Five-year results of a treatment program for chronic hepatitis B in Ethiopia

Hepatitis B infection: Evaluation of demographics and treatment of chronic hepatitis B infection in Northern-western Tanzania

BACKGROUND

Chronic hepatitis B virus (HBV) infection is still a major public health problem. In response to the World Health Organization (WHO), Tanzania implemented immunization and treatment to achieve the eradication of HBV infection by 2030. To achieve this goal, frequent updates of demographic data, antiviral therapy eligibility, and uptake are essential. We therefore evaluated demographic data, antiviral therapy eligibility, and uptake among chronically HBV-infected patients attending at Bugando Medical Centre (BMC), Tanzania.

METHODS

A cross-sectional study enrolled 196 chronic HBV patients from April 23, 2023, to October 10, 2023, at BMC, where 100 and 96 patients were retrospectively and prospectively enrolled, respectively. Study's ethical clearance and permission were observed by the Catholic University of Health and Allied Sciences/Bugando Medical Centre research ethics and review committee and the Bugando Medical Centre management respectively. For all patients, socio-demographic data and whole blood samples were obtained. Full blood picture, alanine and aspartate amino transferases, and HBV viral load parameters were determined. Aspartate-Platelet Ratio Index (APRI) and Fibrosis Four (FIB-4) scores were calculated according to their respective formulas. Therapy eligibility and uptake were evaluated according to the 2015 WHO HBV prevention, treatment, and care guidelines. The data were summarized and analysed using STATA version 15.

RESULTS

The median age for all patients was 39 [IQR: 32-47.5] years. Nearly all study patients, 99% (194/196), were older than 20 years old, with significant male dominance (73.5% [144/196] versus 26.5% [52/196]; p<0.0001). Anti-HBV antiviral therapy eligibility was 22.4%, while uptake was 6.8% (3/4), which was significantly lower than the WHO expectation of 80% (p <0.0001).

CONCLUSION

Almost all chronically HBV-infected patients attending at BMC were older than 20 years old and were significantly dominated by males. Antiviral therapy uptake was remarkably lower than expected by the WHO towards combating HBV infection by 2030.

Tackling a worrisome rate of lost to follow-up among migrants with hepatitis B in French Guiana

OBJECTIVES

Management of Hepatitis B virus (HBV)-infected patients, whether they are receiving treatment or not, necessitates long-term follow-up. This study evaluated the rate of lost to follow-up (LTFU) among HBV-infected patients and the feasibility of a callback strategy to re-engage these patients in HBV care.

PATIENTS AND METHODS

We conducted a retrospective study involving HBV-infected patients attending the outpatient clinic at Cayenne Hospital, French Guiana. LTFU was defined as patients who had not attended the clinic for more than 18 months. A callback strategy was implemented to re-engage LTFU patients in HBV care.

RESULTS

Between 1st January 2015 and 31st December 2018, 203 HBV-infected patients were referred to the outpatient clinic; 95/203 (46.8 %) were LTFU, resulting in a crude LTFU rate of 2.6 (95 % CI, 2.1-3.2) per 100 person-years. At baseline, patients aged 30-40 years (aOR, 0.48; 95 %CI, 0.24-0.95) and those who initiated treatment (aOR, 0.26; 95 %CI, 0.10-0.60) were less likely to be LTFU. Through application of the callback strategy, 55/95 (58 %) patients were successfully contacted, and 46/55 (84 %) attended the outpatient clinic for a liver assessment. The EASL criteria for treatment eligibility were met by 3/46 (4 %) patients. Compared to non-LTFU patients, LTFU patients were more likely to be in informal employment (p = 0.03) and to be receiving state medical assistance (p < 0.01), and had lower levels of knowledge about their condition (p < 0.01).

CONCLUSIONS

The callback strategy to re-engage LTFU patients in HBV care is feasible and effectively identifies those eligible for antiviral therapy.

Development and evaluation of a simple treatment eligibility score (HEPSANET) to decentralise hepatitis B care in Africa: a cross-sectional study

BACKGROUND

Hepatitis B virus (HBV) elimination requires expanding and decentralising HBV care services. However, peripheral health facilities lack access to diagnostic tools to assess eligibility for antiviral therapy. Through the Hepatitis B in Africa Collaborative Network (HEPSANET), we aimed to develop and evaluate a score using tests generally available at lower-level facilities, to simplify the evaluation of antiviral therapy eligibility in people living with HBV.

METHODS

We surveyed the availability of clinical and laboratory parameters across different health-care levels in sub-Saharan Africa. We used data from the HEPSANET dataset, the largest cross-sectional dataset of treatment-naive people living with HBV in sub-Saharan Africa, to derive and validate the score. Participants from this dataset were included in the analysis if they were aged 18 years or older and had liver fibrosis stages determined by a liver stiffness measurement or liver histopathology. Participants with co-infections or metabolic disorders were excluded. We allocated participants to the derivation and validation sets by geographical site. In the derivation set, we used stepwise logistic regression to identify the best performing parameters for identifying participants that met the 2017 European Association for the Study of the Liver (EASL) criteria. Regression coefficients were converted into integer points to construct simplified algorithms for different health-care levels. In the validation set, we estimated the area under the receiver operating characteristic, sensitivity, and specificity of the simplified algorithm for identifying antiviral therapy eligibility defined by the 2017 EASL criteria.

FINDINGS

At 11 sites from eight countries that returned surveys, aspartate aminotransferase (AST), alanine aminotransferase (ALT), and platelet count were generally available at district hospital levels, and hepatitis B e antigen and point-of-care HBV DNA tests were available only at regional and provincial hospital levels or above. Among 2895 participants included from the HEPSANET database (1740 [60·1%] male, 1155 [39·9%] female), 409 (14·1%) met EASL antiviral therapy eligibility criteria. In the derivation set, the optimal district-level hospital score was: ALT (IU/L), less than 40 (0 points), 40-79 (+1), 80 or greater (+2); AST (IU/L), less than 40 (0), 40-79 (+1), 80 or greater (+2); and platelet counts (109/L), less than 100 (+2), 100-149 (+1), 150 or greater (0). When combined with family history and clinical data for decompensated cirrhosis that do not require any biological tests, a cut-off of 2 points or more had a sensitivity and specificity of 82% (95% CI 76-86) and 95% (93-96) to identify treatment-eligible individuals in the derivation set, and 78% (71-85) and 87% (86-89) in the validation set, respectively.

INTERPRETATION

Using a score incorporating platelet counts, AST, and ALT, the majority of people living with HBV requiring antiviral therapy can be identified. Our findings suggest that clinical staging can be decentralised down to district hospital level in sub-Saharan Africa.

FUNDING

European Association for the Study of the Liver Foundation, John C Martin Foundation.

TRANSLATION

For the French translation of the abstract see Supplementary Materials section.