Insights From Dr. Tatyana Kushner on New CHD Recommendations

By Tatyana Kushner, MD, MSCE

Chronic hepatitis delta (CHD) is the most severe form of viral hepatitis, yet it remains underrecognized. People living with CHD face increased risks of cirrhosis, liver cancer, and liver failure, but inconsistent testing often delays diagnosis until the disease has advanced. Although considered an orphan disease, CHD warrants far greater attention and earlier detection.

Hepatitis delta occurs in people living with hepatitis B, and can dramatically change the course of their liver disease. Yet our research in the national Veterans Affairs medical system found that fewer than 10% of patients with hepatitis B had ever been screened for hepatitis delta.¹ More recently, our study in NYC, previously identified as a U.S. “hotspot” for hepatitis delta virus (HDV), found significant disparities in which patients are being offered screening.²

With the new American Association for the Study of Liver Diseases (AASLD) Expert-Based Practice Opinion recommendations on CHD, there is an emphasis for a more comprehensive approach to HDV care, calling for universal screening and reflex testing among people with hepatitis B, along with appropriate disease assessment, ongoing surveillance, broader consideration of antiviral treatment and guidance on emerging treatment options. We now have a clear framework for testing more completely with greater ability to connect more people to care who have been living with CHD without knowing it.

Moving from “who is at risk?” to “have we tested?”

Historically, U.S. guidelines have taken a risk-based approach to hepatitis delta screening, while the European Association for the Study of the Liver and World Health Organization have recommended universal screening among people with hepatitis B.

Risk-based screening depends on clinicians recognizing risk factors in the first place. When awareness and testing are already low, patients can easily be missed. Universal screening changes the question from “Which patients are at risk?” to "Have we tested every patient with hepatitis B?” Making HDV testing a routine part of hepatitis B care can reduce guesswork and help identify more patients before their liver disease progresses.

Making screening easier in the real world

Recommendations are useful only if they work for clinicians and patients. Reflex testing can help by automatically initiating an HDV antibody test after a positive hepatitis B surface antigen result, followed by HDV RNA testing when the antibody result is positive.

This approach makes better use of the moment when a patient is already receiving care. Asking someone to return for another blood draw can create a barrier and a missed opportunity for earlier diagnosis.

The evidence demonstrates the practical benefits. In one U.S. health system, patients with a reflex order received HDV antibody testing after a positive hepatitis B surface antigen result, with results available in two days rather than the 11 days when testing required a separate order.³

In my own practice, the recommendation to test is the easy part. The harder part is making sure testing happens consistently and that patients move through each step of the care pathway without being lost along the way. Guidelines can provide an important framework, but putting them into practice requires awareness and coordination across clinicians, laboratories and healthcare systems.

A moment to rethink our expectations

For many years, clinicians could reasonably ask: Why look harder for a disease when our treatment options are so limited? But that landscape is changing. The availability of an FDA-approved therapy for hepatitis delta, along with additional treatments in development, makes timely diagnosis increasingly consequential.

For me, the next step is to translate recommendations into routine practice. Primary care clinicians, hepatologists, infectious disease specialists, laboratories and health systems all have a role in simplifying testing and helping patients move through the care pathway without being lost along the way.

If a patient has hepatitis B, hepatitis delta should no longer be an afterthought. Finding patients earlier creates an opportunity to connect them with appropriate care earlier, and that is an opportunity we should not miss.

¹ Kushner T, Serper M, Kaplan DE. Delta hepatitis within the Veterans Affairs medical system in the United States: Prevalence, risk factors, and outcomes. J Hepatol. 2015 Sep;63(3):586-92.

² Alpert L, Zhang X, Smith R. et al. Analysis of a PCORnet® database identifies multi-level predictors of delta hepatitis in a U.S. hotspot. Commun Med. 2026; 6(239.

³ Mageras A, Rodriguez N, Katzenstein C. et al. Novel Implementation of Hepatitis B to Hepatitis Delta Reflex Testing in a US Healthcare System. American Journal of Gastroenterology, 2025. 121(7), 1650–1658.