Women Are 33% Less Likely to Be Treated Than Men
Robert J. Wong, MD, Clinical Associate Professor of Medicine at Stanford University School of Medicine and Staff Physician in Gastroenterology and Hepatology at VA Palo Alto Health Care System
PALO ALTO, CA — Chronic hepatitis B virus (HBV) infection continues to pose a significant public health challenge in the United States, even though effective antiviral treatments are available and known to slow disease progression, prevent liver failure and reduce the risk of hepatocellular carcinoma (HCC).
Although clinical guidelines outline who should receive therapy, it remains unclear how consistently those recommendations are followed in real-world clinical practice. To address this gap, researchers conducted a large cross-sectional analysis of U.S. clinical data to determine whether patients who meet criteria for HBV treatment are actually receiving care.
The results of the study, published in JAMA Network Open, raised serious concerns. Drawing on data from the TriNetX Dataworks-USA Network, Robert J. Wong, MD—a clinical associate professor of medicine at Stanford University School of Medicine and a staff physician in the gastroenterology and hepatology section at the VA Palo Alto Health Care System—and colleagues analyzed treatment patterns among adults with chronic HBV infection from 2016 through 2022. Of the 8,594 patients included in the analysis, only 2,134 received antiviral therapy. Notably, substantial treatment gaps persisted even among patients with advanced liver disease—individuals for whom treatment is universally recommended.1
“[M]ost problematic was the observation that more than 40% of individuals with advanced fibrosis, cirrhosis, or liver decompensation had no evidence of antiviral therapy; furthermore, some of these patients may have been receiving suboptimal levels of antiviral therapy,” the researchers reported.
The study highlighted significant disparities in HBV treatment based on sex and race. Although women made up more than half of the study population, they were substantially less likely to qualify for treatment and 33% less likely to be treated than male patients, even after adjusting for clinical and demographic factors.
Racial disparities also were pronounced. Compared with Asian patients, African American or Black patients, white patients and those of unknown or other race had significantly lower odds of receiving treatment. These differences persisted in multivariable analyses and, in some cases, varied by sex. The authors explain that “the reasons for the sex- and race-specific differences in meeting treatment eligibility are unclear,” pointing to possible contributors such as screening practices, comorbid conditions and socioeconomic or genetic factors.
Perhaps the most alarming findings relate to patients with advanced liver disease. Among individuals with a Fibrosis-4 score greater than 3.25, 43% were untreated. Similarly, 40% of patients with diagnosed cirrhosis or liver decompensation had no evidence of antiviral therapy.
“This observation is particularly alarming given that presence of advanced fibrosis or cirrhosis is associated with significantly increased HCC risk, hepatic decompensation, and liver-related mortality,” the researchers wrote, further emphasizing that “the need to treat those with advanced fibrosis or cirrhosis is uniformly agreed on.”
The study also draws attention to gaps in treatment among women of childbearing age. Although mother-to-child transmission (MTCT) of HBV is relatively uncommon in the United States, recent regional increases make treatment and viral suppression in eligible women especially important. The investigators observed similar treatment gaps among women who qualified for therapy or had advanced disease, along with persistent racial disparities.
The authors state that several structural and clinical factors might contribute to low treatment rates. They noted that more than 60% of patients were missing hepatitis B e antigen (HBeAg) status, reflecting the complexity of older treatment guidelines. Although recent guideline updates have simplified eligibility criteria, gaps in clinician awareness and implementation likely remain.
The study also acknowledged limitations related to data completeness and prescription tracking. However, the investigators cautioned that actual treatment rates might be even lower than reported, since prescriptions do not guarantee medication adherence. Despite these limitations, the overall message is clear.
“[T]he low treatment rate we observed highlights an important missed opportunity to reduce the risk of HBV progression,” the researchers wrote. They emphasized that improving clinician education and addressing disparities in care could significantly reduce the burden of HBV-related liver disease in the United States.
- Wong RJ, Telep LE, Wentworth CE, Liu Y, et. Al. Hepatitis B Virus Treatment Gaps in the US. JAMA Netw Open. 2025 Nov 3;8(11):e2542744. doi: 10.1001/jamanetworkopen.2025.42744. PMID: 41259026; PMCID: PMC12631494.
