Hepatitis B eradication in France remains a critical public health challenge as thousands remain undiagnosed and vaccination gaps persist

The elimination of viral hepatitis by 2030, a cornerstone of the French National Sexual Health Strategy, faces significant hurdles, according to the latest epidemiological bulletins published by Santé publique France (SPF). Despite the robust success of universal infant vaccination programs, the country continues to grapple with approximately 140,000 individuals living with chronic Hepatitis B (HBV), nearly half of whom are unaware of their infection status. As the global community moves toward the World Health Organization’s (WHO) ambitious goal of eradicating viral hepatitis, French health authorities have identified a widening gap between clinical capability and public health reach, particularly among marginalized and high-risk populations.

The Clinical Landscape of Hepatitis B and D

Hepatitis B remains one of the most prevalent chronic infectious diseases globally, affecting an estimated 254 million people. The virus is a primary driver of long-term liver damage, including cirrhosis and hepatocellular carcinoma (CHC), the most common form of primary liver cancer. The complexity of the infection is compounded by the presence of Hepatitis D (HDV), a satellite virus that relies on the HBV surface antigen to replicate.

HDV infection is exclusively found in individuals already positive for Hepatitis B. Its presence is clinically significant because it dramatically accelerates the progression of liver fibrosis, leading to faster onset of cirrhosis and increased risk of cancer. Experts emphasize that identifying these co-infections is vital for effective management, yet current testing protocols in outpatient settings remain inconsistent.

Chronology of Policy and Epidemiological Shifts

The current state of HBV management in France is the result of decades of policy evolution:

• 1994: France introduces universal vaccination recommendations for infants.
• 2018: The French government mandates the Hepatitis B vaccine as part of the compulsory immunization schedule for all infants, resulting in a remarkable 95% coverage rate in the two-year-old demographic.
• 2020-2023: Growing concern emerges regarding the "hidden" population of HBV carriers, specifically among migrant communities and those with limited access to traditional healthcare pathways.
• September 2024: The launch of the "Mon test IST" initiative allows citizens to access free, prescription-free screening for STIs, including Hepatitis B, in medical laboratories across the country.
• September 2026: Santé publique France releases a consolidated report highlighting the urgent need to bridge the gap between screening and immunization for adults in high-risk categories.

Vaccination Gaps in High-Risk Populations

While the success of the pediatric vaccination mandate is undisputed, the narrative for adolescent and adult populations is markedly different. SPF data indicates that vaccination coverage among groups at high risk of exposure—including intravenous drug users, individuals with multiple sexual partners, those living with HIV, and men who have sex with men (MSM)—remains well below the 80% target set for 2030.

Current research, including the "Rapport au sexe" (Eras) 2023 survey, shows that only 68% of MSM report having received at least one dose of the vaccine. Furthermore, the shift in HIV prevention technologies has introduced a new clinical complication. Patients using oral Pre-exposure Prophylaxis (PrEP) receive a secondary benefit, as the drug Tenofovir, which is a component of the oral regimen, also acts as an antiviral against Hepatitis B. However, as the medical community moves toward injectable PrEP (cabotegravir)—which provides no protection against HBV—there is a heightened risk of new infections if these patients are not independently vaccinated against the virus.

Socio-Economic Barriers and Public Health Access

The most vulnerable populations—specifically migrants and those in precarious socio-economic situations—often exist outside the standard, codified medical system. For these individuals, the barrier to testing is not necessarily the availability of technology, but the structural complexity of navigating the healthcare system.

Health authorities note that while screening is available at free centers and local laboratories without a prescription, these services remain underutilized by those who face language barriers, lack of documentation, or geographic isolation. The "Mon test IST" initiative is designed to mitigate these territorial inequalities by removing the requirement for a medical referral, yet experts argue that this must be paired with proactive community outreach. If patients are not engaged in the healthcare system for routine checks, they are unlikely to present for a screening test unless they are symptomatic, which is often too late to prevent chronic liver damage.

The Case for Reflex Testing and Advanced Therapeutics

A significant portion of the SPF recommendations focuses on "reflex testing." This process involves automatically testing for Hepatitis D whenever a laboratory confirms a positive Hepatitis B surface antigen (AgHBs) result. By formalizing this, clinicians can immediately identify those at the highest risk of rapid liver deterioration.

Once identified, patients can be directed toward advanced therapeutic options. Treatments such as bulevirtide, either in monotherapy or in combination with pegylated interferon, have shown promise in managing HDV. However, these therapies are only effective if the infection is caught during the diagnostic window. The current failure to perform systematic reflex testing means that many patients are missing out on life-saving treatments until their liver disease has reached an advanced, often irreversible, stage.

Implications for the 2030 Global Goals

The goal of eradicating viral hepatitis by 2030 is increasingly viewed as a challenge of social equity rather than medical innovation. France has the tools to treat and, in the case of vaccination, prevent the disease. The primary obstacle remains the "siloed" nature of current health programs.

Integrating hepatitis prevention into other public health efforts—such as HIV care, addiction services, and immigration support—is essential. As the reliance on oral PrEP diminishes in favor of injectable alternatives, the medical community must ensure that HBV vaccination is treated as a mandatory adjunct to the HIV prevention conversation.

The analysis provided by SPF concludes that the path to 2030 requires a multi-pronged approach:

1. Systematic Outreach: Engaging with community organizations that serve precarious populations to normalize testing and vaccination.
2. Clinical Integration: Standardizing the reflex testing protocol for HDV across all laboratory networks to ensure immediate diagnostic clarity.
3. Policy Alignment: Ensuring that pharmaceutical advancements in HIV prevention do not inadvertently increase the risk profile for other sexually transmitted viruses.

The findings underscore a sobering reality: medical progress is only as effective as the distribution of the resources it offers. For France, the challenge for the next four years is not to invent new solutions, but to ensure that the existing, highly effective ones reach the 70,000 individuals currently navigating their lives unaware of the viral threat in their bodies. If the current trajectory of low vaccination coverage among at-risk adults continues, the 2030 target will remain an aspiration rather than an achievement. Public health officials are now signaling that the focus must shift from broad-spectrum messaging to hyper-targeted, barrier-free access to both screening and the vaccine.