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Professor of Medicine
Director of Hepatology
Stanford University School of Medicine
Palo Alto, California
Paul K. Kwo, MD, has disclosed that he has received consulting fees from AbbVie, Conatus, Dova, EdiGene, Eisai, Ferring, Gilead Sciences, Quest, and Surrozen; has received funds for research support from Allergan, Assembly, Gilead Sciences, La Jolla, and HCV-TARGET Registries; and has ownership interest in Durect.
Despite advances in HBV treatment and an effective vaccine, HBV remains a major public health concern. Diagnosis and treatment gaps mean many patients are not receiving the appropriate care. Here’s my take on these challenges, which I will discuss further at an upcoming symposium in Boston.
Closing the Diagnosis Gap
In 2016, it was estimated that only 10.5% of those living with HBV were aware of their infection, and in the United States, large pools of individuals remain undiagnosed.
In particular, foreign-born persons represent a large majority of undiagnosed individuals with chronic hepatitis B (CHB) in the United States: 70% of US persons with CHB are foreign born.
Asians and Pacific Islanders represent the largest population of infected individuals, and it is estimated that only 30% of them are aware of their infection.
In all, closing the diagnosis gap in the United States will require a high degree of awareness among providers and the use of multiple resources to find these individuals with undiagnosed HBV infection. The CDC has recommended that immigrants from medium- to high-prevalence regions of the world undergo screening for HBV, and there are large community-based efforts to try to screen for HBV in regions with large immigrant populations. With the transition to electronic medical records, efforts are being made to screen using surname, country of origin, native language, or race/ethnicity to identify high-risk individuals from endemic areas.
For patients who have emigrated from an endemic area, we providers must be vigilant about suggesting screening and then linking them to care. Without uniform medical records and access to care pipelines for persons living with HBV, all healthcare providers need to maintain a high level of awareness.
In their treatment recommendations, both the AASLD guidelines and the US Algorithm identify those at risk for developing liver-related complications, recognizing that foregoing HBV treatment has the potential to lead to adverse outcomes. Although there is broad agreement between the 2 guidance documents, the main differences are the thresholds for the ALT and HBV DNA levels at which we should consider treatment.
Historically, development of resistance has been a concern when initiating treatment for HBV, but the likelihood of developing resistance with our current first-line therapies has declined to negligible rates. In addition, both sets of guidelines have evolved to include an increasingly larger proportion of patients that should be closely monitored, as we now have additional tools to assess fibrosis other than liver biopsy. With careful monitoring, treatment can be initiated in a timely manner if abnormalities develop or persist to prevent future complications.
Of course, our approach to treatment will continue to evolve as we develop more effective therapies that can lead to greater rates of hepatitis B surface antigen clearance. However, until those therapies are developed, the main goal of therapy remains the prevention of cirrhosis, liver cancer, and death due to HBV. Because up to 40% of persons with CHB still develop significant clinical complications and 25% will die prematurely from complications, we need to keep refining our approach to timely treatment by identifying those at greatest risk for these complications.
We can only know when patients develop abnormalities that indicate treatment if we are closely monitoring them and following them longitudinally. To do this, it is imperative to establish relationships with patients infected with HBV and explain to them that this infection will require that they return regularly for follow-up visits.
I often explain to my patients that they have an infection that, if left untreated, increases their risk of liver cancer. I make it clear that HBV is a carcinogen and that the level of virus and assessments of liver tests will guide our approach to management.
Monitoring untreated patients also provides us with an opportunity to promote good liver health as well as counsel patients on lifestyle modifications to help them remain as healthy as possible.
Finally, we should always ensure that all family members of persons with HBV infection have been screened, which will bring us full circle in our attempt to close the diagnosis gap.
Which challenges in HBV care do you encounter most often in your practice? Please share your thoughts in the comment box below. Then, please join me and my colleagues Manal F. Abdelmalek MD, MPH, and Oluwaseun Falade-Nwulia, MBBS, MPH, for a CME/MOC-certified symposium in Boston, where we will discuss these and other topics related to advances in liver health. If you can’t be there in person, you can register to attend a live simulcast from your home or office.
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