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Addressing Social Determinants of Liver Disease

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Ani Kardashian, MD

Assistant Professor of Medicine
Division of Gastrointestinal and Liver Diseases
Department of Medicine
Keck School of Medicine
University of Southern California
Los Angeles, California

Ani Kardashian, MD, has no relevant conflicts of interest to report.

View ClinicalThoughts from this Author

Released: November 23, 2021

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Social determinants of health (SDOH) are the conditions in which people are born, grow, live, and work—and they affect health outcomes in individuals with liver disease, including those with viral hepatitis. This commentary describes how SDOH contribute to disparities in viral hepatitis prevalence, outcomes, and access to treatment and discusses how COVID-19 has exacerbated these disparities. I also suggest interventions to address health inequities in viral hepatitis care.

SDOH and Viral Hepatitis Disparities
Social conditions are closely linked to viral hepatitis prevalence, outcomes, and access to treatment. Racial and ethnic minorities and other marginalized populations in the United States are at elevated risk for chronic liver disease. The prevalence of chronic hepatitis B is markedly greater in immigrant populations, including non-Hispanic Black people and non-Hispanic Asian people, who also carry a greater risk of developing hepatocellular carcinoma.

There also has been a dramatic increase in the incidence of hepatitis C virus (HCV) in the United States during the past decade, driven by the opioid epidemic, with most new cases occurring in people experiencing homelessness and those who inject drugs. Other social determinants, including neighborhood poverty, lower educational status, and language barriers, have been linked to greater risk of HCV acquisition and poorer HCV-related outcomes, including mortality.

These differences among groups extend to access to medical treatments. Although substantial progress has been made in treating noninstitutionalized people with HCV, significant gaps in the treatment cascade have been identified in incarcerated individuals, who represent the largest population infected with HCV in the United States; people experiencing homelessness; active-duty military; nursing home residents; and immigrant populations. In addition, individuals with public insurance are less likely to receive HCV treatment because of payer restrictions.

Minority groups also are less likely to be treated for HCV or be referred for liver transplant, in large part due to socioeconomic factors and disparities in social conditions. Immunization rates for hepatitis A virus (HAV) and hepatitis B virus (HBV), which are required for patients with chronic liver disease, are lower in communities of color because of decreased access to vaccinations and mistrust of institutionalized healthcare.

The Impact of the COVID-19 Pandemic
The economic disruption and physical distancing policies brought on by the COVID-19 pandemic have exacerbated the impact of SDOH on liver disease outcomes. Rates of unemployment and homelessness have increased in many urban communities, leaving individuals with viral hepatitis—many of whom already were marginalized before the pandemic with even more limited access to healthcare.

On the individual level, competing demands between basic human needs (eg, sufficient food or housing) and medical care may be particularly harmful in people with viral hepatitis, who require higher-acuity, specialized care.

At the community level, nearly two thirds of organizations providing viral hepatitis services have received inadequate or no funding to adapt services during the COVID-19 pandemic, resulting in a significant reduction in HBV and HCV testing, HAV/HBV vaccinations, and outreach. Furthermore, disruptions in healthcare services during the pandemic have resulted in an approximately 40% reduction in prescriptions for HCV treatment, which has disproportionately affected racial and ethnic minorities, people who use drugs, and people experiencing homelessness. 

How Can Healthcare Professionals Bridge the Gap in Health Equity?
To address each patient’s distinctive social needs and reduce disparities in viral hepatitis burden and outcomes, changes are needed at both the healthcare professional and community level. As healthcare professionals, methodical screening for social barriers in the clinical setting can help identify marginalized patients who may need additional support to improve health and healthcare interactions. For example, clinic staff can teach patients the digital skills needed to conduct telemedicine visits where these are lacking. If limited access to vaccination services is identified, either due to lack of resources or lower compliance, clinics should enhance services by encouraging the use of shorter vaccination regimens if available (eg, the 2-dose HBV vaccination series given over 4 weeks instead of the 3-dose series given over 6 months due to recognized noncompliance with the third dose).

At the community level, partnerships are needed among healthcare professionals, researchers, and public health workers to link patients and their families to available community resources and services. Programs that include alternative models for care delivery, such as mobile HCV screening and treatment centers, can meet patients where they are and reduce barriers to treatment access. Ongoing public health messaging and outreach programs are needed to achieve the goal of HCV elimination, especially during the COVID-19 pandemic. Ultimately, social barriers to care must be confronted so that we can improve the health of our most susceptible patients with viral hepatitis during future economic and public health emergencies. 

Your Thoughts
In what ways have you worked to address social barriers to healthcare for your patients with viral hepatitis?

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