Rethinking Standard of Care and the Promise of Functional Cure

Welcome back to another AJMC Insights series. In "Rethinking Standard of Care and the Promise of Functional Cure," moderator Raymond Chung, MD is joined by Robert Gish, MD to pick up the series on chronic hepatitis B, turning to how standard of care is evolving.

Dr. Chung welcomes Dr. Robert Gish to the program, who introduces himself as medical director of the Hepatitis B Foundation, an academic appointee at UCSD, Loma Linda, and the University of Nevada, Las Vegas, and a clinician who sees patients with hepatitis B across five active clinic sites, where the disease makes up roughly 10% of his practice.

Asked to describe the current standard of care, and why clinicians should consider raising the treatment threshold when most patients are already managed effectively without a cure, Dr. Gish says standard of care itself is a moving target given how many competing guidelines exist. He notes that he favors a treat-all approach, which the recent Asia-Pacific guidelines adopted and which the World Health Organization largely supports, while AASLD remains more conservative but has moved toward shared decision-making.

Dr. Gish notes that clinicians no longer describe treatment as lifelong or indefinite, instead telling patients they will remain on therapy until a better option becomes available, since the real patient demand is for finite therapy, driven by concerns about side effects and occasionally cost. He explains that moving toward treating everyone with nucleoside or nucleotide analogs also sets the stage for functional cure. He describes functional cure as something of an oxymoron rather than a true cure, defined as long-term, off-treatment loss of surface antigen alongside undetectable HBV DNA. When both occur, he says, patients, families, and their broader environment experience real excitement, not only from markedly lower cancer and cirrhosis risk but also from reduced stigma and discrimination and meaningfully improved quality of life.

The next episode in this series, "How Bepirovirsen Targets the Hepatitis B Viral Lifecycle," features the panel examining the first pipeline agent in detail.