AASLD EXPO: Diagnosis and management of hepatitis delta virus (HDV) infection

BACKGROUND: HDV infection represents a rare co-infection or super-infection among persons with HBV infection and is associated with significant morbidity and mortality due to an increased risk of liver events such as hepatic decompensation and HCC. METHODS: The Expert Practice Opinion (EXPO) document was developed by subject matter experts and commissioned by the AASLD Practice Guidelines Committee to provide timely guidance on the screening, diagnosis, and management of HDV infection. Writing group members performed a targeted literature review and generated EXPO statements which were agreed upon by group consensus. RESULTS: All individuals who are HBsAg positive should be tested at least once for HDV infection with HDV antibody. HDV antibody positive individuals should undergo HDV RNA testing to confirm active infection. All individuals with chronic HDV should undergo further evaluation including non-invasive fibrosis testing, preferably with elastography. Lab monitoring and HCC surveillance imaging is suggested every 6 months. All adults with chronic HDV viremia and compensated liver disease should be considered candidates for HDV therapy with bulevirtide for chronic virologic suppression, or alternatively bulevirtide plus peg-IFN alfa-2a for individuals without contraindications to peg-IFN and who desire a finite duration regimen. Considerations for patient selection, treatment regimen, monitoring, assessment of response, and care of patients in special populations are summarized in the document. CONCLUSIONS: All HBsAg positive individuals should be screened for HDV. All adults with chronic HDV and compensated liver disease are candidates for HDV therapy. Recent advances in HDV treatment offer hope for meaningful improvement in clinical outcomes.