Present and Future Therapies of Hepatitis B From Discovery To Cure

REVIEW
Present and Future Therapies of Hepatitis B: From

Discovery to Cure
T. Jake Liang,1 Timothy M. Block,2 Brian J. McMahon,3 Marc G. Ghany,1 Stephan Urban,4 Ju-Tao Guo,2
Stephen Locarnini,5 Fabien Zoulim,6 Kyong-Mi Chang,7 and Anna S. Lok8
Hepatitis B virus (HBV) is a significant global pathogen, infecting more than 240 million people worldwide. While treatment for HBV has improved, HBV patients often
require lifelong therapies and cure is still a challenging goal. Recent advances in technologies and pharmaceutical sciences have heralded a new horizon of innovative therapeutic approaches that are bringing us closer to the possibility of a functional cure of
chronic HBV infection. In this article, we review the current state of science in HBV
therapy and highlight new and exciting therapeutic strategies spurred by recent scientific
advances. Some of these therapies have already entered into clinical phase, and we will
likely see more of them moving along the development pipeline. Conclusion: With growing interest in developing and efforts to develop more effective therapies for HBV, the
challenging goal of a cure may be well within reach in the near future. (HEPATOLOGY
2015;62:1893-1908)
espite the availability of effective vaccines for

three decades and improvement of treatment,
the prevalence of chronic hepatitis B viral
(HBV) infection worldwide has declined minimally
from 4.2% in 1990 to 3.7% in 2005.1 Moreover, the
actual number of persons who are chronically infected is
estimated to have increased slightly from 223 million to
240 million during this same period. Treatment for this
infection, while advancing to the stage that viral replication can be effectively suppressed and disease successfully controlled, is still handicapped by various
limitations and cannot be considered as curative. Recognizing that HBV therapeutics is at the cusp of innovations and breakthroughs, this review summarizes new
targets among the HBV viral and host immune systems
for which drugs are now in late preclinical development
and clinical testing. In addition, novel and potentially
promising therapeutic strategies that would likely result
in more durable and complete responses are highlighted.

To put these advances in the context of the current state
of the science, we summarize the current HBV therapies
and their limitations and spotlight the continued impact
of fundamental scientific discoveries in advancing the
research and development of new HBV therapies.
Natural History of Chronic Hepatitis B

The course of chronic HBV infection has been
grouped into four phases: the immune tolerant phase,
the immune active/hepatitis B e antigen (HBeAg)positive chronic hepatitis phase, the HBeAg-negative inactive phase, and the immune active/HBeAg-negative
chronic hepatitis phase. However, these terms may not
accurately reflect the immunological status of patients in
each phase but are useful for prognosis and determining
need for therapy.2,3 The duration of each phase varies
Abbreviations: anti-HBs, antibody to HBsAg; CAR, chimeric antigen receptor; cccDNA, covalently closed circular DNA; HBeAG, hepatitis B e antigen; HBsAg,
hepatitis B surface antigen; HBV, hepatitis B virus; IFN, interferon; IL, interleukin; ISG, interferon-stimulated gene; NRTI, nucleos(t)ide reverse transcriptase
inhibitor; NTCP, sodium/taurocholate cotransporter; PEG-IFN, pegylated interferon; RNAi, RNA interference; TLR, toll-like receptor; WHV, woodchuck hepatitis
virus.
From the 1Liver Diseases Branch, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD; 2Baruch S.
Blumberg Institute, Doylestown, PA; 3National Center for Emerging and Zoonotic Infectious Diseases, Centers for Disease Control and Prevention, Anchorage,
AK; 4Department of Infectious Diseases, Molecular Virology and German Center for Infection Diseases, University Hospital Heidelberg, Heidelberg, Germany;
5
Hepatology Department, Lyon University and Cancer Research Center of Lyon, INSERM U1052, Lyon, France; 6Victorian Infectious Diseases Reference Laboratory, Doherty Institute, Melbourne, VIC, Australia; 7Department of Medicine, Philadelphia Veterans Affairs Medical Center and the University of Pennsylvania
Perelman School of Medicine, Philadelphia, PA; 8Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI.
Received March 29, 2015; accepted July 31, 2015.
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LIANG ET AL.
from months to decades. Transition can occur from an

earlier to a later phase, but regression back to an earlier
phase can also occur.4 It should be noted that not all
patients go through all four phases. Furthermore, while
the cutoff levels of alanine aminotransferase used to
define different phases were traditionally based on upper
limits of normal determined by clinical diagnostic laboratories, recent studies suggest that the true normal values are lower.5
HBV Replication: From Basic Science to

Drug Development
Advances in understanding the molecular biology and
replication cycle of HBV have provided unprecedented
insight into the mechanisms of action and treatment
response of currently available drugs against HBV as
well as potential future targets for therapeutic development (Fig. 1). HBV gains entry into hepatocytes initially
through a low-affinity interaction between heparan sulfate proteoglycans on the hepatocytes involving the antigenic loop (a determinant or antibody neutralization
domain) of the HBV envelope proteins6,7 and then a
high-affinity interaction of the myristoylated pre-S1
domain with the liver-specific receptor sodium/taurocholate cotransporter (NTCP).8 NTCP is exclusively
expressed on the basolateral/sinusoidal membrane of
hepatocytes. Its natural function is to transport conjugated bile salts (e.g., taurocholate) into hepatocytes as
part of the enterohepatic pathway.9 Accordingly, NTCP
plays a key role in the liver tropism of HBV.10,11 NTCP
is also crucial for the host specificity of HBV. Two short
sequence motifs within NTCP are sufficient to render
the respective proteins from cynomolgus monkey and
mouse functioning as an HBV receptor.12,13 Additional
host factors are probably required for efficient HBV
entry. Fusion of HBV particles and release of nucleocapsids into the cells involves receptor-mediated
endocytosis.14,15
The HBV genomecontaining nucleocapsid is transported into the nucleus through a yet-undefined path-
HEPATOLOGY, December 2015
way, probably involving microtubule and nuclear

importin machinery.16 In the nucleus, the relaxed circular, partially double-stranded genome is then repaired to
a full-length, circular DNA by covalently attached viral
polymerase (P) and other incompletely understood
mechanisms probably involving tyrosyl DNA phosphodiesterase of the topoisomerase and DNA repair pathway.17 The circularized protein-free genome then
complexes with host histone and nonhistone proteins
including various histone-modifying enzymes into a
minichromosome that functions as the template for
transcription.18 Its transcriptional activity is regulated
by epigenetic modifications and specific host transcriptional factors, such as hepatocyte nuclear factor 4.19
HBV core and X proteins are also present on the minichromosome and probably play an important role in
HBV transcription.18,20,21 The covalently closed circular
DNA (cccDNA) is transcribed to three classes of HBV
RNAs: genome-length RNAs (pregenomic and precore
RNAs coding for core gene products and P protein), S
RNAs (S proteins), and X RNA (HBx protein). The
pregenomic RNA transcript is reverse-transcribed by the
P protein to relaxed circular DNA in the corecontaining nucleocapsid. The nucleocapsid can either
assemble into an infectious virion with the envelope
proteins through the multivesicular body pathway22 or
recycle back to the nucleus for cccDNA amplification in
a process probably controlled by the pre-S1 envelope
protein and other host factors.23 The steady-state population of cccDNA is about one to 10 molecules per
infected hepatocyte.24
Current Therapies of Hepatitis B and

