Review article: current gaps and opportunities in HBV prevention, testing and linkage to care in the United States—a call for action

Abstract

SummaryBackgroundThe World Health Organization (WHO) has set an elimination goal for hepatitis B virus (HBV) by 2030, so a comprehensive review of current HBV testing and care gaps are needed to help formulate solutions and opportunities for action.AimsTo summarise current gaps and barriers, and to propose solutions for HBV prevention, testing and linkage to care in the United StatesMethodsRelevant guidelines and studies were reviewed including a systematic review of HCC surveillance adherence.ResultsA total of 64.5 million (95% CI, 61.3‐67.5) high‐risk US adults had no evidence of HBV immunity. Only 18.6% (95% CI, 13.5‐29.9) of privately insured patients with HBV infection have been diagnosed. Among those with known HBV infection, linkage to care rate (33.3%‐57%) was poor and the adherence to guidelines regarding anti‐viral therapy (30.66% [95% CI, 30.28‐31.03]) and HCC surveillance (8%‐87%, from a systematic review) were poor with even more concerning data for care and treatment retention. The causes are complex and include lack of access to medical care, lack of physician knowledge, lack of patient health literacy and awareness, linguistic and cultural barriers and fear of stigma.ConclusionsA ‘scale‐up’ effort is needed to optimise the care continuum to achieve the WHO 2030 targets. As targeted screening policy has leftover 80% of patients undiagnosed, we advocate for universal screening which can help to remove barriers regarding stigma. More active and system level interventions are also needed to improve linkage to care for patients with HBV infection.

Antiviral Therapy Utilization and 10-Year Outcomes in Resected Hepatitis B Virus– and Hepatitis C Virus–Related Hepatocellular Carcinoma

“…The barriers to care for HBV are complex, ranging from poor access to social stigma and lack of curative treatment with finite treatment duration. [16][17][18]37,38 Asian countries/territories had lower HBV utilization compared with non-Asian countries, which may be related to local reimbursement barriers. For HCV-related HCC, the introduction of well-tolerated and efficacious DAA therapy in 2014 is the likely reason for the dramatic rise in the rate of antiviral utilization from 2015 onward.…”

“…Despite demonstrated benefits, antiviral therapy is underutilized. [16][17][18][19] free survival (RFS) is poor. [20][21][22][23][24][25] Antiviral therapy can help stabilize the underlying liver disease and may help lower the risk of HCC recurrence and de novo HCC development.…”

Hepatitis B virus (HBV) screening, linkage and retention-in-care in inclusion health populations: Evaluation of an outreach screening programme in London

“…Asian ethnicity, proximity of residence to clinic, older age and being on treatment have been identified as predictors of RIC, whereas refugee status predicts LTFU ( 26 , 27 ). Accessible care, patient and provider education and reduction in stigma are key factors to improve the HBV care cascade in the United States ( 28 ).…”

Optimizing hepatitis B virus screening in the United States using a simple demographics‐based model

“…This study developed an algorithm to prioritize patients for hepatitis B screening using data from a populationbased cohort in the USA and relying only on demographic data that are routinely available in typical health To reiterate, CHB is a major public health concern and a significant cause of morbidity and mortality, but it is estimated that worldwide 90% and in the USA 80% of people with CHB have not been diagnosed. [1,3,5,6] As a result, opportunities for HCC surveillance and antiviral therapy to prevent HCC and ESLD are lost. Identifying patients with HBV also allows for targeted vaccination of family members, partners, and other close contacts, an inexpensive and effective way to prevent HBV transmission.…”

“…[1] In the USA, CHB affects an estimated 840,000 to 1.59 million persons, [2,3] with population-based studies reporting a patient disease awareness and diagnosis rate of only 15%-19%. [4][5][6] Whereas CHB can progress to cirrhosis, hepatic failure, and HCC, many patients remain asymptomatic until onset of end-stage liver disease (ESLD) secondary to cirrhosis and/or HCC, [7][8][9] further contributing to the observed low diagnosis and awareness rates. Delayed diagnosis consequently leads to delayed initiation of antiviral therapies that have been shown to be well tolerated and effective in preventing the development of cirrhosis, HCC, and premature death.…”