Hepatology · WHO

Hepatitis B — chronic infection

WHO

Source:WHO Guidelines on Prevention, Diagnosis, Care and Treatment for People With Chronic Hepatitis B Infection (2024 update)

Verified Apr 2026

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Red Flags

Acute liver failure on chronic hepatitis B (jaundice, INR ≥1.5, encephalopathy) — emergency transplant centre referral; immediate antiviral^[1]
Hepatocellular carcinoma identified on surveillance — multidisciplinary hepatobiliary meeting; multiphasic CT or MRI^[1]
Reactivation during immunosuppression (rising HBV-DNA or ALT) — start nucleos(t)ide analogue immediately, do not wait for hepatitis^[1]
HBeAg-positive or HBV-DNA >200,000 IU/mL in pregnancy — start tenofovir at week 24–28 to prevent vertical transmission^[1]

First-line treatment

Interventions

Simplified WHO 2024 treatment criteria^[1]
Treat all adults with chronic HBV who have any of: significant fibrosis (APRI >0.5 or transient elastography ≥7 kPa) OR persistent ALT >ULN OR HBV-DNA >2000 IU/mL OR cirrhosis OR co-infection HIV/HCV/HDV OR family history of HCC OR extrahepatic manifestations OR pregnancy with HBV-DNA >200,000 IU/mL
Universal infant immunisation^[1]
Hepatitis B birth-dose vaccine within 24 hours; complete schedule per UIP; closes the principal route of vertical transmission in high-burden settings
Vertical transmission prevention^[1]
HBeAg-positive or HBV-DNA >200,000 IU/mL: start tenofovir at week 24–28 of pregnancy; HBIG + birth-dose vaccine to neonate within 12 h; complete vaccination series; check infant HBsAg/anti-HBs at 9–12 months
HCC surveillance^[1]
Ultrasound + AFP every 6 months for cirrhosis at any HBV-DNA level; non-cirrhotic Asian men >40 or women >50; family history of HCC; persistent ALT elevation
Antiviral prophylaxis for immunosuppression^[1]
All HBsAg-positive patients receiving anti-CD20 (rituximab), corticosteroids ≥10 mg prednisolone equivalent for ≥4 weeks, BMT, or solid organ transplant — start TDF/TAF/entecavir before therapy and continue ≥12 months after immunosuppression ends

First-line drug therapy

Drug	Class	Adult	Paediatric	Notes
Tenofovir disoproxil fumarate (TDF)^[1]	Nucleotide analogue reverse transcriptase inhibitor	300 mg PO once daily	≥12 years and ≥35 kg: 300 mg daily	WHO-preferred first-line including pregnancy (most safety data); high genetic barrier to resistance; monitor renal tubular and bone effects with prolonged use; widely available
Tenofovir alafenamide (TAF)^[1]	Nucleotide analogue reverse transcriptase inhibitor	25 mg PO once daily	≥12 years and ≥35 kg: 25 mg PO once daily	Alternative; preferred over TDF in CKD G3+, osteoporosis, or pre-/post-transplant; less widely available than TDF in many programmes
Entecavir^[1]	Nucleoside analogue reverse transcriptase inhibitor	0.5 mg PO once daily on empty stomach (1 mg if lamivudine-resistant or decompensated cirrhosis)	≥2 years weight-based per package insert	First-line alternative; high genetic barrier; renal dose adjustment; not preferred in pregnancy due to limited data

Tenofovir disoproxil fumarate (TDF)^[1]

Nucleotide analogue reverse transcriptase inhibitor

Adult: 300 mg PO once daily
Paediatric: ≥12 years and ≥35 kg: 300 mg daily

WHO-preferred first-line including pregnancy (most safety data); high genetic barrier to resistance; monitor renal tubular and bone effects with prolonged use; widely available

Tenofovir alafenamide (TAF)^[1]

Nucleotide analogue reverse transcriptase inhibitor

Adult: 25 mg PO once daily
Paediatric: ≥12 years and ≥35 kg: 25 mg PO once daily

Alternative; preferred over TDF in CKD G3+, osteoporosis, or pre-/post-transplant; less widely available than TDF in many programmes

Entecavir^[1]

Nucleoside analogue reverse transcriptase inhibitor

Adult: 0.5 mg PO once daily on empty stomach (1 mg if lamivudine-resistant or decompensated cirrhosis)
Paediatric: ≥2 years weight-based per package insert

First-line alternative; high genetic barrier; renal dose adjustment; not preferred in pregnancy due to limited data

Safety-net

Do not stop antiviral therapy without specialist supervision — discontinuation can trigger flares including life-threatening hepatitis^[1]
Family members and sexual partners should be tested and vaccinated if not immune; avoid sharing razors, toothbrushes, needles^[1]
Yellowing of eyes/skin, abdominal swelling, confusion, or vomiting blood — same-day medical review (cirrhosis decompensation)^[1]

Referral criteria

All chronic HBsAg-positive patientsHepatology or primary-care HBV programme for staging and treatment decision under simplified WHO criteria^[1]
Cirrhosis, decompensation, HCC, or transplant evaluationHepatology and transplant centre^[1]
HDV co-infection (anti-HDV positive with HDV-RNA detectable)Specialist hepatology — bulevirtide or interferon-based therapy^[1]
Pregnancy with chronic HBV and high viraemiaJoint hepatology and obstetric clinic by week 24^[1]

Clinical summary

Diagnosis, simplified treatment criteria, and primary care–led management of chronic hepatitis B; HBV elimination targets in high-prevalence settings.

References

1.WHO Guidelines on Prevention, Diagnosis, Care and Treatment for People With Chronic Hepatitis B Infection (2024 update) (2024)

Drug

Class

Adult

Paediatric

Notes

Tenofovir disoproxil fumarate (TDF)^[1]

Nucleotide analogue reverse transcriptase inhibitor

300 mg PO once daily

≥12 years and ≥35 kg: 300 mg daily

WHO-preferred first-line including pregnancy (most safety data); high genetic barrier to resistance; monitor renal tubular and bone effects with prolonged use; widely available

Tenofovir alafenamide (TAF)^[1]

Nucleotide analogue reverse transcriptase inhibitor

25 mg PO once daily

≥12 years and ≥35 kg: 25 mg PO once daily

Alternative; preferred over TDF in CKD G3+, osteoporosis, or pre-/post-transplant; less widely available than TDF in many programmes

Entecavir^[1]

Nucleoside analogue reverse transcriptase inhibitor

0.5 mg PO once daily on empty stomach (1 mg if lamivudine-resistant or decompensated cirrhosis)

≥2 years weight-based per package insert

First-line alternative; high genetic barrier; renal dose adjustment; not preferred in pregnancy due to limited data