Mechanisms of Action
There are currently two classes of drugs approved for
the treatment of hepatitis B: nucleos(t)ide reverse transcriptase inhibitors (NRTIs) and interferon-a (IFN-a).
The first-line antiviral HBV medications include a
nucleoside analogue, entecavir; a nucleotide analogue,
tenofovir; and pegylated IFN-a (PEG-IFN-a), used as
Address reprint requests to: T. Jake Liang, LDB/NIDDK/NIH, Bldg. 10-9B16, 10 Center Drive, Bethesda, MD 20892-1800. E-mail: jliang@nih.gov; tel:
11-301-496-1721. fax: 11-301-402-0491.
C 2015 by the American Association for the Study of Liver Diseases. This article has been contributed to by U.S. Government employees and their work is
Copyright V
in the public domain in the U.S.A.
View this article online at wileyonlinelibrary.com.
DOI 10.1002/hep.28025
Potential conflict of interest: Dr. Guo received grants from Janssen. Dr. Block is on the Board of and owns stock in Contravir. He received grants and holds
intellectual property rights with Oncore-Tekmira. Dr. Lok consults and received grants from Gilead. She consults from GlaxoSmithKline, Merck, MYR, and
Tekmira. She received grants from Bristol-Myers Squibb. Dr. Chang advises Genentech, Arbutus, and Alnylam. Dr. Zoulim consults and received grants from
Roche, Gilead, and Novira. He consults for Janssen. Dr. Locarnini received royalties and holds intellectual property rights with Melbourne Health. He consults and
received fees from Arrowhead. He consults for Gilead.
HEPATOLOGY, Vol. 62, No. 6, 2015
LIANG ET AL.
1895
Fig. 1. HBV life cycle and targets of therapeutic development. The complete HBV life cycle including entry, trafficking, cccDNA formation, transcription, encapsidation, replication, assembly, and secretion is shown. The functions of the HBV gene products are incorporated into the life
cycle. Drugs or biologics, in clinical use or development, targeting various steps of the HBV life cycle, are illustrated in red. See text for details
of these drugs. Abbreviations: ER, endoplasmic reticulum; HSPG, heparan sulfate proteoglycan; siRNA, small interfering RNA.
monotherapy.25-27 PEG-IFN is administered for 48-52

weeks. While it has a weaker antiviral activity than
NRTIs, it is associated with a higher rate of HBeAg and
hepatitis B surface antigen (HBsAg) loss, possibly
through a combination of direct antiviral and immunomodulatory effects. By contrast, NRTIs target only the
reverse-transcription of pregenomic RNA to HBV DNA
and have no direct effect on cccDNA. Long-term treatment with more potent NRTIs can lead to progressive
loss of HBeAg and HBsAg with time.
IFN-a, as a front-line host defense against viral infections, is known to induce IFN-stimulated genes (ISGs),
which have promiscuous antiviral functions against a
variety of viruses. Depending on the viruses, these ISGs
play a diverse and pleiotropic role in targeting various
viral functions at different steps of the viral replication
cycle and potently suppress viral infection and spread.
IFN-a has a direct anti-HBV effect and acts on multiple
steps of the HBV replication cycle (Fig. 1).28,29 In addition, it has an immunomodulatory effect that can indi-
rectly inhibit HBV replication by affecting cell-mediated

immunity in vivo.30 Studies of the HBV kinetics in
IFN-a-treated patients suggest a more relevant role of
the latter mechanism in mediating IFN-as anti-HBV
effects.31
Despite targeting multiple steps of HBV replication,
the molecular mechanisms underlying IFN-as action
remain to be fully defined. IFN-a is thought to induce
specific ISGs that inhibit HBV transcription or prevent
the formation of nucleocapsid or target it for degradation.28,29,32 The responsible ISGs have not been clearly
defined. IFN-as effect on HBV transcription is partly
mediated by epigenetic modifications of the cccDNA
minichromosome.33 Recent development of infectious
HBV cell culture systems provided the much needed
tools and models to study the effects of antivirals,
including IFN, on HBV replication.33,34 A recent study
demonstrated that IFN-a and another putative antiviral
cytokine, lymphotoxin-b, induce the degradation of
cccDNA in infectious cell culture systems.35 This effect
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LIANG ET AL.
is mediated by induction of the APOBEC3 family of

proteins, specifically APOBEC3A by IFN-a and APOBEC3B by lymphotoxin-b; APOBEC3 functions to
restrict foreign DNAs, such as those from invading
microbial genomes, which activate the IFN response
including induction of APOBEC3s as ISGs.36 The
APOBEC3s are DNA editing enzymes and deaminate
foreign double-stranded DNA cytidines to uridines.36
This conversion can lead to either C to T mutations or
degradation of foreign DNA. In contrast, cellular
genomic DNA is unaffected. APOBEC3s are known to
target human immunodeficiency virus, adeno-associated
virus, and possibly other DNA viral genomes for degradation.36 For HBV, the role of APOBEC3 has been controversial. APOBEC3G was shown to inhibit HBV
replication in cell culture, but the mechanism had been
attributed to either direct inhibition of HBV replication
or hypermutations from DNA editing.37-40 All of the
earlier studies were performed in HBV DNA transfection systems that could not be used to investigate
cccDNA. In an HBV infectious culture system, the
induced APOBEC3 interacted with the core protein
and translocated to the nucleus to target cccDNA.35
The development of nucleoside analogues owes much
of its success to the comprehensive understanding of
how HBV replicates. Based on the model of HBV replication, the P protein has been the primary therapeutic
target in HBV drug development (Fig. 1). While this
advance represents a pivotal step in the chronicle of
HBV treatment, knowledge of the mechanism of action
of this class of anti-HBV drugs also exposes its limitation, as discussed above.
While the second-generation NRTIs, such as entecavir and tenofovir, can potently suppress the DNA synthesis step of HBV replication, they have little effect on
the level and activity of cccDNA, which has a long halflife and can persist for decades in the infected liver
despite successful antiviral treatment.24 This limitation
explains the necessity for a prolonged, possibly indefinite, treatment with this class of anti-HBV drugs. The
turnover of cccDNA has been the subject of intense
research because of its fundamental importance in HBV
replication and therapy. Several mechanisms appear to
explain the turnover of cccDNA in vivo. First, the direct
cytopathic effect of activated HBV-specific T lymphocytes can cause death of infected cells. Second, gradual
loss of the cccDNA pool by cell proliferation in injured
liver can account partly for gradual loss of cccDNA.
Finally, a noncytopathic mechanism of eliminating
cccDNA from infected cells contributes to the turnover
of cccDNA.41 IFNs and other cytokines have been
implicated in this cell cure mechanism, but the precise

