Viral Hepatitis B & C — Super-Pocket Investigation + Treatment Guide (2025)
1 Hepatitis B (HBV)
Investigate
- Screen: HBsAg, anti-HBs, total anti-HBc ± IgM anti-HBc (if acute suspected)
- If HBsAg + : HBeAg, HBV DNA (quantitative), ALT; stage liver (APRI/FIB-4 or elastography) who.int
Start drug when ≥ 1 of these triggers (WHO 2024 simplified):
- Cirrhosis - clinical or APRI > 2 / FIB-4 > 3.25 / LS ≥ 11 kPa who.int
- HBV DNA ≥ 2 000 IU/mL and ALT > ULN (30 U/L men, 19 U/L women) who.int
- LS ≥ 8 kPa plus DNA ≥ 2 000 IU/mL (even with normal ALT) who.int
- High-risk host (HIV/HCV/HDV, strong family HCC, age > 30, impending immunosuppression) and DNA ≥ 2 000 IU/mL who.int
- Pregnancy 28-32 wk with DNA ≥ 200 000 IU/mL or HBeAg + worldhepatitisalliance.org
- Severe acute/fulminant hepatitis (INR ≥ 1.5, encephalopathy) hcvguidelines.org
First-line drug (choose ONE potent NA)
| Drug | Daily dose | Pick when… |
| Tenofovir DF | 300 mg | default |
| Tenofovir AF | 25 mg | renal/BMD issues |
| Entecavir | 0.5 mg (1 mg if 3TC-resistant) | eGFR < 15 mL/min or TDF/TAF unavailable |
No combination tablets needed; monotherapy is standard. hepb.org
Follow-up ALT + HBV DNA q3–6 mo (then q6–12 mo once suppressed); ultrasound ± AFP q6 mo when ≥ F3.
2 Hepatitis C (HCV)
Investigate
- Screen: Anti-HCV antibody.
- If Ab + → Reflex HCV RNA (or core Ag) on the same sample for confirmation. cdn.who.int
- Stage liver: APRI/FIB-4 ± elastography.
Start DAAs when: any detectable HCV RNA (acute or chronic) — treat immediately. hcvguidelines.org
Pan-genotypic regimens (pick ONE)
| Liver status | Regimen | Duration |
| No cirrhosis | Glecaprevir 300 mg / Pibrentasvir 120 mg | 8 wk hcvguidelines.org |
| Sofosbuvir 400 mg / Velpatasvir 100 mg | 12 wk hcvguidelines.org | |
| Compensated cirrhosis (Child-Pugh A) | Same two options | 8 wk (G/P) or 12 wk (SOF/VEL) hcvguidelines.org |
| Decompensated cirrhosis (B/C) | SOF/VEL + Ribavirin | 12 wk (24 wk if RBV-ineligible) hcvguidelines.org |
Follow-up
- Few/no on-treatment labs (unless cirrhotic or ribavirin).
- SVR12 (RNA – 12 wk post-Rx) = cure.
- Ultrasound ± AFP q6 mo lifelong if baseline F3/F4.
Vaccinate against HAV & HBV if non-immune.
Lightning Mnemonics
- HBV: “C or 2K + ALT → Tenofovir or Entecavir.”
- HCV: “RNA = Rx; 8/12 weeks → cure.”