He had no symptoms of Hepatitis B, yet it was too late: Why Indians need early therapy

Why most patients are left untreated

For decades, hepatitis B treatment has been offered only to those who have a high viral load, raised liver enzymes, or scarring or stiffening of the liver. Unfortunately, seven in 10 infected patients do not get the treatment based on these guidelines.

These restrictions may be valid when the treatment is unaffordable or drug resistance is common. When it comes to India, as the pharmacy of the world, the country supplies generic antivirals globally. Potent low cost (less than Rs 1,000/month), once-daily generics, such as tenofovir and entecavir, which are part of the National Viral Hepatitis Control Programme (NVHCP), can safely and effectively suppress the virus life-long.

A new treat-all approach

The theme of this year’s World Hepatitis Day (July 28) is ‘Let us break it down’. This is good news for the people living with Hepatitis B. The new Asian guidelines released in June 2026 have made very important recommendations. These recommend treatment at any level of detectable hepatitis B DNA and above normal liver enzyme levels, irrespective of scarring. This, in a way, supports ‘Treat All’ rather than ‘Treat Select’ policy. This is already true for the country’s AIDS control programme, which initiates antiretroviral therapy for any detectable level of viral load. The AIDS programme demonstrates that it is possible.

It would be a matter of pride for India if the NVHCP moves towards early viral suppression and cancer prevention. We should not wait for hepatitis B to produce advanced fibrosis, cirrhosis or liver cancer before offering protection. Some fear that patients without symptoms may not take the drugs regularly. This is ill-founded as more than 75 per cent patients adhere to treatment and reach virus undetectable state. Like HIV, the treatment should not be stopped.

The other barrier: Stigma

Another key issue is the social stigma as hepatitis B is often clubbed with HIV. Marriages break if the wife tests positive for hepatitis B during pregnancy. Job offers are withdrawn; promotions are denied. Students are excluded. Surgery or dental care are refused. Families isolate individuals who pose no risk through ordinary social contact. This injustice is due to sheer ignorance. In India, a majority of hepatitis B infections are transmitted from mother to baby. The infected child can’t choose their mother; they have no choice but to receive and silently carry the virus. Decades later, once detected, the person is deemed as one with moral failing and shamed publicly. This is the reason most relatives of a patient never get tested and treated. Overcoming the stigma is as important as providing treatment.

The law is changing but mindsets must too

The Kerala High Court in 2025 held that denial of public employment solely because a candidate had hepatitis B violated Article 14 of the Constitution and is “illegal, unfair and unjustifiable” if the person is otherwise medically fit. India already has an instructive model in the HIV and AIDS Act, 2017. But, does India need a change of mindset or want millions approaching the court for their justified status and rights in the society?

We, at the Institute of Liver and Biliary Sciences, launched a campaign, EMPATHY (Empowering People Against Hepatitis), in 2018 to address stigma through advocacy, behaviour-change communication and patient empowerment. This should become part of national policy. There is also a need to prevent mother-to-child transmission. Every pregnant woman should be screened and those with high hepatitis B DNA should receive antiviral prophylaxis. Every newborn should receive hepatitis B vaccination, preferably within 24 hours.

As for the millions already living with chronic infection, antiviral treatment is prevention of fibrosis, decompensation, liver cancer and premature death. For them the new Asian guidelines open a way to get antiviral medications. Now, general physicians are empowered to diagnose and prescribe antiviral therapy and not refer all patients. India can surely build and showcase the most effective model for elimination of hepatitis B.

(Dr Sarin is Director of the Institute of Liver and Biliary Sciences in New Delhi)