prove to me you need to be treated.”

We have traditionally forced people with HBV to navigate complex specialist referrals, highly specialized testing, and follow-up protocols, and we lost too many along the way.

Studies show the toll of this fragmented care cascade: many people never receive a complete evaluation or an offer of treatment because they do not complete the required battery of tests. In a large nationwide US cohort, more than half of people with chronic HBV did not receive a complete laboratory evaluation (HBeAg, HBV DNA, and ALT testing). Among those eligible for treatment according to American Association for the Study of Liver Diseases (AASLD) guidelines, more than one third received no antiviral therapy within 12 months.

Bearing in mind all these missed opportunities, we must flip the script to a far simpler question: “Prove to me you do not need to be treated.”

Recently, major global guidelines, including those from the WHO, European Association for the Study of the Liver, and AASLD, and expert recommendations have been updated to support this shift. Although international recommendations vary based on target audiences and resource settings, they have expanded treatment eligibility.

Many guidelines use similar thresholds of an HBV DNA level of 2000 IU/mL paired with any abnormal ALT, regardless of HBeAg status (a test that adds complexity for many PCPs). Other guidelines advocate for a broad “treat-all” approach, but other recommendations still demand specialized testing.

Rather than relying on rigid clinical rules, as PCPs, we should recognize this overall push toward lower barriers: we should offer treatment broadly.

Declaration From the People
As part of the HBV community, I was one of the authors of our “Declaration From People Living with Hepatitis B,” where we argued that placing the patient at the center of decision-making and prioritizing their lived experiences is essential to overcoming long-standing barriers to engagement and retention in care. This aligns directly with what patient advocates have long requested: a whole-person approach that treats the individual rather than just the liver.

It may seem like specialists are better equipped to manage HBV care, but primary care is uniquely positioned to deliver this comprehensive, whole-person care. Through multiple longitudinal touchpoints, PCPs can integrate routine monitoring, including regular assessment of HBV DNA and periodic liver ultrasounds for HCC surveillance, directly into their annual visits.

A Primary Care How-To
Screening and engagement in care can be so simple. Start by ordering screening. When you identify someone with HBV, add a test for HBV DNA. If HBV DNA is undetectable or very low, that is reassuring and indicates lower risk, but you should continue monitoring every 6 months. If it is higher than 2000 IU/mL and you are unsure of next steps, consider treatment or specialist intervention.

Think of ordering liver cancer surveillance when you are also ordering a mammogram or colonoscopy. It’s simple: you order a liver ultrasound and alpha-fetoprotein. If you want to screen for cirrhosis, order an ultrasound elastography for the liver. Because many people already have metabolic risk factors such as hyperlipidemia, obesity, or diabetes, the ultrasound also assesses for metabolic dysfunction–associated steatotic liver disease.

I find viral hepatitis management to be less complex than other primary care conditions, such as diabetes.

For HBV, treatment consists of 3 primary oral medications, 2 of which are generic, administered once daily, and very safe with few interactions with other medications. The HBV Primary Care Workgroup Guidance outlines clear, simplified clinical pathways compiled by frontline experts to empower nonspecialists.

Curing HCV is even simpler, with pangenotypic regimens consisting of 8-12 weeks of once-daily oral therapy and cure rates exceeding 95%. Excellent tools, such as the AASLD/Infectious Disease Society of America HCV online guidance, provide clear pathways to guide care. For HCV, I have found it exceptionally rewarding to cure a chronic disease; many patients feel they have a new lease on life and become motivated to tackle other chronic conditions.

Viral hepatitis elimination is fully within our reach. This frontline model of hepatitis care is a call to action for PCPs, but it also extends to other care settings such as women’s health providers and addiction settings. Let us bring hepatitis B and C into the larger fold to ensure our patients do not fall through the cracks.

Your Thoughts
What is your approach to HBV and HCV screening for new patients? Do you have strategies you’ve found successful for preventing missed opportunities for treatment or vaccination? Leave a comment to join the discussion!

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