Around 254 million people live with chronic hepatitis B, and most of them do not know it. This guide explains what your test results mean, who needs treatment, how to protect your family, and how to live a long, healthy life with the virus.
Imagine you are told at a job medical that your “HBsAg is positive”. Nobody explains what that means. You go home frightened, wondering whether you have infected your partner, whether you can have children, and whether you will die young. One clear conversation could answer most of those questions.
What is hepatitis B?
Hepatitis B is a liver infection caused by the hepatitis B virus (HBV). It can cause a short-term (acute) illness or a long-term (chronic) infection. Chronic hepatitis B can quietly damage the liver over many years, leading to scarring (cirrhosis), liver failure and liver cancer.,WHO estimates that 254 million people were living with chronic hepatitis B in 2022, with about 1.2 million new infections and 1.1 million deaths each year, mainly from cirrhosis and liver cancer. The highest burden is in the Western Pacific and African regions. Yet only a small fraction of people with chronic infection have been diagnosed, and fewer still are treated.
How hepatitis B spreads
- From mother to baby at birth, the most common route worldwide
- Contact with infected blood, including through unsterile needles, razors, tattoo or piercing equipment, and medical procedures
- Unprotected sex with an infected partner
- Sharing toothbrushes or razors
- Close household contact, particularly among young children with cuts or sores
- It does not spread through hugging, kissing on the cheek, sharing food or utensils, coughing or breastfeeding
Why age matters
The younger a person is when infected, the more likely the infection is to become chronic. About 90 percent of babies infected at birth develop chronic hepatitis B, compared with 20 to 50 percent of children infected between ages one and five, and fewer than 5 percent of healthy adults. This is why preventing mother-to-child transmission and vaccinating babies at birth are so important.
Symptoms of acute hepatitis B
Many people, especially children, have no symptoms when first infected. When symptoms occur, usually 1 to 4 months after exposure, they can include tiredness, loss of appetite, nausea, vomiting, pain under the right ribs, dark urine, pale stools, joint pain and yellowing of the skin and eyes (jaundice).,Most adults clear the virus within six months. Rarely, acute hepatitis B causes severe liver failure, which needs emergency care. Signs include confusion, drowsiness, bleeding or bruising easily, and a swollen tummy.
Chronic hepatitis B
If the virus is still present after six months, the infection is chronic. Many people feel completely well for decades. The virus and the immune system interact in phases, and liver damage may happen silently. Regular monitoring is essential because liver cancer can develop even without cirrhosis, particularly in people of African or Asian origin, older adults and those with a family history of liver cancer.
Who should be tested?
- Everyone born in or with parents from a country where hepatitis B is common
- All pregnant women, in every pregnancy
- People with HIV or hepatitis C
- Household and sexual contacts of anyone with hepatitis B
- People who inject drugs, and men who have sex with men
- People on dialysis or about to start immunosuppressive treatment or chemotherapy
- Healthcare workers
- Anyone with abnormal liver tests
- The US CDC now recommends that all adults be tested at least once
Understanding your test results
- HBsAg (hepatitis B surface antigen) positive: the virus is present. If positive for more than six months, the infection is chronic
- Anti-HBs (surface antibody) positive: you are immune, either from vaccination or past infection that cleared
- Anti-HBc (core antibody) positive: you have been infected at some point, now or in the past
- IgM anti-HBc positive: a recent (acute) infection
- HBeAg positive: the virus is usually multiplying actively and is more infectious
- Anti-HBe positive: often a less active phase, though the virus can still cause damage
- HBV DNA (viral load): how much virus is in the blood
- ALT: a liver enzyme that rises when the liver is inflamed
Common result combinations
HBsAg negative, anti-HBs positive, anti-HBc negative: you are immune through vaccination. HBsAg negative, anti-HBs positive, anti-HBc positive: you had hepatitis B in the past and cleared it, and you are immune. HBsAg negative, anti-HBs negative, anti-HBc negative: you have never been infected and are not immune, so you should be vaccinated.,HBsAg positive with anti-HBc positive: you have hepatitis B, and further tests will show whether it is acute or chronic and how active it is. Always ask your nurse or healthcare provider to go through your results with you, because some combinations need specialist interpretation.
