Updated October 2025

Evidence Update • Viral Hepatitis

Hepatitis B and C Management in 2025: Guideline-Driven, Elimination-Focused Care

In 2025, chronic hepatitis B (CHB) management is shifting toward broader treatment eligibility to reduce morbidity and transmission, while hepatitis C (HCV) management emphasizes simplified, universal DAA treatment with short, highly effective pangenotypic regimens. Policies align with elimination goals, prioritizing test-and-treat models, decentralized delivery, and attention to high-risk populations.

Clinical question

What are the 2025 best practices for screening, treatment initiation, antiviral selection, monitoring, and public health priorities for hepatitis B and C?

Hepatitis BHepatitis CDAAsTenofovirEntecavirEpidemiologyGuidelinesElimination

Key points

Simplified HCV regimens for all adults

WHO-backed pangenotypic options for 8–12 weeks with SVR ≥94–95% enable scale-up in primary care and community settings ^[8], ^[1], ^[2].

CHB thresholds are evolving

2025 expert discussions and guideline updates support broader CHB treatment, including persons in the ‘indeterminate/grey zone’ and special populations to curb progression and transmission ^[6], ^[9], ^[10], ^[11], ^[7].

Prevention and elimination alignment

CDC national progress reports target ≥20% reduction in incident HCV and stress surveillance, linkage-to-care, and harm reduction integration ^[3], ^[4], ^[5].

Beyond the liver: extrahepatic gains

Successful DAA therapy is associated with reduced extrahepatic manifestations risk, reinforcing treatment for all eligible HCV patients ^[12].

Evidence highlights

≥94–95% SVR12 in 8–12 weeks ^[1], ^[2]

HCV cure with DAAs

≥20% reduction in new HCV infections by 2025 ^[3], ^[4], ^[5]

Strategic goal

Movement to expand therapy beyond classic ALT/DNA thresholds ^[6], ^[7]

HBV treatment trend

Foundational Actions

Screening and Initial Evaluation (HBV and HCV)

Prioritize universal, once-in-a-lifetime testing in adults with opt-out reflex pathways; repeat based on risk. Integrate vaccination and harm reduction.

HBV: Who to test and what to obtain

Use HBsAg, anti-HBs, and anti-HBc (total or IgG) with reflex HBeAg, anti-HBe, and quantitative HBV DNA for those HBsAg positive. Baseline ALT/AST, bilirubin, albumin, INR, platelet count, fibrosis staging (transient elastography preferred), and HDV screening in HBsAg-positive individuals. 2025 updates emphasize broader screening and routine HDV assessment in HBsAg-positive patients ^[9], ^[10], ^[11].

HCV: Who to test and what to obtain

Adopt universal, one-time anti-HCV testing with reflex HCV RNA; repeat testing for ongoing risk (e.g., injection drug use, high-risk exposures). Baseline labs include ALT/AST, bilirubin, platelet count, eGFR, HIV, HBV serologies (vaccinate non-immune), pregnancy testing when relevant, and noninvasive fibrosis staging. Streamlined pathways support same-day treatment starts where feasible ^[8], ^[13], ^[4].

Vaccination and prevention

Offer HBV vaccination to all non-immune, including those with HCV. Counsel on harm reduction, sterile injection supplies, and naloxone distribution; integrate opioid use disorder treatment. These measures align with national reduction targets for incident HCV ^[3], ^[4], ^[5].

Chronic Hepatitis B

When to Start, What to Use, and How to Monitor (2025)

Guidelines increasingly support earlier treatment to reduce progression and transmission while tailoring to fibrosis and special populations.

Initiation signals

Classic criteria: elevated ALT with high HBV DNA or significant fibrosis/cirrhosis.

2025 perspective: consider treatment in the indeterminate/grey zone, particularly with age >30–35, family history of HCC, or fluctuating ALT/DNA ^[6], ^[9], ^[11], ^[7].

Treat all with cirrhosis and detectable HBV DNA regardless of ALT; treat if on immunosuppression or chemotherapy.

Screen and treat HBV in pregnancy if HBV DNA >200,000 IU/mL to prevent MTCT; use tenofovir disoproxil fumarate (TDF) in late pregnancy per evolving practice patterns ^[9], ^[11].

First-line antivirals

Tenofovir (TDF or TAF) and entecavir are preferred for potency and high barrier to resistance.

TAF is favored when renal dysfunction or bone disease risk exists; entecavir requires consideration of prior lamivudine resistance.

Pegylated interferon has niche use; most adults use nucleos(t)ide analogues ^[9], ^[11].

Targets and outcomes

Primary: sustained HBV DNA suppression to undetectable; ALT normalization; fibrosis stabilization or regression.

HBeAg-positive: aim for HBeAg seroconversion with confirmed DNA suppression.

HBsAg loss remains uncommon; therapy is generally long-term or indefinite in most non-cirrhotic adults.

Monitoring

Every 3–6 months: ALT/AST, HBV DNA; HBeAg/anti-HBe as indicated; adherence assessment.

Renal function and phosphate with TDF; bone health in at-risk patients.

HCC surveillance with ultrasound ± AFP every 6 months in at-risk groups (all with cirrhosis; non-cirrhotic with high-risk demographics/family history).

Special populations

Pregnancy: antiviral prophylaxis if high DNA; neonatal HBV vaccine + HBIG at birth.

Coinfections (HIV/HDV/HCV): coordinate regimens; screen all HBsAg-positive for HDV per 2025 updates ^[9], ^[10], ^[11].

Immunosuppression: prophylaxis for HBsAg-positive and selected anti-HBc–positive individuals to prevent reactivation.

Hepatitis C

Simplified Treatment and Delivery in 2025

Short-course pangenotypic DAAs achieve very high cure rates; prioritize test-and-treat models and outreach in high-incidence settings.

Who to treat

Treat all adults and adolescents with chronic HCV unless life expectancy is too short to benefit.

People who use or inject drugs should be offered treatment without delay; outcomes are excellent with supportive services ^[8], ^[13].

Acute HCV: treat upon diagnosis to reduce transmission and accelerate elimination programs ^[8].

First-line DAA regimens

WHO-endorsed options include two to three pangenotypic combinations for 8–12 weeks, delivering SVR ≥94–95% across populations ^[8], ^[1], ^[2].

Choice depends on cirrhosis status, prior therapy, drug–drug interactions, and renal function.

No head-to-head randomized trials show superiority among the leading regimens as of 2025 ^[8].

Pretreatment essentials

Confirm viremia with HCV RNA; stage fibrosis noninvasively to identify cirrhosis.

Review concomitant medications for interactions; check pregnancy status when applicable.

Screen for HBV and vaccinate if non-immune; counsel on reinfection risk and prevention.

Effectiveness and broader benefits

SVR12 ≥94–95% with contemporary DAAs in routine practice ^[1], ^[2].

DAA cure is associated with lower risk of extrahepatic manifestations (e.g., mixed cryoglobulinemia, certain lymphomas) ^[12].

Cirrhotics require continued HCC surveillance post-cure.

Models of care and access

Deliver DAAs in primary care, opioid treatment programs, and syringe services; onsite initiation improves uptake ^[13].