People living with HBsAG+ should begin treatment with antivirals based on the following.

Cirrhosis

• With low level virema (less than 2,000 IU/ml)
• Regardless of eAg and ALT

Decompensated cirrhosis

• Regardless of HBV DNA, eAg, and ALT

Pregnant

• If HBV DNA is greater than 2,000 IU/ml
• Regardless of eAg and ALT

HBeAg negative

• Immunoactive equals ALT greater than 2x ULN or significant histologic disease
• HBV DNA is greater than 2,000

HBeAg positive

• Immunoactive equals ALT greater than 2x ULN or significant histologic disease
• HBV DNA is greater than 20,000

Only treat normal ALT if

• Adult over 40 years old with an HBV DNA greater than 1 million IU/mL
• Cirrhosis

Other factors to consider

• Family history of hepatocellular carcinoma
• Family history of cirrhosis
• Older age (over 40 years old)
• Extrahepatic manifestations of HBV

Prophylaxis against HBV reactivation

• During treatment with immunosuppressive medication
• During treatment with HCV direct-acting antiviral therapy