Further tests if you have chronic hepatitis B
- Liver function tests and a full blood count
- HBV DNA viral load and HBeAg status
- A liver ultrasound
- A non-invasive scarring test such as transient elastography (FibroScan) or a blood score such as APRI or FIB-4
- Tests for hepatitis D (delta), hepatitis C and HIV
- Alpha-fetoprotein (AFP) in some settings, to help screen for liver cancer
Who needs treatment?
Not everyone with chronic hepatitis B needs medicine straight away. Treatment decisions depend on viral load, ALT, the degree of liver scarring, age, family history of liver cancer and other conditions. In 2024, WHO simplified and expanded its guidelines, recommending treatment for a much larger group of people, including all adults with significant fibrosis or cirrhosis, and those with detectable HBV DNA and raised ALT, among other criteria. WHO estimates that around half of people with chronic hepatitis B could benefit from treatment under these guidelines.,People not yet on treatment still need regular monitoring, usually every 6 to 12 months, because the infection can become active at any time.
The main treatments are tenofovir (tenofovir disoproxil fumarate or tenofovir alafenamide) and entecavir. They are taken as one tablet a day, are very effective at suppressing the virus, have few side effects and rarely lead to resistance. Tenofovir is available as an affordable generic in many countries.,These medicines control the virus and greatly reduce the risk of cirrhosis and liver cancer, but they rarely cure the infection, so most people need to take them long term. Never stop treatment suddenly without advice, because the virus can flare and cause serious liver damage. Kidney function and bone health are monitored during treatment.
Is there a cure?
A “functional cure”, meaning loss of HBsAg, happens in only a small number of people on current treatment. Many new medicines, including siRNA drugs, antisense molecules such as bepirovirsen, and therapeutic vaccines, are in clinical trials with the aim of achieving a cure. Ask your specialist whether a trial might suit you.
Liver cancer screening
People with chronic hepatitis B at higher risk of liver cancer, including those with cirrhosis, a family history of liver cancer, and men over 40 or women over 50 of Asian origin and adults of African origin from a younger age, are usually advised to have a liver ultrasound every six months, sometimes with an AFP blood test.,Liver cancer found early can often be treated successfully with surgery, ablation or transplant. Found late, options are limited. Do not miss surveillance appointments, even when you feel well.
Hepatitis D
Hepatitis D (delta) only infects people who already have hepatitis B, and together they cause the most severe form of viral hepatitis. Everyone with hepatitis B should be tested for hepatitis D at least once. Bulevirtide is a treatment approved in Europe for chronic hepatitis D. Hepatitis B vaccination also prevents hepatitis D.
Hepatitis B and pregnancy
All pregnant women should be tested. If you have hepatitis B, your baby can be protected. Babies should receive the hepatitis B vaccine within 24 hours of birth, ideally within 12 hours, and those born to mothers with hepatitis B should also receive hepatitis B immunoglobulin (HBIG) where available. They then complete the vaccine series and are tested at around 9 to 12 months to confirm protection.,Women with a high viral load are offered tenofovir from around 24 to 28 weeks of pregnancy to reduce the chance of passing the virus to their baby. WHO now recommends tenofovir prophylaxis more widely, including in settings where viral load testing is not available. A caesarean section is not needed just because of hepatitis B, and breastfeeding is safe.
The hepatitis B vaccine
The hepatitis B vaccine is safe and around 95 percent effective. It has been part of routine childhood immunisation in almost every country for many years. A birth dose followed by two or three more doses gives long-lasting protection.,Adults who are not immune should be vaccinated, especially healthcare workers, partners and household members of people with hepatitis B, people with diabetes, kidney or liver disease, travellers to high-prevalence areas, and anyone at higher risk. Healthcare workers are usually checked for antibodies after vaccination to make sure they responded.
