Treatment of hepatitis B needs global overhaul, per WHO study
New, better care models urged to meet 2030 goal of eliminating virus
Current approaches to hepatitis B care across the globe are failing to adequately connect patients with treatment, and also to retain them for long-term disease management, a new analysis commissioned by the World Health Organization (WHO), a United Nations agency that coordinates responses to international medical issues, has found.
If the WHO’s goal to eliminate hepatitis B as a public health threat by 2030 is to be met, there’s a pressing need for new and better care models, according to the scientists.
“This is the first global review to map our progress across the hepatitis B care pathway. Without urgent changes, millions will miss out on lifesaving treatment,” Alexander Stockdale, PhD, the study’s first author at the University of Liverpool in the U.K., said in a university news story outlining the study’s findings.
“Strengthening primary care in low- and middle-income countries is essential to prevent hepatitis B-related deaths — already estimated at 1.1 million in 2022,” Stockdale said.
Titled “Service delivery models and care cascade outcomes for people living with chronic hepatitis B: a global systematic review and meta-analysis,” the study was published in the journal The Lancet Gastroenterology & Hepatology.
In patients, infection with the hepatitis B virus leads to liver inflammation. When this infection persists over the long term, it can cause serious liver damage and liver cancer. Chronic hepatitis B is a leading global cause of liver-related deaths.
There are available antiviral therapies that can effectively prevent these serious outcomes, but they require that individuals be promptly started on treatment and adhere to it long term.
Patients lost to hepatitis B care at every stage of treatment
An estimated 254 million people were living with chronic hepatitis B in 2022, and more than 1 million people died due to the disease, estimates show. Still, as few as 13% of people with the liver disease were estimated to have been diagnosed with it, and 3% treated for it.
WHO has set a goal of eradicating chronic hepatitis B as a public health threat by 2030. But, the researchers wrote, this will require “a substantial scale-up in testing and treatment coverage.”
New hepatitis B care guidelines, including expanded criteria for starting treatment, were released by WHO last year to address these needs. While these efforts help, “simplifying criteria alone is not enough,” according to Philippa Easterbrook, MD, the study’s senior author and a professor at Imperial College London in the U.K.
“Too many still lack access to services, and even where clinics exist, patients often fall through the cracks,” said Easterbrook, who used to work for WHO’s global hepatitis program.
In this WHO-sponsored study, scientists in the U.K., the U.S., Gambia, India, the Philippines, and Vietnam aimed to look more closely at where healthcare systems are falling short in hepatitis B treatment and long-term management. The goal was to inform the appropriate care delivery approach.
Altogether, the team reviewed and analyzed data from 106 studies, covering more than 1.7 million people with chronic hepatitis B across 50 countries.
The data showed that patients were lost at every stage of the care pipeline, across various types of care models and in both low- and high-income countries.
With hospital-based specialist care models — which generally performed better than other care settings, per the analysis — 73.9% of people diagnosed with chronic hepatitis B were evaluated for treatment eligibility. However, of those deemed eligible, nearly a quarter didn’t start treatment.
Overall, 12.3% of patients who started antiviral treatment and more than half of those not on antivirals were not retained in care between one and four years of follow-up.
“Considerable attrition was seen across the chronic hepatitis B care cascade,” the researchers wrote.
Researchers point to the success of HIV treatment plans
Community-based screening followed by connections with specialist care did well in terms of assessing individuals for treatment eligibility (82.3%), the data showed. However, not enough data were available related to long-term outcomes, according to the authors.
Importantly, for women diagnosed with hepatitis B during pregnancy, postpartum follow-up rates were particularly low. Places where individuals had to pay out-of-pocket for testing and treatment also retained fewer patients across the care pipeline.
Accordomg to Stockdale, “many patients are not being fully assessed or being started on antivirals when they could benefit, and far too many are lost to follow-up over time.”
The HIV response has proven that streamlined care can achieve over 90% diagnosis, treatment initiation, and retention. … It’s time we applied those lessons to hepatitis B.
Based on these findings, the researchers made a number of recommendations to improve chronic hepatitis B care. The scientists suggested expedited access through same-day assessments and treatment, as well as efforts to improve long-term treatment adherence and retention. The elimination of out-of-pocket costs for hepatitis testing and treatment also was a key recommendation.
The team strongly recommended a move toward decentralized models where hepatitis B care can occur in primary care settings or be incorporated into existing chronic disease services, to include those for HIV. The HIV virus is spread in many of the same ways as hepatitis B and has many of the same risk factors.
Easterbrook, who called for “an integrated approach” toward hepatitis B care, noted that “the HIV [healthcare] response has proven that streamlined care can achieve over 90% diagnosis, treatment initiation, and retention.”
The scientist added: “It’s time we applied those lessons to hepatitis B.”
Optimizing the best chronic hepatitis B care model will now require “methodologically rigorous studies to compare packages of different service delivery models and specific interventions for chronic hepatitis B, focusing on different steps in the care cascade,” the team concluded.
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