mechanism is unknown.41
Entecavir and tenofovir can decrease the level of
HBV DNA by 6 logs within 1 year of treatment and
have low rates of antiviral drug resistance (0%-1% after
5 years of continued treatment).42-44 However, rates of
HBeAg seroconversion (20% after 1 year and 40%50% after 5 years) and HBsAg loss (5%-10% after 5
years) are low. Therefore, most patients require many
years and often lifelong treatment with associated costs
and risks of adverse reactions, drug resistance, and nonadherence.45 Despite these limitations, antiviral treatment can reverse liver fibrosis and even cirrhosis,
prevent cirrhosis complications, and reduce, though not
eliminate, the risk of hepatocellular carcinoma.44,46
Derivatives of tenofovir as prodrugs with improved
pharmacological properties are being developed and
may be of benefit in certain situation.47
For patients who do not have cirrhosis or do not
require immunosuppressive therapy, professional society
guidelines recommend treating those in the immune
active phase,25-27 although treatment at an earlier stage
has been proposed to minimize unrecognized yet significant liver damage.48 However, treatment during the
immune tolerant phase is associated with a low rate of
HBeAg seroconversion and failure to completely suppress HBV DNA to nondetectable levels.49
The ultimate goal of antiviral therapy would be to
eliminate all forms of potentially replicating HBV, but
this may not be feasible because even in persons who
recover from acute HBV infection with HBsAg to antibody to HBsAg (anti-HBs) seroconversion, HBV persists in the liver in the form of cccDNA and can be
reactivated during immunosuppressive therapy. A more
realistic goal is a functional cure in which HBV DNA
is not detectable after the completion of a finite course
of treatment with loss of HBsAg and minimization of
hepatocellular carcinoma risk over time. To accomplish
this goal, a combination of antiviral drugs that target
different steps in the HBV life cycle or immunomodulatory therapies to restore host immune response to HBV
will be needed.
Combination Studies of Current Therapies

Given that only two classes of anti-HBV agents are
currently available, combination therapy consist of two
NRTIs or an NRTI plus PEG-IFN. In the latter case, an
NRTI and PEG-IFN may be combined simultaneously,
sequentially, starting with either drug first, or as an addon strategy with either drug first.
Initially, the clinical need to increase the potency of

first-generation antivirals and to prevent emergence of
antiviral resistance was the primary reason to test combination therapy with NRTIs. Unfortunately, this
approach suffered from the fact that all NRTIs have the
same virological target, the HBV polymerase. Thus, the
treatment response observed in patients was similar to
that of the most potent agent in the combination. The
issue of antiviral resistance is now greatly diminished
with the development of second-generation NRTIs,
such as entecavir and tenofovir. The efficacy and safety
of entecavir and tenofovir combination therapy were
compared to entecavir monotherapy in previously
untreated HBV patients.50 A greater proportion of subjects receiving combination therapy achieved viral suppression compared to entecavir alone, but the difference
was not statistically significant.50 However, HBeAgpositive subjects with baseline HBV DNA 108 IU/mL
receiving combination therapy had a significantly higher
rate of virological response compared to those receiving
monotherapy.50
Conceptually, combination of PEG-IFN with an
NRTI would be more likely to result in synergy because
the drugs have different mechanisms of action, the concept being that inhibition of viral replication with an
NRTI may augment the immune effects of PEG-IFN.
Unfortunately, while studies of PEG-IFN in combination with first-generation NRTIs did show synergy in
achieving viral suppression and reducing the incidence
of antiviral resistance, off-treatment responses were similar to that of PEG-IFN alone.51,52 The availability of
more potent, second-line NRTIs together with a
renewed interest in achieving HBsAg clearance has
stimulated interest in combining these agents together
or in combination with PEG-IFN.
Simultaneous PEG-IFN and tenofovir was evaluated
in treatment-naive patients with HBeAg-positive and
HBeAg-negative chronic hepatitis B.43 Patients receiving
PEG-IFN and tenofovir had a higher rate of HBsAg loss
than those receiving either drug along.43 Although these
results are encouraging, they represent a small increase
(6%) in HBsAg loss over PEG-IFN monotherapy, and a
benefit was mainly observed in those with genotype A
infection.
Sequential therapy beginning either with an NRTI
followed by PEG-IFN or vice versa for variable durations has been conducted in both HBeAg-positive and
HBeAg-negative subjects. In general, these studies have
not demonstrated a substantial benefit in terms of either
on-treatment or sustained off-treatment HBV DNA
suppression or HBeAg and HBsAg loss compared to
PEG-IFN as a historical control.53-55
LIANG ET AL.
1897
Starting with NRTI first and adding PEG-IFN later

would seem to be the most logical approach to combination therapy. The idea is that the NRTI would rapidly
lower viral load and restore T-cell responsiveness, then
adding PEG-IFN might hasten the decline of circulating
and intrahepatic viral antigens leading to an improvement in the innate immune response.56 Several recent
studies seem to support such an approach.57-59 Among
HBeAg-positive subjects, higher rates of HBeAg seroconversion were achieved with add-on combination
therapy of PEG-IFN and NRTI (27%) compared to
NRTI only (0%).58 Among HBeAg-negative subjects,
HBsAg loss was reported in 6.6% of subjects at the end
of therapy in the combination arm versus 1% in the
NRTI-only arm.59 None of these studies included an
arm using PEG-IFN monotherapy, and when compared
to historical studies of PEG-IFN monotherapy, the
results obtained with combination therapy are
comparable.
A recent study compared PEG-IFN alone to PEGIFN followed by add-on entecavir or entecavir followed
by add-on PEG-IFN.60 Rates of HBeAg seroconversion
posttreatment were similar across treatment groups.60
With an add-on strategy, a longer duration of NRTI
before add-on PEG-IFN and a longer duration of PEGIFN therapy was associated with higher rates of HBeAg
and HBsAg loss.
In summary, there are insufficient data at present to
recommend the use of combination therapy except in
very special circumstances, such as in subjects with very
high baseline viral levels (>108 IU/mL) or for management of subjects who have failed a first-line agent due to
a suboptimal response or the development of multidrug
resistance. Further studies are needed to address the benefit of various formats of combination therapy with
PEG-IFN and more potent NRTIs.
HBV Entry Inhibitors

