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Thirty years ago, a phone call from Taiwan alerted me that my brother had liver cancer and liver cirrhosis caused by hepatitis B virus (HBV). Later on, my 2 sisters and their children were all diagnosed with HBV. I was not surprised when I also tested positive. The burning question was: Would I develop liver cirrhosis and/or liver cancer soon?
Getting access to care wasn’t a problem for me at that time. I had blood tests and a liver biopsy and was told I had severe fibrosis with active hepatitis. Unfortunately, my care was interrupted after relocating out of state. It is not easy to find a doctor for a chronic condition with no symptoms and no good treatment options. However, the risk of liver disease progression was nerve-racking. Seven years later, when I relocated again, I decided to find a doctor to help me. This wasn’t easy, as primary care physicians usually were reluctant to treat HBV.
Barriers in the United States
By switching my insurance plan to one that allows direct visits to specialists, I found an infectious disease specialist who was knowledgeable and open to initiating HBV treatment. Ironically, it was my family members―who had started HBV antivirals overseas―who persuaded me to get treated. I am grateful that my insurance has covered all medication costs for the past 13 years and that my viral load always has been undetectable.
Current HBV treatment guidelines are complicated and confusing to patients who are deciding whether to take treatment. Difficulties in finding a specialist and limitations on insurance coverage are major issues that hinder treatment uptake. It is hard for me to imagine how anyone could afford the cost of long-term therapy out of pocket. My insurance charges a high copay if I chose a brand name over a generic drug, and requires monthly refills. These barriers work against the WHO goal of increasing access to treatment. Strong political will and policy revamps are needed to achieve the goal of eliminating viral hepatitis by 2030.
Barriers in Other Countries
Undoubtedly, accessing HBV treatment in other countries is even more challenging. For example, most patients with HBV in Taiwan are left untreated or need to pay for expensive medication themselves. Strict conditions for initiating treatment, limited treatment duration, and a lack of public awareness are also obstacles to progress. It is important for countries such as the United States and Taiwan to set examples to the world by alleviating all barriers to HBV care and treatment in a timely and efficient manner.
Hope for a Cure
A cure for HBV remains elusive. Even the most effective HBV drug combination can deliver only a low rate of functional cure, defined as loss of hepatitis B surface antigen (HBsAg). Current treatment may require administration of multiple drugs, and treatment is often required for an extended duration. Obviously, we all hope that magic bullets like those for treating hepatitis C can be developed for use against HBV.
However, while we wait for HBV drugs with the potential for cure, people with active HBV infection can’t wait! Patients with HBV should not be abandoned, and this vicious virus should not be left unguarded. Currently available antiviral agents are effective enough to suppress viral replication, prevent liver inflammation, block transmission, and reduce risks of liver cancer―all with low risk of toxicity or drug resistance―and should be offered to all patients who need HBV treatment until a cure is available to us all.
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