Which sexually active patients should be tested for hepatitis B (HB) when screening for sexually transmitted infections (STIs) and are asymptomatic?

Hepatitis B Testing for Asymptomatic Sexually Active Patients During STI Screening

Sexually active patients who should be tested for hepatitis B when screening for asymptomatic STIs include those who are not in mutually monogamous relationships, have multiple sex partners, men who have sex with men, those recently diagnosed with another STI, and sex partners of HBsAg-positive individuals. 1

High-Risk Groups Requiring HBV Testing

Based on the most recent CDC guidelines, the following asymptomatic sexually active individuals should be tested for hepatitis B:

1. Sexual risk factors:

   • Persons with multiple sex partners (more than one partner in the previous 6 months) 1
   • Men who have sex with men 1
   • Sex partners of HBsAg-positive persons 1
   • Persons not in long-term, mutually monogamous relationships 1
   • Persons seeking evaluation or treatment for any STI 1

2. Additional high-risk groups:

   • Current or recent injection drug users 1
   • Persons with HIV infection 1
   • Persons with hepatitis C virus infection 1
   • Persons with chronic liver disease 1
   • International travelers to regions with high or intermediate HBV endemicity (≥2% HBsAg prevalence) 1

Testing Approach

When testing for hepatitis B in asymptomatic sexually active patients:

• The preferred serologic test for screening is hepatitis B surface antigen (HBsAg) to identify current infection 1
• For those with risk factors who may have been previously infected, testing for antibody to hepatitis B core antigen (anti-HBc) can identify resolved or chronic infection 1
• For adults attending STD clinics, consider prevaccination testing due to the higher prevalence of HBV infection 1

Clinical Considerations

• For adults attending STD clinics, the prevalence of HBV infection and vaccine cost may justify prevaccination testing 1
• When conducting prevaccination testing, administer the first dose of vaccine at the time of testing to improve compliance 1
• The risk of sexual transmission is particularly high among men who have sex with men and those with multiple partners 1, 2
• Hepatitis B testing should be considered part of comprehensive STI screening in high-risk populations, even when asymptomatic 1

Common Pitfalls to Avoid

• Missed opportunities: Failing to test high-risk individuals during routine STI screening
• Incomplete testing: Testing only for HBsAg without considering other markers that might indicate past infection or immunity
• Delayed vaccination: Waiting for test results before initiating vaccination in high-risk individuals
• Overlooking non-sexual risk factors: Injection drug use is a major risk factor that often coexists with sexual risk factors 3
• Assuming monogamy equals safety: Even those in seemingly monogamous relationships may have partners with undiagnosed HBV

Implementation in Practice

1. Integrate HBV screening questions into standard STI risk assessment
2. Offer testing to all patients meeting any high-risk criteria
3. Consider immediate vaccination for high-risk individuals regardless of testing status
4. Ensure appropriate follow-up for those testing positive
5. Educate patients about HBV transmission and prevention strategies

By following these evidence-based recommendations for hepatitis B testing in asymptomatic sexually active patients, clinicians can identify undiagnosed infections early, prevent complications, and reduce transmission in high-risk populations.