Management and care of hepatitis B
Key takeaways:
- All people living with chronic hepatitis B need ongoing monitoring and care every 6 months.
- There are several settings in which care and/or antiviral treatment can be provided.
- The most appropriate setting will depend on geography, clinician experience and patient preferences.
On this page
What management of hepatitis B is required in primary care?
Everyone living with chronic hepatitis B requires initial assessment and then regular monitoring. It is recommended that certain people with hepatitis B undergo hepatocellular carcinoma (HCC or liver cancer) surveillance.
Regular monitoring includes blood tests every 6 months to monitor for progression from one phase of infection to another and determine antiviral treatment eligibility. The natural history of hepatitis B can be divided into 4 progressive phases based on viral load, liver function tests and HBeAg/Ab status. Eligibility for antiviral treatment and specific monitoring is based on the patient’s current disease phase.
For detailed information on monitoring requirements see the hepatitis B decision making tool.
For information on HCC screening eligibility see here.
Medicare covers hepatitis B DNA testing once per year for patients not on treatment and 4 times per year for patients on treatment.
Monitoring and/or HCC surveillance can be done by a GP or nurse practitioner, with support and advice from and referral to either a tertiary specialist or hepatitis B s100 prescriber when required.
“The demand on specialist liver services is increasing with the complexity of MASLD-related liver disease, along with other aetiologies of advanced liver disease. Chronic HBV can be effectively managed within primary health, with support from specialist liver centres. Find out who your local HBV-expert is and have them on speed-dial – we are always happy to take phone calls or emails about patients with chronic HBV.” – Liver Nurse | Regional Victoria
Quick Links
Decision making in hepatitis B | PDF| ASHM
Detailed Information
B Positive: Clinical assessment of patients with hepatitis B virus infection | Website | ASHM
Australian consensus recommendations for the management of hepatitis B infection | PDF | Gastroenterological Society of Australia
Does everyone living with chronic hepatitis B require medication?
No, medication is only required for some people living with hepatitis B.
- Treatment is advised if there is cirrhosis or ongoing liver damage. Evidence of ongoing liver injury is part of assessing the phase of infection.
- It is important to provide regular care and monitoring as recommended because the phases can change over time.
- Currently, there is no evidence of benefit to support treating everyone who lives with hepatitis B.
When treatment is indicated, the primary goals are to control viral replication and improve both quality of life and survival by:
- normalising alanine aminotransferase (ALT) levels (the ALT reference range is < 19 for women and < 30 for men)
- achieving HBeAg seroconversion (HBeAg positive to HBeAg negative and anti-HBe positive)
- achieving sustained suppression of hepatitis B viral replication
- achieving HBsAg loss with or without anti-HBs seroconversion
- reducing risk of progression to cirrhosis and hepatocellular carcinoma by up to 75%.
Quick Links
B Positive: Treatment of hepatitis B infection | Website | ASHM
I am not an s100 community prescriber. Can I write a maintenance script for hepatitis B medication?
In most instances scripts for hepatitis B medications can only be written by an s100 community prescriber or a tertiary specialist/clinician affiliated with a hospital.
However, there is a provision for medical practitioners to prescribe maintenance therapy when it is impractical to get a prescription from the treating affiliated specialist medical practitioner and the specialist has agreed to the prescription.
For more information on HSD prescriber requirements go to Prescriber eligibility for highly specialised drugs on the Services Australia website.
Quick Links
Community access arrangements | Website | Services Australia
How long does my patient require medication for?
In most cases, once medication for hepatitis B starts it must be continued for life.
There are some cases in which medication can be discontinued. For example, if a non-cirrhotic patient loses HBsAg irrespective of the development of anti-HBs.
In non-cirrhotic HBeAg-positive patients, who have seroconverted to Anti-HBe positive and have had a HBV DNA VL < 20 IU/mL over a sustained period (e.g. at least two years), stopping therapy can be considered.
These are uncommon circumstances and should be managed by or in collaboration with a tertiary specialist.
People who start medication while pregnant are often recommended to discontinue after birth. For more information on hepatitis B and pregnancy see here.
Quick Links
B Positive: Treatment of chronic hepatitis B virus infection | Website | ASHM
When should I refer my patient?
If treatment needs to be initiated, you need to refer your patient to either an accredited GP hepatitis B s100 prescriber in a community setting or a tertiary specialist (such as a liver clinic).
People with cirrhosis and hepatitis B should be referred to a tertiary centre or you should seek advice on management.
Certain situations require referral to a tertiary centre or further advice if geography or wait lists mean referral is not appropriate.
