**Background:** Chronic hepatitis B (CHB) affects an estimated 2.4 million people in the US, disproportionately impacting Asian and African-descent populations. Racial disparities exist in CHB prevalence, hepatocellular carcinoma (HCC) incidence, and outcomes, but whether these stem from differences in treatment access, disease biology, or social determinants of health is unclear. The Hepatitis B Research Network (HBRN) adult cohort provided an opportunity to examine racial differences in treatment initiation and outcomes in a diverse, prospectively followed population.
**Methods:** The HBRN adult cohort enrolled HBsAg-positive adults (≥18 years) not on antiviral therapy (unless pregnant or hepatitis D coinfected) from 20 US centers and 1 Canadian center between January 14, 2011, and January 28, 2018, with follow-up through January 28, 2019. Exclusion criteria for this analysis: acute HBV, HIV, hepatitis C or D coinfection, follow-up <24 weeks, treatment at enrollment or immediate enrollment into an HBRN treatment trial, or unknown race. Of 2,032 enrolled, 1,550 met criteria. Race and household income were self-reported. Treatment eligibility followed 2016 AASLD guidelines: cirrhosis, or if no cirrhosis, HBV DNA >20,000 IU/mL + ALT ≥2×ULN (HBeAg-positive) or HBV DNA >2,000 IU/mL + ALT ≥2×ULN (HBeAg-negative). The primary analysis focused on participants meeting criteria on 2 consecutive visits (or cirrhosis once). Multivariable Cox proportional hazards models evaluated associations between time to treatment initiation and age, sex, HBV DNA (log₁₀ IU/mL), ALT (log₁₀ × ULN), cirrhosis, race, education, income, insurance, and time since immigration, with HBV DNA, ALT, and cirrhosis as time-varying covariates.
**Key Results:** Baseline: Median age 41.2 years (IQR 32.9–51.6); 51% female; 12% African American/Black, 75% Asian, 10% White, 3% other. African American/Black participants had lower educational levels, income, and employment, and higher uninsured/public insurance rates. They also had lower HBeAg positivity (12% vs. 30% Asian) and lower HBV DNA among HBeAg-negative participants (median 2.9 vs. 3.3 log₁₀ IU/mL, p<0.001).
TREATMENT INITIATION
Over 5,727 person-years, 504 participants initiated treatment. Crude incidence per 100 person-years: African American/Black 4.8, Asian 9.9, White 6.6, other 7.9 (p<0.001). Among African American/Black participants, incidence varied by birth region: US/Canada 14.3, East Africa 2.8, West Africa 3.6 (p<0.001). However, a lower percentage of African American/Black participants (14%) met treatment criteria vs. Asian (22%) and White (27%) (p=0.01). Among those meeting criteria (cirrhosis once or non-cirrhosis on 2 consecutive visits), cumulative probability of treatment initiation by 144 weeks was 0.64, with no significant difference by race (p=0.68). In multivariable analysis, only higher ALT (HR 6.76, 95% CI 3.91–11.68, p<0.001), higher HBV DNA (HR 1.17, 95% CI 1.04–1.32, p=0.01), cirrhosis (HR 2.84, 95% CI 1.51–5.34, p=0.001), and older age (HR 1.02, 95% CI 1.00–1.04, p=0.04) were associated with shorter time to treatment. Race (p=0.82), education (p=0.42), income (p=0.31), insurance (p=0.44), and years since migration (p=0.72) were not significant.
OUTCOMES
Adverse liver outcomes were rare (composite incidence 0.1 per 100 person-years). Seven HCC cases (0 African American/Black, 5 Asian, 2 White), 2 hepatic decompensations, 47 incident cirrhosis cases, 93 ALT flares, 90 HBsAg losses, and 112 HBeAg losses occurred. No significant racial differences in outcomes except lower HBsAg loss among Asian participants.
**Clinical Implications:** In this large, multiracial CHB cohort linked to specialty liver care, race and socioeconomic factors were not independently associated with treatment initiation among guideline-eligible patients, suggesting that access to specialist care may mitigate disparities. However, a substantial treatment gap persisted: only 62% of eligible participants initiated therapy. Many patients who met criteria at one visit no longer qualified subsequently, reflecting the dynamic nature of CHB. The lower rate of meeting treatment criteria among African American/Black participants (driven by lower HBeAg prevalence and HBV DNA levels) raises the question of whether race-specific treatment thresholds are needed, though no HCC occurred in African-born African American/Black participants during follow-up. The findings support efforts to increase HBV awareness, simplify treatment guidelines, and ensure linkage to care to achieve WHO HBV elimination goals by 2030.