(Lok and McMahon, 2009). Initial laboratory evaluation should include a full liver panel, complete blood count (CBC), and hepatitis B e antigen (HBeAg), anti-HB e antibody (anti-HBe), and HBV DNA tests. Further management will depend on the results. Persons who are HBeAg-positive and have increased alanine aminotransferase (ALT) should be referred for evaluation for possible liver biopsy and treatment. Likewise, persons who are HBeAg-negative and anti-HBe-positive, have increased HBV DNA (over 2,000 IU/mL), and have increased ALT should be referred to a specialist. People who have normal ALT, are HBeAg-negative and anti-HBe-positive, and have HBV DNA below 2,000 IU/mL can be followed with ALT and aspartate aminotransferase (AST) tests every 6 months by a primary care provider. If ALT increases above the normal limit, HBV DNA should be tested again; if it is above 2,000 IU/mL, the patient should be referred to a specialist. If a patient is HBeAg-positive and has normal ALT (that is, in the immune tolerant phase), tests for ALT, AST, HBeAg, and anti-HBe should be repeated every 6 months. If ALT rises above the normal range, the patient should be referred to a specialist. In patients who have increased ALT and HBV DNA, liver biopsy is often appropriate to determine the best candidates for treatment because it is recommended that patients who have more than mild inflammation and fibrosis on biopsy receive treatment, and laboratory tests are often unable to distinguish degrees of liver involvement (Lok and McMahon, 2004; NIH, 2008). In addition, any patient who has stigmata of liver disease—ascites, enlarged spleen, jaundice, or encephalopathy—or a platelet count below 100,000 (which is a sign of possible splenomegaly) should be referred immediately to a specialist. The AASLD provides hepatitis B–specific treatment guidelines, including how to select appropriate candidates for treatment, guidance on which antiviral medications to use, and how to address antiviral resistance (Lok and McMahon, 2009). All chronically HBV-infected patients, regardless of their ALT and HBV DNA status, must be followed on a regular basis, every 3–12 months depending on the activity of their disease.

Persons who are identified as anti-HCV-positive and who have HCV RNA present in their serum may initially be evaluated by a primary care provider (Ghany et al., 2009). The primary care provider should take a history and perform a physical examination with emphasis on symptoms and signs of liver disease. The initial laboratory evaluation should include a full liver panel, CBC, and HCV genotype tests. Patients found to have signs or symptoms of liver disease or a low platelet count (below 100,000) should be referred to a specialist who has experience in managing persons with advanced hepatitis C. Patients who are infected with HCV genotype 2 or 3 and who are interested in receiving treatment can be referred immediately for treatment consideration. A primary care provider should discuss with a patient who is infected with HCV genotype 1 the possibility of receiving



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