For information on assessing whether or not a person requires medication see the hepatitis B decision making tool.
Medications for hepatitis B on the PBS include entecavir and tenofovir. These can only be initiated and prescribed by an accredited hepatitis B community s100 prescriber or a tertiary specialist.
There is a provision for GPs to prescribe maintenance therapy when it is impractical to get a prescription from the treating affiliated specialist medical practitioner and the specialist has agreed to the prescription. For more information see here.
For information on hepatitis B and pregnancy see here.
Co-infection with HIV, HCV or HDV. For information on co-infection see here.
For guidance on where to refer your patient see here.
Local information regarding referral can be found on HealthPathways. For further information and links to location-specific HealthPathways in Victoria see here.
Quick Links
Hepatitis B referral and clinical support resources | Website & various resources | ASHM
Detailed Information
For further training on hepatitis B care options and referrals, complete the Clinical Extensions of Hepatitis B: Care options, monitoring, treatment and referrals module | Online learning module | ASHM
Where should I refer to?
“Whenever I have told a patient that I can manage their hepatitis B in general practice, they have always been really keen to take this up. If they can come and see me, instead of going through the public hospital system, it saves them time and enhances their continuity of care and whole person care.” – Hepatitis B s100 Community Prescribing GP | Melbourne
Whether a referral to a tertiary specialist or an s100 GP is most appropriate depends on your patient’s geographic location, clinical and social situation and other requirements.
When there is an option for primary care referral, patient choice should be taken into account.
Use the Hepatitis B referral options tool to determine the best referral options for your patient. This tool will help you decide whether a primary care referral to an s100 prescriber is appropriate or if a referral to a tertiary specialist is required.
See information on how to complete the referral here.
Quick Links
Hepatitis B referral options tool | Interactive tool | ASHM
Detailed Information
Hepatitis B referral and clinical support resources | Website & various resources | ASHM
What do I need to do to complete the referral (s100 or tertiary specialist)
Referral to an s100 community prescriber
Find a hepatitis B s100 community prescriber here.
Use this referral letter template to initiate the referral.
This roles and responsibilities template and ongoing communication template can also be used to communicate with s100 prescribers.
We suggest making contact with the clinic and/or s100 prescriber before sending the referral.
Referral to a tertiary specialist
In Victoria referral pathways to tertiary specialist differ depending on region. HealthPathways provides localised information. See below for a link to your relevant HealthPathways.
“The things that have worked really well over time … are the nurse-led clinics that [the VH outreach nurses] offer … they’re brilliant … they know the patients … they are an amazing resource and support” – Dr Jacqui Richmond | Viral Hepatitis Nurse Consultant | Barwon Public Health Unit and Burnet Institute
Quick Links
Hepatitis B s100 community prescriber map | Website | ASHM
Detailed Information
Hepatitis B referral and clinical support resources | Website & various resources | ASHM
What lifestyle information can I provide to my patient?
It is important to support your patient with information about lifestyle modifications that can improve liver health:
- Provide advice about safe consumption of alcohol.
- Counsel people with cirrhosis not to drink alcohol.
- Provide support regarding smoking cessation (where relevant) as this is an independent risk factor for liver cancer.
- Provide information on healthy eating and limiting processed food.
- Discuss the importance of regular exercise for good health.
It is important to encourage patients to discuss any complementary or traditional Chinese medicines they may be taking or planning to take as many of these can have an adverse effect on liver health and/or interact with other medications.
Quick Links
Foundation for Alcohol Research and Education | Website
Quit (including Quitline) | Website
Detailed Information
Guide for preventative activities in general practice (Red Book) | Website & PDF | RACGP
How do I support my patients with information about care options and the importance of ongoing care
“My hepatologist told me to see her again when I turn 50. I am 35 now. I almost forgot I was a hep B carrier until wanting to pursue studies in nursing. When I researched online it says to monitor the virus every 6-12 months. I’m confused why my hepatologist didn’t mention this but only to see her again when I’m 50. Does it mean nothing can happen to me in between and I’m ok before then?” – Community member with lived experience of hepatitis B
See below for a list of relevant community resources
Further Information
Who can give me care for hepatitis B? (multiple languages available) | PDF | Hepatitis Australia
Treatment for hepatitis B & Check-ups for hepatitis B (multiple languages available) | PDF | St Vincent’s Hospital Melbourne
The Hep B Story App | Web-based app | Menzies School of Health Research
The Hepatitis B Story (multiple languages available) | Website & PDF | St Vincent’s Hospital Melbourne