Entry inhibitors have been used successfully in treating viral infections. In particular, small molecules and
antibody-based treatments are quite effective in treating
acute viral infections.61 For chronic viral infection like
human immunodeficiency virus, entry inhibitors have
also been successfully developed.62 For HBV, entry
inhibitors can be applied in two ways. The first is in a
preventive setting: entry inhibition, such as using antiHBs antibodies, blocks de novo HBV infection. This
application has been successfully demonstrated in animal models63 and is clinically a standard of care using
HBsAg-specific immunoglobulins to prevent reinfection
after liver transplantation, to avoid vertical transmission
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LIANG ET AL.
of HBV from infected mothers to children, and for

postexposure prophylaxis.64 Regarding chronic hepatitis
B patients, whether entry inhibition would be a viable
therapeutic option is debatable. It is conceivable that
potent blockade of HBV reinfection in chronically
infected patients can reduce viral load due to the turnover of HBV-infected hepatocytes.65 Previous studies
suggested that hepatocyte turnover is indeed much faster
in HBV-infected liver than in healthy hepatocytes
because of immune-mediated cytotoxicity.66 A sustained
inhibition of de novo formation of cccDNA in hepatocytes may contribute to the eventual clearance of the
virus with prolonged therapy, especially if it is used in
combination with other potent anti-HBV drugs.
Because hepatitis D virus shares the same entry pathway,
another potential application of entry inhibitors is in
HBV/hepatitis D virus coinfection.
HBV entry depends in part on the pre-S1 sequence,
more specifically the myristoylated N terminus of the
large envelope protein. Both the myristoylation and the
N-terminal 75 amino acids are required for infectivity
of HBV.67,68 It was shown that synthetic lipopeptides
representing this subdomain potently inhibit HBV
infection. The mode of action of such peptidic inhibitors (Myrcludex B, for example) can be attributed to
specific receptor binding.11 Myrcludex B successfully
passed phase 1 clinical trials.69 Moreover, because the
natural role of NTCP as a bile salt transporter has been
studied in some detail, molecules already known to bind
or inhibit the function of NTCP have been tested.
Cyclosporin A and its derivatives (e.g., alisporivir) or
approved drugs like ezetimibe are among those that
have been demonstrated to inhibit HBV entry.70-72
Myrcludex B, cyclosporin A, and other substrate analogues inhibit bile salt transport by NTCP. Accordingly,
these molecules may elevate bile salts and other transported substrates in the serum of patients. This concern
may be a clinically manageable problem. First, people with
polymorphisms in NTCP resulting in a functional knockdown show very moderate clinical symptoms and do not
develop any specific pathology.73 Second, NTCP knockout mice are viable and show elevated conjugated bile salt
levels without symptoms but have a slight retardation in
growth during development.74 Most importantly, the antiviral effect of Myrcludex B and cyclosporin A is already
apparent at a much lower concentration than that required
for inhibiting bile acid transport (>100-fold difference).12,71 Thus, entry inhibition should be clinically
achievable without significant interference with the transporter function of the receptor.
Myrcludex B is currently being tested in two ongoing
clinical trials.75 Preliminary results suggested that Myr-
cludex B is safe and well tolerated in HBsAg-positive

patients with or without HDV coinfection. A decline in
the HBV DNA level (>1 log10) was reported in 87% of
patients at 12 weeks of treatment (10 mg/day), and the
decline continued with extended treatment beyond 12
weeks. Myrcludex B treatment at high doses was associated with some bile acid elevation.
HBV Capsid Inhibitors

Several classes of inhibitors of pregenomic RNA packaging and HBV capsid assembly have been identified.
They function to dysregulate or selectively inhibit either
pregenomic RNA encapsidation or nucleocapsid assembly or both. The first of these were the phenylpropenamide derivatives AT-61 and AT-130.76 These
compounds selectively inhibit viral pregenomic RNA
packaging77 and are active against both wild-type and
lamivudine-resistant HBV.78,79 As a class and at the
molecular level, these agents have been shown to induce
tertiary and quaternary structural changes in HBV capsids. AT-130 binds to a promiscuous pocket at the core
dimerdimer interface.80 This binding decreases viral
production by initiating virion assembly prematurely in
the replication cycle, resulting in morphologically normal capsids that are empty and noninfectious.77
The second group of inhibitors is the heteroaryldihydropyrimidines, which inhibit HBV virion production
in vitro and in vivo by preventing capsid formation.81
The best studied of the heteroaryldihydropyrimidines,
Bay 41-4109, has a dual mechanism of action by inhibiting encapsidation directly and causing a concomitant
reduction in the half-life of the core protein. Structural
studies of this class of inhibitors revealed that they
induce inappropriate capsid assembly at low concentrations and, when in excess, promote a misdirected assembly reaction and decreased capsid stability.82,83 Like the
phenylpropenamides, the heteroaryldihydropyrimidines
are active against NRTI-resistant strains of HBV.79
Other inhibitors targeting the nucleocapsid are being
developed by several biotech companies (Tables 1).84 In
vitro studies have demonstrated strong synergy when
these inhibitors are used in combination with currently
approved NRTIs.78,79
Inhibition of HBV Gene Expression

Persistence of HBV results from an ineffective antiviral immune response against the virus, and one of the
ways HBV orchestrates this is through excess production
of subviral particles containing HBsAg. These noninfectious subviral particles may act as a decoy for the
LIANG ET AL.
1899
Table 1. Experimental HBV Therapeutics in Late Preclinical or Clinical Stage*

Compound
Direct-acting antivirals:
GS-7340 (tenofovir
alafenamide fumarate
CMX157
Mechanism/ Target
Stage of Development
Sponsor
Reference
Phase 2/3
Gilead Sciences
47; NCT0194047; NCT01940341
Phase 1/2
Contravir (Chimerix)
146; NCT01080820
Phase 1/2
Animal
Phase 1
Phase 1
Phase 1/2
Phase 1/2
Novira
Oncore
HEC Pharm Group, China
AiCuris
Replicor
Arrowhead
RNAi
RNAi
RNAi
Antisense
Phase 1
Animal
Animal
Phase 1
Tekmira
Alnylam
Benitec
Isis
84; NCT02112799
147
148
83
NCT02233075
94; sponsors website;
NCT02065336
Sponsors website; NCT02041715
Sponsors website
Sponsors website
Sponsors website
Entry/NTCP
Apoptosis/second
mitochondrial activator of
caspases
STING agonist (pattern
recognition receptor)
Cyclophilins, IRF-9
Glucosidase/therapeutic
vaccine
Phase 1/2
Phase 1
Myr-GmbH/Hepatera
Tetralogic
75
Sponsors website; NCT02288208
Animal
Oncore
149
Animal
Animal
Oncore (NeuroVive)
Blumberg Institute
Sponsors website
150
Immune modulatory agents:

