Is 6-monthly liver screening necessary if the Hepatitis B (HBV) surface Antigen (HBsAg) test is negative?

No, 6-Monthly Liver Screening is Not Required if HBsAg is Negative

If you are HBsAg negative, you do not have chronic hepatitis B infection and therefore do not require routine 6-monthly liver screening for hepatitis B-related liver disease. 1, 2

Understanding HBsAg Negative Status

• HBsAg negativity definitively excludes chronic HBV infection, as HBsAg persistence for more than 6 months is the defining criterion for chronic hepatitis B. 2, 3
• A negative HBsAg test means you either have never been infected with hepatitis B, have cleared a past infection, or have been successfully vaccinated. 1

Critical Exception: Anti-HBc Positive Patients

However, the clinical picture changes significantly if you are HBsAg negative BUT anti-HBc (hepatitis B core antibody) positive:

• These patients have had prior HBV exposure and carry a small risk of HBV reactivation, particularly if they undergo immunosuppressive therapy or chemotherapy. 1, 4
• Occult HBV infection (HBsAg negative but HBV DNA detectable in liver or serum) exists in a small subset of anti-HBc positive patients and can reactivate under immunosuppression. 4, 5
• For HBsAg negative/anti-HBc positive patients not receiving antiviral prophylaxis and undergoing immunosuppression, monitoring with ALT and HBV DNA testing every 1-3 months is recommended, though this is based on weak evidence. 1

Screening Recommendations Based on HBV Status

If You Are Completely HBV Negative (HBsAg negative, anti-HBc negative):

• No routine liver screening is needed unless you have ongoing risk factors for HBV acquisition (injection drug use, high-risk sexual behavior, healthcare exposure). 1
• If you have ongoing risk factors, monthly HBsAg screening is recommended to detect new infection early. 1

If You Are HBsAg Negative but Anti-HBc Positive (Resolved Infection):

• No routine screening is needed in the absence of immunosuppression. 1
• If you are on or planning immunosuppressive therapy, you need antiviral prophylaxis and close monitoring. 1

If You Are HBsAg Positive (Chronic HBV):

• This is the only scenario requiring regular liver surveillance, including 6-monthly monitoring for hepatocellular carcinoma with ultrasound and alpha-fetoprotein, plus periodic ALT and HBV DNA monitoring. 1, 2

Special Populations Requiring Different Approaches

Hemodialysis Patients:

• HBsAg negative patients with negative anti-HBs require monthly HBsAg screening due to high exposure risk in dialysis units. 1
• Patients immune from vaccination (anti-HBs >10 IU/mL) need annual anti-HBs level checks. 1

Patients with Ongoing High-Risk Behaviors:

• People who inject drugs require at least annual HCV and HBV screening, not 6-monthly, unless there is documented infection. 1
• Men with HIV who have unprotected sex with men also require annual screening. 1

Common Pitfalls to Avoid

• Do not confuse HBsAg screening intervals with hepatocellular carcinoma surveillance intervals—the latter applies only to those with chronic HBV infection (HBsAg positive). 1
• Do not assume HBsAg negative means no risk forever—patients with resolved infection (anti-HBc positive) can reactivate under specific circumstances. 1, 4
• Do not order routine liver imaging or AFP in HBsAg negative patients unless there is another indication for liver disease (alcohol use, hepatitis C, fatty liver disease). 1