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HBV in Key Communities

CE / CME

HBV in Key Communities: Strategies to Overcome Barriers and Elevate Care

Pharmacists: 0.75 contact hour (0.075 CEUs)

Physicians: maximum of 0.75 AMA PRA Category 1 Credit™

Nurse Practitioners/Nurses: 0.75 Nursing contact hour

Released: March 12, 2026

Expiration: March 11, 2027

Su Wang
Su Wang, MD, MPH, FACP
CME/CE Information

Activity

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Impact of National Screening Strategies in the US: HIV vs HBV Care Cascade

To explore how HBV screening can be improved, I want to start by contrasting our historical, risk-based approach to HBV screening with a universal approach, which has been used in HIV care for a number of years.

Let's start with HIV as an example. The CDC recommends routine screening for HIV in the form of a 1-time test. The resulting care cascade shows that most people with HIV have been diagnosed, with only 13% unaware and not in care. Because most have been diagnosed, most are also linked to care and virologically suppressed. Although this could be better, the key is that most people living with HIV have been diagnosed and have the opportunity to engage in care.15-20

In contrast, our historical, risk-based screening for HBV required doctors to identify who was at risk of HBV exposure and then screen those people. However, risk assessment is very difficult and often inaccurate, as perception of risk can differ widely from individual to individual. As a consequence, and unlike HIV, most people with HBV are unaware of their status and not in care. This is practically the opposite of the successes seen with routine HIV screening.15-20

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New CDC Recommendations: Universal HBV Screening

In response to that gap in screening and diagnosis, the CDC started recommending universal HBV screening in 2023. This is similar to the routine screening we have for HIV and hepatitis C virus, which was recommended for universal screening starting in 2021.20

Certain parts of the HBV screening recommendations remained unchanged: Pregnant persons should still be screened with each pregnancy, regardless of vaccination status or history of testing. Anyone with a history of risk, regardless of age, should also receive hepatitis B screening.20

The key addition to the screening recommendations is this universal screening: all adults, regardless of risk factors, should be screened at least once in their lifetime.

You should also screen anybody who requests it and anyone with ongoing risks, as listed in the slide.20

The new recommendations also note that hepatitis B screening should be done with a 3-test panel: hepatitis B surface antigen (HBsAg), hepatitis B surface antibody (anti-HBs), and total anti-hepatitis B core antibody (total anti-HBc).20

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Interpretation of Serologic Test Results for HBV

Interpretation of 3 different test results can be confusing, but I always tell people that you can find simple interpretation tables, like this one, online.

In summary, if all the tests are negative, that means the patient is susceptible to hepatitis B. They're not infected, but they're also not immune and have never been exposed. The key point of this interpretation is that they should be vaccinated.21

A positive HBsAg, but negative HBsAb, and positive anti-HBc means that the person is currently infected.21

If the HBsAg is negative, but the anti-HBs and anti-HBc are positive, that means the patient was infected or exposed at some point, and they are now immune thanks to that past exposure or infection.21

If just the anti-HBs is positive and the rest of the tests are negative, that person is immune as a result of previous vaccination, but they've never been exposed to the virus.21

Finally, if only the anti-HBc test is positive, this interpretation can be a little bit tricky, as this can be a number of scenarios. Usually this means that the person had a prior HBV infection and developed immunity, but their surface antibody response waned over time. However, if they were ever exposed in the future, they would start creating antibodies again. This is what we call an anamnestic response. There's a very small chance that this could be a false positive, but the current core antibody tests are highly sensitive. So, we don't believe that false positives are much of a consideration anymore.21

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Barriers to Viral Hepatitis Screening and Linkage to Care

Let’s delve deeper into examining the barriers to viral hepatitis screening and linkage to care on multiple levels.

On the provider level, HCPs may be unaware of the burden of hepatitis B. Low awareness means that preventative care may not be prioritized, or may take a backseat to more urgent concerns in a busy healthcare setting.

In terms of delivering actual HBV care, there is a limited number of people who feel qualified to care for people with hepatitis B. There are not enough hepatologists to care for everybody with hepatitis B.

HCPs may also still have some misperceptions of who should be tested or who needs to be treated. That is, implicit bias may exist against people who are using substances or engage in behaviors that increase their risk for reinfection. These factors don’t mean that they cannot be candidates for treatment.22-27

At the patient level, similar to the barriers that we already discussed for certain high-risk groups, people may lack access to regular healthcare services, so when they do engage with the healthcare system, there may be substance abuse or mental illness that makes it difficult for them to access healthcare regularly.

Stability factors such as housing and employment can also impede access to care.

Patients may simply be unaware that hepatitis B has serious consequences. Fears of treatment and stigma can also come into play.26-29  

At the healthcare system level, much of the difficulty comes from a sprawling, dispersed system. It can be complicated, involving multiple steps where patients have to see their primary care provider before they get referred to a specialist.

Or, the provision of certain services outside of their primary healthcare system can also make accessing specialist care very prohibitive. People may need support services to navigate the system, or they may just have difficulty accessing care at certain locations.26,30,31

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Timely Linkage to Care Is Important but Often Delayed

All those barriers contribute to delayed linkage to care.

Once linked to care and treatment, adherence to therapy is key for improving outcomes and reducing long-term risk of cirrhosis and HCC, but getting refills can be difficult because of insurance coverage or prior authorizations.32,33

These delays in the diagnosis and linkage to care also happen more often among underserved populations and racial and ethnic minorities and underserved populations, further contributing to a disproportionate burden of liver complications in these communities.34

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