GS-9620
Nivolumab
TLR-7 agonist
PD-1 blockade
Phase 2
Phase 1||
Gilead Sciences
BMS
SB 9200HBV
GS-4774
ANRS HB02
RIG-I and NOD2 activation

Therapeutic vaccine
Therapeutic vaccine
Phase 1/2
Phase 2/3
Phase 1/2
Heplisav B Dynavax 601

Nasvac
TG1050
HBIG 1 GM-CSF 1 HBV vaccine
HBV vaccine 1 IFN-a2b 1 IL-2
HBV vaccineactivated dendritic
cells
Euvax 1 PEG-IFN-a
PD-1 monoclonal antibody
Altravax HBV
INO-1800
Therapeutic
Therapeutic
Therapeutic
Therapeutic
Therapeutic
Therapeutic
Phase
Phase
Phase
Phase
Phase
Phase
INC/Springbank
Gilead Sciences/GlobeImmune
French National Agency for
Research on AIDS and Viral
Hepatitis
Dynavax
CGEB, Cuba
Transgene
Beijing 302 Hospital
Tongji Hospital
Third Affiliated Hospital, Sun
Yat-Sen University
Seoul National University
AcadSin
Altravax
Innovio
122; NCT02166047
151; Sponsors website,
NCT01658878
152; NCT01803308
144; NCT02174276
141; NCT02166047
NVR1221/3778
Sulfamoylbenzamides
GLS4
Bay41-4109
REP 2139-Ca
ARC-520
TKM-HBV
ALN-HBV
DNA-directed RNAi
ISIS HBV
Host targeting agents:
Myrcludex B
Birinapant
Flavonoids
NVP018
Epitope HBV
Polymerase (prodrug of
tenofovir)
Polymerase (prodrug of
tenofovir)
Capsid
Capsid
Capsid
Capsid
Assembly/HBsAg
RNAi
vaccine
vaccine
vaccine
vaccine
vaccine
vaccine
Therapeutic vaccine
PD1 blockade
Therapeutic vaccine
Therapeutic vaccine
1
2/3
1/1b
1/2
2/3
1/2
Phase 2/3
Animal
Animal
Animal
153; NCT01023230
154
NCT02428400
NCT01878565
NCT02360592 (labeled as Phase 4)
NCT01935635
NCT02097004 (labeled as Phase 4)
155
Sponsors website
Sponsors website
*Compounds are organized by names and targets with developmental phase based on authors estimates derived from the literature where available or the sponsors website and presentation information.
Mechanisms are characterized as either direct acting antiviral, indicating action against a virus-specified gene product; immune modulatory agent, activating
host immune response; or host targeting agent, which targets a host function required for the HBV replication cycle.
Identifier for Clinicaltrials.gov.
In phase 2 for human immunodeficiency virus.

k
Trial indication is for treatment of HBV-associated hepatocellular carcinoma.
Abbreviations: GM-CSF, granulocyte-macrophage colony-stimulating factor; HBIG, hepatitis B immune globulin.
immune system,85 especially for mopping up potentially

neutralizing anti-HBs. High levels of HBsAg, in the
range of 400 lg/mL (0.4% of total serum protein), are
commonly found in the blood of patients with chronic
hepatitis B86 and may interfere with HBV-specific
immune responses.87,88
A molecular approach to inhibit HBV gene expression has been successfully achieved in vitro using
molecule-based therapies targeting the viral messenger
RNA. Viral messenger RNA can be directly targeted
using antisense oligonucleotides, ribozymes, or RNA
interference (RNAi).89 Of these, RNAi appears most
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LIANG ET AL.
promising because efficient in vivo delivery systems have

been developed by a number of biotech companies
(Table 1).
RNAi is a process by which small interfering RNA
molecules of 21-25 nucleotides induce gene silencing at
the posttranscriptional level to effectively knock down
the expression of the gene(s) of interest. Such short
interfering RNA can lead to transcriptional silencing or
translational repression.90 These processes are critical in
cell growth regulation and tissue differentiation and
involve the Drosha and Dicer enzyme complexes, the
RNA-induced silencing complex, and the nuclease
Argo.90 The extensive use of overlapping RNAs and
open reading frames within the HBV genome makes for
an attractive target for inhibition by RNAi.91 Both cell
culture and mouse model studies have shown that
RNAi, delivered as an expression plasmid, is able to
inhibit all steps of HBV replication.92 In transgenic
mice, RNAi expression has been shown to significantly
reduce the secretion of HBsAg in serum, reduce both
HBV messenger RNAs and genomic DNA in the liver,
and eliminate hepatocytes stained positive for core antigen.93 These mouse studies have been extended to a
chronically infected chimpanzee.94 Currently, a phase 2
placebo-controlled dose-escalation study with the DPCNAG-ARC-520 formulation has been initiated in
HBeAg-negative chronic hepatitis B whose viremia was
controlled by entecavir and showed a 50% drop in
HBsAg levels in treated compared to placebo patients.95
Another RNAi platform has demonstrated similar
success in its preclinical evaluation with a 2.3-log10
reduction in HBsAg in chronically HBV-infected chimpanzees (Alnylams company press release).96 Other
RNAi-based regimens are currently being developed and
tested (Table 1).
Inhibitors of HBV cccDNA Formation and

Stability
Because the cytoplasmic nucleocapsid DNA is the
precursor for cccDNA biosynthesis, complete inhibition
of viral DNA replication in the nucleocapsids with polymerase inhibitors should preclude de novo cccDNA formation. However, clinical studies demonstrated that
although NRTI monotherapy for 48-52 weeks reduced
circulating viremia by 5 log10 and cytoplasmic HBV
DNA levels in hepatocytes by approximately 2 log10,
reduction of cccDNA was much less pronounced, only
by 0.11 to 1.0 log10.24,97 Moreover, sequential analyses
of viral DNA replicative intermediates and core antigenpositive hepatocytes in the livers of woodchuck hepatitis
virus (WHV)-infected woodchucks before and during
clevudine (an NRTI) therapy revealed that after more

