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nature outlook article

OUTLOOK 30 March 2022

Simplify access to hepatitis B care

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Overhauling the guidelines for who has access to testing and treatment would lower
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costs and improve patient outcomes.
Hepatitis B

Margaret Hellard & Jessica Howell

Closing in on a cure for hepatitis B

Developing a cure for chronic

hepatitis B requires a fresh approach

How to stop mother-to-child

transmission of hepatitis B

Destigmatizing hepatitis B

Facing the challenge of eliminating

hepatitis B

The global fight against hepatitis B is

benefitting some parts of the world
Cells infected with hepatitis B growing in culture. Credit: Philippe Gontier/Eurelios/SPL more than others

Hepatitis B is a major global killer: almost 300 million people worldwide are living with Africa’s struggle with hepatitis B
chronic hepatitis B infections, and more than 800,000 people die every year from hepatitis-
B-related liver failure and liver cancer1. The impact of this viral disease is greatest in low-
resource settings.
Why hepatitis B hits Aboriginal
Australians especially hard
Safe, effective and affordable hepatitis B treatments are available that suppress the virus,
protecting the liver from continuing damage and reducing transmission risk. Globally,
however, less than 10% of people with the disease are diagnosed and less than 8% receive
Hepatitis B and the liver cancer
treatment2. Clearly, our current approach to hepatitis B diagnosis and management is not up
endgame
to the task. New strategies are urgently needed.

On the basis of current guidelines set by international organizations, which in turn inform
Research round-up: hepatitis B
national prescribing policies, not all people infected with the hepatitis B virus (HBV) are
eligible for treatment. Finding those who qualify requires several blood tests to check for liver
inflammation, hepatitis B immunological responses and HBV levels in blood. Further tests are
needed to assess liver scarring (fibrosis). Many of these tests are unaffordable or simply
Sponsor feature: Charting a new frontier in chronic
unavailable in low- and middle-income countries. An HBV level test, for instance, requires hepatitis B research to improve lives worldwide
trained workers and expensive machines, and can cost as much as US$100 in sub-Saharan
Africa. Hepatitis B can become a chronic disease, requiring lifelong regular monitoring to
ensure treatment is started at the right time to prevent complications. This complexity Sponsor feature: Addressing the unmet need for a
functional cure for chronic hepatitis B
requires specialist management. But in low-resource settings, there are not enough
experienced health workers to manage everyone with the condition.

So, the first task is to reduce the frequency and complexity of Subjects
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the tests required for hepatitis B monitoring. This change would Diseases Health care Public health
remove some of the barriers people face in accessing care in two
ways: first, by reducing the need for multiple visits to health
services, and second, by allowing non-specialist health workers
to manage hepatitis B. This could be achieved by substituting
expensive laboratory tests with cheaper, rapid point-of-care
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tests that provide same-day results.
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This simplified approach to hepatitis B testing entails a trade- every weekday.
off. The lower-cost technologies that make more widespread
Part of Nature Outlook:
use possible also deliver less-accurate results than the gold-
Hepatitis B Email address
standard laboratory tests. However, this small loss of accuracy is
e.g. jo.smith@university.ac.uk
outweighed by the benefits of increasing the number of people
who can be tested and diagnosed. Yes! Sign me up to receive the daily Nature Briefing
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An even simpler approach would be to offer treatment to everyone with hepatitis B, as already Limited Privacy Policy.

happens with two other viral diseases: HIV and hepatitis C. A ‘treat-all’ system of care would
prevent someone missing out on the therapies they need. This strategy also requires less Sign up

frequent monitoring, because the risk of hepatitis flare-ups is reduced.

Past concerns that influenced the decision to advise against a treat-all approach to hepatitis B
are outdated. Hepatitis B treatments are off-patent, so they are now affordable. And fears that
hepatitis B would become resistant to treatment if medications were unnecessarily
prescribed have so far proved to be unfounded; no viral resistance to the hepatitis B drug
tenofovir has been documented despite decades of use. There is thought to be only a small
risk of the virus developing resistance to the other most commonly used medication,
entecavir.

It is true that treating every person who has a diagnosed

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infection would mean some people with only mild liver disease
would receive a treatment that they might not need — and,
although it is generally safe, some of them might still experience
side effects. They might also be at risk of a hepatitis flare-up if
they ever stopped the medication. Despite that potential
downside, we think that the time might be right to change our
More from Nature Outlooks
approach and treat all diagnosed people.

This strategy offers other health benefits as well. For example, there is emerging scientific
evidence that a high level of virus is linked to the risk of developing liver cancer. These
findings suggest that suppressing virus levels early on might be an effective strategy to
reduce cases of this cancer3. Reducing virus levels in individuals also has the benefit of
lowering the risk of transmission to unvaccinated people — including from pregnant people
to their babies, a common source of chronic infections4.

Finally, a growing body of evidence shows that a treat-all approach for hepatitis B is more
cost-effective than current practice5. The medications are less costly than the tests required
to determine treatment eligibility. And removing those expensive tests would allow people to
be treated by non-specialist health-care workers in community settings, instead of by
specialists in hospitals.

The current approach to managing hepatitis B is not working. Testing and treatment
guidelines are impractical for many low-resource countries, leaving most people with
hepatitis B without lifesaving treatment. Simplified approaches to the disease that consider
its prevalence and the socio-economic context are crucial if we are to achieve hepatitis B
elimination globally. However, it is essential that people living with this disease are at the
centre of any decision to change hepatitis B care, because until there is a cure, a treat-all
approach means every infected person would have to take medication for life. For some, this
might be a significant barrier; they would be confronted with their hepatitis B every day when
taking a tablet, whereas previously it could be ignored for months on end. It is therefore
imperative that we develop an optimal approach to testing and treatment that enshrines
dignity, informed choice and equity in access to care.

Nature 603, S53 (2022)

doi: https://doi.org/10.1038/d41586-022-00815-y

This article is part of Nature Outlook: Hepatitis B, an editorially independent supplement

produced with the financial support of third parties. About this content.

References

1. Howell, J. et al. J. Hepatol. 74, 535–549 (2021).

PubMed  Article  Google Scholar 

2. World Health Organization. Global Hepatitis Report 2017 (WHO, 2017).

Google Scholar 

3. Kennedy, P. T. F., Litwin, S., Dolman, G. E., Bertoletti, A. & Mason, W. S. Viruses 9, 96 (2017).
Article  Google Scholar 

4. Pan, C. Q. et al. N. Engl. J. Med. 374, 2324–2334 (2016).

PubMed  Article  Google Scholar 

5. Kim, H.-L. et al. Gut 70, 2172–2182 (2021).

PubMed  Article  Google Scholar 

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COMPETING INTERESTS

M.H. receives investigator-initiated research funding from Gilead Sciences and Abbvie for
work unrelated to this article. J.H. has received speaker fees from Gilead Sciences, Eisai (MSD),
and investigator initiated grant funding from Gilead Sciences (Australia fellowship 2017,
2020). J.H. is a member of the Victorian Hepatitis B Alliance community organization, a
research and advocacy organization (Australia), and a member of the International Coalition
for Elimination of Hepatitis B, global hepatitis B research organization.

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