Wenxiong Xu

Antiviral treatment for chronic HBV infection in the “high‐replicative low‐inflammatory” phase has not been widely recommended. This study aimed to evaluate the safety and efficacy of antiviral therapy in this patient population and analyze peripheral immunological characteristics in relation to treatment response. In this randomized controlled trial, HBeAg‐positive patients with normal ALT and elevated HBV DNA were randomly allocated 1:1 to receive TAF 25 mg/day or observation. The primary endpoint was the decline from baseline in HBsAg at Week 48. Secondary endpoints included HBV DNA response rates and the magnitude of HBV DNA reduction. The treatment group was further divided into virological response (VR) and low‐level viremia (LLV) subgroups based on HBV DNA response at Week 48. PBMCs from VR ( n = 3) and LLV ( n = 3) patients underwent scRNA‐seq for comparative immunological analysis. A total of 59 patients were allocated to the treatment ( n = 30) and control ( n = 29) groups. No serious adverse events occurred, except for one control patient who developed an ALT flare and required antiviral initiation. At Week 48, the treatment group demonstrated significantly greater reductions in HBsAg (0.19 vs. 0 log10 IU/mL, p = 0.005) and HBV DNA (6.32 vs. 0.19 log10 IU/mL, p < 0.001) compared to controls. In the treatment group, 20% achieved HBV DNA < 20 IU/mL and 3.3% achieved HBeAg seroconversion, while none occurred in the untreated patients. PBMCs scRNA‐seq revealed dominant distributions of NK_FCER1G, NK_KLRF1, NK_XCL1, and NKT_FCGR3A subclusters in the VR group, with upregulated expression of genes such as SLC27A4 and PTMA . Taken together, our findings revealed that TAF demonstrates favorable safety and antiviral efficacy in patients with high‐replicative, low‐inflammatory HBV infection during the 48‐week follow‐up period, although complete virological suppression rates remain suboptimal. NK‐mediated mechanisms may contribute to antiviral success. Trial Registration: The trial was registered on ClinicalTrials.gov (NCT 04231565).

The optimal strategy for chronic hepatitis B virus (HBV) infected patients with negative hepatitis B e‐antigen (HBeAg) and normal alanine aminotransferase (ALT) remains uncertain. This study aimed to evaluate the safety and efficacy of tenofovir alafenamide fumarate (TAF) treatment in this patient population. This prospective, open‐label, randomised controlled trial enrolled HBeAg‐negative patients with normal ALT and randomised them 1:1 to either the treatment group (TAF) or the control group (no treatment). The primary endpoint was the reduction in hepatitis B surface antigen (HBsAg) levels from baseline to week 48. A total of 62 patients were enrolled and followed up by 48 weeks ( n = 31 per group). No serious adverse events were reported. At week 48, there was no significant difference in the change in HBsAg between the treatment and control groups [0.01 (−0.06, 0.05) vs. −0.05 (−0.12, 0.06) log ₁₀ IU/mL, p = 0.354]. However, HBV DNA levels were significantly lower in the treatment group (0 vs. 2.86 log ₁₀ IU/mL, p < 0.001). All patients achieved HBV DNA below 20 IU/mL after treatment. Additionally, chitinase‐3‐like protein 1 level was lower in the treatment group (23.8 vs. 44.8 ng/mL, p = 0.019). TAF was well‐tolerated in HBeAg‐negative patients with normal ALT and low‐level HBV DNA viremia. Treatment for 48 weeks led to a high rate of HBV DNA suppression and may potentially delay liver fibrosis progression. Accordingly, early antiviral treatment may benefit this patient population. Trial Registration: Clinical trial number: NCT 04231565

Supplementary Figure 4. No positive viral copies were detected in 242 nasal swabs (3A), 242 urine samples (3B), and 108 stool samples (3C).

Supplementary Table 1. Details of inclusion and Exclusion criteria

Supplementary Figure 3. Viral Distribution and its correlation with efficacy.

Supplementary Table 3. Research process

Supplementary Table 4. Summary of drug exposure and treatment

Supplementary Figure 2. Viral titer testing (CCID50/mL) from samples with positive viral RNA copies in serum.

Supplementary table 2. Representative of Study Participants