than 6 weeks of therapy, all WHV DNA replicative
intermediates were markedly reduced, with the exception of cccDNA, which remained as the predominant
viral DNA species in the liver.98
Concerning the failure of prolonged NRTI therapy to
eradicate cccDNA, one possibility is that the currently
available NRTIs do not completely inhibit viral DNA
synthesis in every infected hepatocyte in vivo, allowing
for continuous replenishment of the cccDNA pool
through the intracellular amplification pathway. NRTIs
are prodrugs requiring activation by host cellular
nucleoside kinases, the expression and function of which
may be heterogeneous in the liver. Therefore, hepatocytes may have varying abilities to activate the NRTIs,
resulting in incomplete inhibition of HBV DNA replication. Emergence of drug-resistance mutations during
apparently effective NRTI therapy suggests that residual
HBV replication and de novo cccDNA synthesis still
occur at a low level.99
Alternatively, failure to eradicate cccDNA by prolonged NRTI therapy may also be due to the extraordinary stability of cccDNA.100 cccDNA may persist in a
latent state amid the host chromosomes and remain as
a reservoir for later HBV replication. Healthy hepatocytes in the absence of immune response or inflammatory reaction have a half-life of over 6 months.101,102
What we have learned from NRTI therapy is that
eradication of cccDNA is essential for the cure of
chronic hepatitis B. Combination therapies with NRTIs
and one or multiple novel antiviral drugs targeting different steps of HBV replication may completely inhibit
HBV DNA replication and thus accelerate the reduction
of cccDNA. The other approach would be to directly
purge the preexisting cccDNA or permanently silence
cccDNA transcription.
A recent strategy to cleave cccDNA molecules or
inhibit their transcription by generating cccDNA
sequence-specific endonucleases with zinc-finger nuclease, transcription activator-like effector nuclease, or
CRISPR/cas9 technology has been tested in cell cultures
and a mouse model103,104; but efficient and targeted
delivery of these antiviral genes to all HBV-infected cells
in vivo is a major challenge for clinical application.
Another approach is to target the other enzymatic function of HBV polymerase, RNaseH, which is required
for HBV replication and cccDNA formation. Recent
studies have identified potential inhibitors of HBV
RNaseH.105
Further understanding the molecular mechanism of
cccDNA metabolism and functional regulation is essential for identifying and validating molecular targets for
rational development of antiviral drugs to eradicate or

transcriptionally silence cccDNA. As discussed above,
recent studies on the molecular mechanism of immune
control of HBV infection by IFN-a demonstrated that
cccDNA can be specifically targeted for degradation by
a cytidine-deamination mechanism35 and its transcription can be silenced by epigenetic modification.33,106
These findings raise a potentially exciting possibility of
targeting cccDNA through pharmacological activation
or augmentation of the host intrinsic antiviral pathways.
Moreover, investigation into the role and mechanism of
HBx and core protein in cccDNA metabolism and function may reveal virushost interactions for selective
elimination or silencing of cccDNA.20
Additional efforts have been made to discover
cccDNA-targeting compounds through high-throughput
cell-based phenotypic screening. This unbiased approach,
while attractive, is currently hampered by a lack of efficient HBV infection cell culture systems and convenient
assays for high-throughput quantification of HBV replication and cccDNA quantification. Disubstituted sulfonamides were identified as cccDNA formation inhibitors in
a screen of 85,000 small molecular compounds.107 The
recent rapid progress in the establishment of an efficient
HBV infection cell culture system may ultimately allow
the development of cell-based assays for high-throughput
screening of cccDNA-targeting antivirals.
Immune Mechanisms of HBV Control and

Implications for Therapy
The pathogenesis of chronic HBV infection involves
not only viral mechanisms by which HBV establishes a
persistent infection but also the host responses to infection. The latter includes the response of hepatocytes to
HBV infection as well as the interplay of the virus and
infected cells with the other parenchymal and nonparenchymal cells in the liver, i.e., Kupffer cells, endothelial cells, fibroblasts, and nonresident immune cells
that are recruited to the site of infection. HBV has
evolved mechanisms to counteract and escape these different host responses to establish a chronic infection.
Recent studies point out a critical role of the liver
microenvironment in the elimination or control of
HBV (Fig. 2). 108,109 While much has been learned
about the HBV-specific adaptive immunity, the early
and innate immune response during acute HBV infection remains largely unknown. In addition, few studies
have examined intrahepatic immune responses in
patients with chronic HBV infection. Available data
suggest impaired responses, but the mechanism of this
impairment is unclear.109
LIANG ET AL.
1901
In chronic hepatitis B, the antiviral B- and T-cell

responses are quantitatively and/or qualitatively defective. For example, anti-HBs is generally undetectable in
the setting of excess circulating HBsAg. Furthermore,
antiviral T cells show impaired antiviral effector function in vitro. However, this host immune response,
despite being dysfunctional, exerts at least partial viral
control in vivo because immune suppression with
immunosuppressive therapies results in increased viremia.58,110 HBV persistence with antiviral immune dysfunction is also associated with the induction of
immune inhibitory pathways including PD-1, CTLA-4,
Bim, arginase, and FoxP31 regulatory T cells.111-116
These pathways, likely induced in response to continued
inflammation, viral replication, and antigen expression,
can dampen both cytopathic inflammatory responses as
well as noncytopathic antiviral effector functions. Thus,
the antiviral effector T-cell function may be enhanced
by blocking one or more of these inhibitory pathways,112,117 raising the possibility for potential therapeutic application in chronic viral infections such as
chronic hepatitis B.
Based on our knowledge of the immune mechanisms
of chronic HBV infection, several approaches to restore
innate or adaptive immunity or both to control HBV
infection in combination with other direct antiviral
strategies have been applied.108,109 These approaches
can be broadly divided into virus-nonspecific and virusspecific modalities. The first involves general immunomodulatory agents, and the latter aims to activate the
HBV-specific immune response by applying the technologies of therapeutic vaccination. As discussed above,
the efficacy of IFN-a therapy can be partly attributed to
its immunostimulatory effect. A promising approach
emerges from the field of toll-like receptors (TLRs). Various TLR agonists with potent immunostimulatory
effects have been developed.118 Their administration to
HBV patients leads to both intrahepatic and extrahepatic induction of type 1 interferons and other cytokines
that may contribute directly to antiviral activity or indirectly result in activation of innate and adaptive immune
responses. The second approach involves the blockade
of negative immunoregulatory pathways (i.e., coinhibitory signals, inhibitory cytokines, regulatory T cells),
which may induce a partial restoration of HBV-specific
T cells. Third, engineering of redirected T cells may
result in a de novo reconstitution of functionally active
HBV-specific T cells and activation of heterologous T
cells. Whether inhibition of a suppressive effect(s) of
HBV can lead to restoration of HBV-specific innate and
adaptive immune responses remains a challenging question. Several lines of evidence suggest that HBV
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LIANG ET AL.
Fig. 2. Innate and adaptive HBV-specific immune responses and immune-based therapeutic development. Immune cells involved in innate
and adaptive immune responses activated by HBV infection and their mechanisms of antiviral actions are shown. They are virus-specific CD81 T
cells that inhibit viral replication by both direct killing of infected hepatocytes and cytokine-mediated antiviral mechanisms; virus-specific CD41 T
cells, which provide essential help for CD81 T-cell priming and effector functions as well as antiviral cytokines; regulatory T cells, which suppress
virus-specific T-cell functions; B cells, which mature to plasma cells, producing neutralizing antibodies and potentially participating in antigen presentation; natural killer cells, which display antiviral but also regulatory activity by eliminating activated virus-specific CD81 T cells; natural killer
T cells that sense virus-infected hepatocytes, produce antiviral cytokines, and activate adaptive immune responses; other immune cells in the
liver that play important roles in the activation and coordination of the innate and adaptive responses such as Kupffer, myeloid, and plasmacytoid dendritic cells. Therapeutic approaches designed to activate various pathways of the innate and adaptive immunities are illustrated in red.
See text for details of these approaches. Abbreviations: CTL, cytotoxic T lymphocyte; DC, dendritic cell; IFNAR, IFN-a receptor; IFNGR, IFN-c
receptor; IFNLR, IFN-k receptor; JAK/STAT, Janus kinase/signal transducer and activator of transcription; Mu, macrophage; NK, natural killer; NKT,
NK T cell; TNF-L, tumor necrosis factorlike molecule (e.g., lymphotoxin-b); TNF-LR, TNF-L receptor; Treg, regulatory T cell.
interferes negatively with these host immune responses.

