Toward a Functional Cure for Chronic Hepatitis B: Current Landscape and Future Directions in Japan

Chronic hepatitis B remains a major contributor to liver-related morbidity and mortality despite available effective antiviral therapies. Nucleos(t)ide analogs provide durable suppression of hepatitis B virus (HBV) replication but rarely achieve hepatitis B surface antigen (HBsAg) loss, and interferon-based regimens are limited by modest efficacy and poor tolerability. Consequently, functional cure, defined as sustained HBsAg loss with undetectable HBV DNA after treatment, has become the central therapeutic goal. Recent advances highlight the promise of RNA-targeting agents, including small interfering RNAs, antisense oligonucleotides, and RNA destabilizers, which directly reduce viral transcripts and antigen production. In parallel, immunomodulators such as pegylated interferon, checkpoint inhibitors, and therapeutic vaccines aim to restore HBV-specific immunity. Emerging evidence shows that rationally designed combination regimens, integrating nucleos(t)ide analogs as a backbone with antigen-lowering agents and immunotherapies, can synergistically enhance functional cure rates. As therapeutic strategies evolve, monitoring biomarkers beyond HBV DNA will be critical. Quantitative HBsAg reflects both covalently closed circular DNA and integrated HBV DNA activity, whereas hepatitis B core-related antigens (HBcrAgs) provide complementary information on covalently closed circular DNA transcriptional activity. Together, these markers enable more precise assessment of treatment response, prediction of relapse risk, and evaluation of long-term outcomes. In summary, the pursuit of functional cure in chronic hepatitis B is shifting toward multidrug strategies that combine potent viral suppression, antigen reduction, and immune restoration. Within this framework, the parallel monitoring of HBsAg and HBcrAg alongside HBV DNA will be indispensable for guiding therapeutic decisions, benchmarking clinical trial end points, and advancing personalized treatment strategies.