Reasons to consider early treatment in chronic hepatitis B patients

In spite of a decrease in the prevalence and incidence seen in recent years, chronic hepatitis B (CHB) still remains a major healthcare challenge, prevalent mostly in developing but also in developed regions. CHB is associated with significant morbidity and mortality, secondary to the complications of disease progression; cirrhosis and hepatocellular carcinoma (HCC). Historically, antiviral treatment has been restricted to patients with active hepatitis, established liver disease, fibrosis or cirrhosis and/or the risk of HCC development. As a result, patients with hepatitis B ‘e’ antigen (HBeAg) -positive chronic infection, formerly referred to as the ‘immune tolerant’ disease phase, have been excluded from treatment, since immune tolerant CHB had been considered ‘benign’ with no ostensible progressive liver disease. However, recent advances in ‘decoding’ the immunopathogenesis of CHB challenged the accuracy of this classical perception: it is now well-recognised that HBeAg-positive chronic infection is not characterized by immunological tolerance and that events associated with tumourigenesis are already present during this early disease phase. These findings have led to a paradigm shift: in 2017, the European Association for the Study of the Liver (EASL) recommended a change in the nomenclature and clinical categorisation of CHB and proposed lowering the threshold for antiviral treatment to include patients with HBeAg-positive chronic infection. It is anticipated that this could delay or even prevent disease progression and the development of HCC, alongside the potential to achieve functional cure (hepatitis B ‘surface’ antigen loss with or without development of hepatitis B ‘surface’ antibody). The current article reviews relevant literature and discusses the reasons for considering early treatment in CHB.