A more detailed understanding of the specific mechanisms is mandatory before new ways of restoring
immune responses by targeting virus-specific factors can
be explored. HBV-specific strategies may prove more
effective and safer than virus-nonspecific approaches.
A concern of the various immunotherapies is the
potential risk of autoimmunity and/or exacerbation of
liver damage by immune-mediated death of hepatocytes
in vivo. Careful consideration of benefit versus risk and
close clinical monitoring would be needed in these

approaches.
HBV-Nonspecific Immunomodulatory Agents

TLR Agonists. The antiviral effect of TLR agonists,
particularly TLR-7, through activation of innate immunity has been evaluated in HBV chronically infected
chimpanzees and woodchucks. Upon stimulation of
TLR-7, plasmacytoid dendritic cells produce IFN-a and
other cytokines/chemokines and induce the activation of

natural killer cells and activation of cytotoxic lymphocytes, thereby orchestrating both innate and adaptive
immune responses.119 The altered responsiveness of
plasmacytoid dendritic cells may contribute to the
reduced innate and adaptive immune responses during
chronic viral infections. Agonist-induced activation of
TLR-7 therefore represents a novel approach for the
treatment of chronic viral infections.120 GS-9620, an
orally administered agonist of TLR-7, was tested in
HBV-infected chimpanzees.121 Short-term administration of the TLR-7 agonist provided long-term suppression of serum and liver HBV DNA. Serum levels of
HBsAg and HBeAg and numbers of HBV antigenpositive hepatocytes were reduced. In parallel, GS-9620
administration induced the production of IFN-a and
other cytokines and chemokines, up-regulated ISG
expression, and activated natural killer cells and lymphocyte subsets, confirming the activation of TLR-7 signaling. Similar effects were also observed in chronically
infected woodchucks. Phase 1 clinical evaluation has
been performed, and patients are now being enrolled in
a phase 2 trial combining tenofovir and GS-9620 in
comparison to tenofovir monotherapy.122
PD1 and Other Coinhibitory Blockers. In chronic
HBV infection, loss of viral control has been explained
by exhausted T cells. One approach would be to recover
existing T cells by correcting the balance between coinhibitory (PD1, CTLA-4, Tim-3, Lag-3) and costimulating (41BB, interleukin-12 [IL-12]) signals.123 Recent
studies in the field of cancer therapy have highlighted
the clinical relevance of PD1 blockade to restore antitumor immunity to improve survival.124 As chronic HBV
infection and tumor immunology share similar characteristics in terms of immune subversion and the role of
PD1, PD1 blockade may be an attractive concept for
HBV therapy. A recent study in chronically infected
woodchucks tested the combination therapy of entecavir
and an anti-PD1 ligand monoclonal antibody together
with a WHV DNA vaccine. PD1 blockade was shown
to synergize with entecavir and therapeutic vaccination
to control viral replication and restore WHV-specific Tcell responses.125
HBV-Specific Modified T Cells

As discussed above, HBV-specific T cells are either
exhausted or nonresponsive in chronic HBV infection.
This therapeutic approach is designed to provide genetically engineered T cells to target and eliminate HBVinfected hepatocytes. The strategy to genetically modify
patients T cells to express HBV-specific T-cell receptors
LIANG ET AL.
1903
and then infuse them into the same patients with HBVassociated hepatocellular carcinoma showed some promise.126,127 But the variable and major histocompatibility
complexrestricted nature of the interaction between Tcell receptor and its ligand and the skepticism that
whether one or two such modified T cells would be sufficient to mount an effective T cellbased immune
response may limit the clinical application of this
approach. The recent emerging technology of chimeric
antigen receptor (CAR) in the field of cancer therapeutics has been extended to treatment of persistent viral
infections.128 The CAR approach is to generate a chimeric receptor expressing an extracellular target-binding
domain, a hinge and membrane-anchoring region, and
one (or more) intracellular signaling domain.128 The
target-binding domain is derived from the light and
heavy chain sequences of a single-chain variable fragment of the immunoglobulin. In the case of HBV, the
target could be the cell-surface form of HBsAg and the
single-chain variable fragment derived from a construct
with high-affinity anti-HBs activity.129 The binding of
the CAR-modified T cells to HBV-infected hepatocytes
can trigger proliferating or activating signals to initiate
an effective anti-HBV T-cell response. This strategy has
been applied to HBV animal models with some promise.130 It remains to be seen whether CAR-modified T
cells can achieve a broadly acting and potent anti-HBV
response that is sufficient for viral clearance in chronic
HBV-infected patients.
Therapeutic Vaccines
The goal for therapeutic vaccination in chronic hepatitis B is to induce sufficient anti-HBV immune
responses to eliminate and/or cure infected hepatocytes
without undue host cell damage, prevent viral spread to
new hepatocytes, and promote long-term viral control.
These approaches leverage our accumulating knowledge
of the adaptive immune responses of HBV infection
and focus on restoring or activating endogenous HBVspecific immune responses that initially targeted HBsAg
and later expanded to other HBV antigens using
recombinant proteins, cytotoxic T-lymphocyte epitope
vaccine, viral vectors, and DNA vaccination. These vaccines are being combined with antiviral drugs and
immune modulators to maximize their effects. An
intriguing strategy to personalize antigen presentation to
induce anti-HBV immune response involving monocytes has been recently proposed.131
HBsAg-Based Vaccine. Because HBsAg-based prophylactic vaccine can induce protective virusneutralizing antibodies, the initial studies involved the
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LIANG ET AL.
use of HBsAg in small trials, with virological and serological responses in some patients.132,133 Combination
of an HBsAg vaccine with lamivudine showed promise
initially in smaller studies.134 However, no difference in
clinical efficacy was shown between vaccinated and control groups despite the induction of vigorous HBsAgspecific cellular and humoral immune responses in a
large open-labeled randomized controlled trial of HBV
patients receiving 12 doses of recombinant HBsAg and
ASO2 adjuvant with 52 weeks of lamivudine.135 Similarly, the use of yeast-derived recombinant HBsAg and
hepatitis B immune globulin immune complex showed
promise in a phase 1/2 study,136 but this was not reproduced in a larger phase 3 study.137
Cytotoxic T-Lymphocyte Epitope Vaccine. Immunization with recombinant proteins (e.g., HBsAg) can
promote antibody and CD4 helper T-cell responses, but
generally not those of CD8 T cells, which require endogenously processed viral peptides. Given the relevance of
antiviral CD8 T cells in HBV clearance, direct augmentation of HBV-specific CD8 T cells was attempted in a
pilot study using a lipopeptide encoding a single immunogenic human leukocyte antigen A2restricted HBV
core 18-27 CTL epitope.138 Despite their immunogenicity in healthy adults, this epitope vaccine was not
immunogenic in patients with chronic hepatitis B and
did not significantly change the HBV DNA titers or
HBeAg status. Inclusion of other epitopes in this
approach may be necessary.
DNA Vaccination With or Without Immunomodulators. DNA vaccination can promote antiviral
CD8 T-cell as well as CD4 T-cell and antibody
responses.139 In this regard, intramuscular injection of
DNA encoding only pre-S2/S was safe, well-tolerated,
and at least transiently immunogenic but only marginally effective in reducing HBV DNA levels in a phase 1
study of chronic hepatitis B patients who did not
respond to IFN-a and/or lamivudine.140,141 It also did
not prevent viremic relapse in the phase 1/2 ANRS
HB02 VAC-AND trial.141 Another phase 1 study using
plasmid DNA encoding all HBV open reading frames
and human IL-12 in addition to daily lamivudine
showed a 50% HBV DNA suppression at 1 year post
treatment cessation.142 However, in a subsequent larger
study, a related HBV plasmid DNA (all HBV open reading frames except HBx) and human IL-12 with daily
adefovir showed only a tendency for greater HBeAg loss
and HBV DNA suppression compared to adefovir
alone.143
Other Therapeutic Vaccine Trials. Currently,
open-label therapeutic HBV vaccine trials on clinicaltrials.gov (as of May 2015) include (1) GS4774, a heat-
killed recombinant yeast expressing HBV S, core, and

