Treatment of hepatitis B: the next five years

The natural history of individuals chronically infected with hepatitis B typically fluctuates, with periods of active viral replication with or without an associated hepatitis and sometimes prolonged periods of spontaneous viral suppression and inactive liver disease. In the majority, this chronic infection is clinically silent unless either liver failure and/or hepatocellular carcinoma (HCC) supervenes. Thus proactive steps are needed to first identify those with hepatitis B infection and to then serially monitor those found to be chronically infected for both level of alanine aminotransferase (ALT) and hepatitis B virus DNA (HBV-DNA) (using sensitive polymerase chain reaction techniques. Antiviral therapy significantly reduces the risk of liver disease progression and HCC in those with ongoing viral replication > 10(5) c/ml and advanced hepatic fibrosis. The decision of when to initiate (possibly lifelong) treatment has to be made judiciously. Before introducing therapy both patient and physician must recognise the need for compliance with both treatment and viral surveillance so as to minimise the development of drug resistance. Drug resistance needs to be identified prior to recurrence of hepatitis (rise in ALT) to prevent hepatic decompensation, this necessitates serial HBV-DNA testing.