Protecting the people around you
- Make sure your partner and household members are tested and vaccinated
- Use condoms until your partner is confirmed immune
- Do not share razors, toothbrushes, nail clippers or needles
- Cover cuts and wounds, and clean blood spills with bleach solution
- Tell healthcare and dental staff so they can follow standard precautions (they should do so for everyone anyway)
- Do not donate blood, organs or semen
Looking after your liver
- Avoid alcohol or keep it to an absolute minimum
- Maintain a healthy weight to prevent fatty liver disease
- Check with a pharmacist before taking any new medicine, herbal remedy or supplement
- Avoid high-dose paracetamol over long periods and unregulated herbal mixtures
- Get vaccinated against hepatitis A if not immune
- Do not smoke
- Eat a balanced diet with fruit, vegetables and whole grains
Stigma and your rights
People with hepatitis B have faced discrimination in employment, education and immigration. In many countries, refusing to employ someone or excluding a child from school because of hepatitis B is unlawful, as the virus is not spread through normal workplace or school contact. Healthcare workers with hepatitis B can usually continue working, sometimes with restrictions on certain procedures depending on viral load and national rules. Patient organisations such as the Hepatitis B Foundation and the World Hepatitis Alliance offer support and advocacy.
Relationships, marriage and having children
A hepatitis B diagnosis does not stop you from having a relationship, getting married or having children. Your partner should be tested; if they are not immune, they can be vaccinated, and once protected they are at very low risk. Using condoms until immunity is confirmed protects them in the meantime.,With testing in pregnancy, antiviral medicine when needed, and the birth-dose vaccine and immunoglobulin for the baby, the chance of passing hepatitis B to your child is very low.
Hepatitis B and other medical treatments
Hepatitis B can flare dangerously if your immune system is suppressed. Before starting chemotherapy, rituximab, steroids at high doses, biologic treatments for arthritis or bowel disease, or certain hepatitis C treatments, you should be tested for hepatitis B. People who are HBsAg positive, and some who have had past infection, may need antiviral medicine to prevent a flare during treatment.
Hepatitis B and HIV
Hepatitis B is common in people living with HIV and progresses faster when both are present. HIV treatment regimens that include tenofovir with lamivudine or emtricitabine treat both infections. Stopping these medicines can cause a hepatitis B flare, so any change should be planned with your HIV team.
Living well: a summary
- Know your results and keep a copy
- Attend monitoring every 6 to 12 months even if you feel well
- Take antiviral medicine every day if prescribed
- Keep liver cancer screening appointments
- Protect your liver from alcohol and unnecessary medicines
- Make sure the people close to you are vaccinated
- Seek support if you feel anxious or isolated
The phases of chronic hepatitis B
Specialists describe chronic hepatitis B in phases, based on HBeAg, viral load and liver inflammation. In the HBeAg-positive chronic infection phase (previously called “immune tolerant”), the viral load is very high but ALT is normal and liver damage is usually minimal. This phase is common in young people infected at birth.
In HBeAg-positive chronic hepatitis, the immune system starts attacking infected liver cells, ALT rises and liver damage can occur. Many people then move to HBeAg-negative chronic infection (previously “inactive carrier”), with low viral load and normal ALT. Some later develop HBeAg-negative chronic hepatitis, with rising viral load and inflammation. People can move between phases, which is why ongoing monitoring matters.
What a FibroScan shows
Transient elastography, often called a FibroScan, is a quick, painless ultrasound-based test that measures liver stiffness. The result, given in kilopascals (kPa), helps estimate how much scarring is present. Lower numbers suggest little or no scarring; higher numbers suggest significant fibrosis or cirrhosis. It avoids the need for a liver biopsy in most people. Eating within a few hours before the test can affect the reading, so follow the fasting instructions.
Cirrhosis: what to know
Cirrhosis means advanced scarring of the liver. Many people with compensated cirrhosis feel well. Treatment with antivirals can slow or even partly reverse scarring. People with cirrhosis need six-monthly liver cancer screening, checks for enlarged veins in the gullet (varices), and vaccination against hepatitis A, flu and pneumococcus.
Signs that cirrhosis is getting worse (decompensating) include a swelling tummy (ascites), yellow skin or eyes, vomiting blood or passing black stools, confusion or drowsiness, and easy bruising. These need urgent medical care.