HBx fusion protein144; (2) ABX203 with recombinant
HBsAg and hepatitis B core antigen in the setting of
PEG IFN-a and oral antivirals; (3) INO-1800, a multiantigen DNA vaccine encoding HBsAg and hepatitis B
core antigen electroporated alone or combined with
INO-9112 encoding IL-12 in patients on either entecavir or tenofovir; (4) TG1050, a nonreplicative E1/E3deleted human adenovirus encoding a fusion protein
combining modified HBV core, polymerase and envelope145; (5) HBV vaccine with hepatitis B immune
globulin and granulocyte-macrophage colony-stimulating factor; (6) HBV vaccine with IFN-a2b and IL-2; (7)
HBV vaccine activated dendritic cells combined with
PEG IFN-a or nucleos(t)ide analogues; (8) intensified
Euvax (HBV S) vaccination with PEG-IFN-a.
Therapeutic Pipeline and Conclusion

Based on the literature, expert input, publicly disclosed information of various pharmaceutical companies, the clinicaltrial.gov website, we generated a table
summarizing the current status of various anti-HBV
drugs or biologics in the development pipeline (Table
1). While many of them are still in preclinical development, several have advanced to clinical trials. As discussed above, some of them showed early promise and
will likely advance to the late clinical trial phase for
more definitive proof of the preliminary success. In this
review, we have summarized the major therapeutic
approaches and novel molecular targets for anti-HBV
drug development and provided a knowledge-based
rationale behind these various strategies. It is possible
that new and additional technologies may emerge as the
field advances. To achieve a more sustained and effective
control of HBV infection, a combination of the existing
HBV therapies and one or more of the above modalities,
either small-molecule drugs or biologics, will be necessary. With the concerted efforts of private and public
sectors, the next milestone in the therapy of HBV infection, a functional cure that has remained elusive, is
likely within our grasp within the next decade.
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Present and Future Therapies of Hepatitis B From Discovery To Cure

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Present and Future Therapies of Hepatitis B: From

espite the availability of effective vaccines for

in more durable and complete responses are highlighted.

Natural History of Chronic Hepatitis B

from months to decades. Transition can occur from an

HBV Replication: From Basic Science to

HEPATOLOGY, December 2015

way, probably involving microtubule and nuclear

Current Therapies of Hepatitis B and

HEPATOLOGY, Vol. 62, No. 6, 2015

monotherapy.25-27 PEG-IFN is administered for 48-52

rectly inhibit HBV replication by affecting cell-mediated

is mediated by induction of the APOBEC3 family of

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implicated in this cell cure mechanism, but the precise

Combination Studies of Current Therapies

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Initially, the clinical need to increase the potency of

Starting with NRTI first and adding PEG-IFN later

HBV Entry Inhibitors

of HBV from infected mothers to children, and for

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cludex B is safe and well tolerated in HBsAg-positive

HBV Capsid Inhibitors

Inhibition of HBV Gene Expression

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Table 1. Experimental HBV Therapeutics in Late Preclinical or Clinical Stage*

47; NCT0194047; NCT01940341

Immune modulatory agents:

RIG-I and NOD2 activation

Heplisav B Dynavax 601

Identifier for Clinicaltrials.gov.

In phase 2 for human immunodeficiency virus.

immune system,85 especially for mopping up potentially

promising because efficient in vivo delivery systems have

Inhibitors of HBV cccDNA Formation and

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clevudine (an NRTI) therapy revealed that after more

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rational development of antiviral drugs to eradicate or

Immune Mechanisms of HBV Control and

In chronic hepatitis B, the antiviral B- and T-cell

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interferes negatively with these host immune responses.

close clinical monitoring would be needed in these

HBV-Nonspecific Immunomodulatory Agents

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other cytokines/chemokines and induce the activation of

HBV-Specific Modified T Cells

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killed recombinant yeast expressing HBV S, core, and

Therapeutic Pipeline and Conclusion

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systems biology identifies unappreciated roles for the innate immune

24. Werle-Lapostolle B, Bowden S, Locarnini S, Wursthorn K, Petersen J,

disoproxil fumarate for chronic hepatitis B: a 5-year open-label

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101. MacDonald RA. Lifespan of liver cells. Autoradiographic study

prolonged suppression of hepatitis B virus in chronically infected

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140. Mancini-Bourgine M, Fontaine H, Brechot C, Pol S, Michel ML.