Hepatitis B in healthcare workers
Healthcare workers are at risk of hepatitis B through needlestick injuries and contact with blood. Vaccination and checking for antibodies afterwards are essential. After a needlestick or splash injury, wash the area, report it immediately and follow your workplace’s exposure policy. Post-exposure vaccination and immunoglobulin, given quickly, are highly effective at preventing infection in people who are not immune.
Global goals
WHO aims to eliminate viral hepatitis as a public health threat by 2030, with targets to reduce new infections by 90 percent and deaths by 65 percent. Key steps include universal birth-dose vaccination, testing everyone at risk, and making tenofovir available to all who need it. World Hepatitis Day is marked on 28 July each year, a good reminder to get tested.
Telling family and friends
Who you tell about your hepatitis B is your choice. Your sexual partner and household members need to know so they can be tested and vaccinated. Many people find it helpful to tell a trusted friend or relative for support. You do not have to tell your employer unless you work in certain healthcare roles where national rules apply.
If you find it hard to start the conversation, a nurse can help you plan what to say, or offer to test family members together. Explaining that the virus is not spread through everyday contact, and that a safe, effective vaccine exists, usually reassures people.
Questions to ask your healthcare team
- What phase of hepatitis B do I have?
- What is my viral load and ALT, and how often will they be checked?
- Do I have any liver scarring?
- Do I need treatment now, and if not, what would change that?
- Do I need liver cancer screening, and how often?
- Have I been tested for hepatitis D, hepatitis C and HIV?
- Are my family and partner tested and vaccinated?
- Are there any clinical trials I could join?
Emotional health
A diagnosis of a long-term infection can bring anxiety, shame or fear, especially where stigma is common. These feelings are normal. Talking to a nurse, counsellor or peer support group can help. Remember that with monitoring and treatment, most people with hepatitis B live a normal lifespan.
Travel and hepatitis B
Having hepatitis B does not usually stop you from travelling. Take enough medicine for the whole trip plus extra in your hand luggage, keep a letter or summary from your clinic, and check that your travel insurance covers your condition. If you are not immune and are travelling to a country where hepatitis B is common, get vaccinated before you go, and avoid tattoos, piercings or medical procedures with equipment that may not be sterile.
Frequently asked questions
Can hepatitis B go away on its own?
Most adults with acute hepatitis B clear the virus within six months. Chronic infection rarely clears on its own, though a small number of people lose HBsAg each year.
Can I breastfeed if I have hepatitis B?
Yes. Breastfeeding is safe once your baby has had the birth-dose vaccine and, where recommended, immunoglobulin. Stop temporarily if your nipples are cracked and bleeding.
Is hepatitis B a sexually transmitted infection?
It can be spread through sex, but it is also spread through blood and from mother to baby. Many people were infected at birth or in early childhood.
Do I need treatment if my liver tests are normal?
Not always. Decisions depend on viral load, liver scarring and other factors. Regular monitoring will show if treatment becomes necessary.
How long does the vaccine protect for?
For most people who respond, protection is long-lasting and booster doses are not routinely recommended, except for some high-risk groups such as people on dialysis.
Can I get hepatitis B from a blood transfusion?
In countries with screened blood supplies, the risk is now extremely low. Blood donations are tested for hepatitis B.
But I feel completely fine. Why do I need all these tests?
Because hepatitis B is called a silent infection for a reason. Liver damage and even liver cancer can develop without any symptoms. Regular checks, and treatment when needed, are how people with hepatitis B live long, normal lives.
Your next step: If you have never had a hepatitis B test, ask for one at your next clinic visit, and check that your family are vaccinated.
Related: Hepatitis B symptoms and vaccine · Birth-dose vaccination · Hepatitis C cure · Premarital health checks
Sources: World Health Organization (Guidelines for the prevention, diagnosis, care and treatment of chronic hepatitis B, 2024; Global Hepatitis Report 2024), US Centers for Disease Control and Prevention, European Association for the Study of the Liver, Hepatitis B Foundation.
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