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In sub-saharan Africa, the level of awareness regarding hepatitis B virus (HBV) infection remains critically low. A significant number of individuals are either unaware of their infection status or hold misconceptions about the nature and treatment of HBV. Current statistics reveal that only 0.2% of these people are receiving treatment, which is inadequate given the scale of the problem. The scenario is further complicated by the prevalence of advanced complications, including decompensated liver disease and hepatocellular carcinoma (HCC), which often go unrecognized until they reach critical stages.
Hepatitis B is a vaccine-preventable disease, and the introduction of a birth dose vaccine as part of routine immunization programs is essential in combating this public health challenge. In Africa, however, only 15 out of the 43 countries have implemented this vital practice, leaving a substantial gap that could otherwise lead to the eradication of the disease in future generations. Alongside vaccination efforts, it is crucial to develop comprehensive programs aimed at identifying and treating individuals who are currently infected or undiagnosed, as they can unknowingly transmit the virus and may present with severe liver disease complications.
In Ethiopia, we initiated the Ethio-Norwegian Hepatology Consortium (EtNoHep) program in 2015, which has since become a cornerstone of our strategy to tackle hepatitis B. The program is centred around the diagnosis, treatment, and ongoing monitoring of HBV patients through a robust research initiative. In its early months, we successfully enrolled 1,300 patients primarily through grassroots efforts, where physicians played a pivotal role in referring diagnosed patients for treatment and support.
The pilot phase of the EtNoHep program yielded striking results. The program also revealed that a mere 1% of patients without cirrhosis died over a five-year follow-up period, in contrast to the 46% mortality rate observed among those with decompensated cirrhosis. This finding underscores the critical importance of early diagnosis and treatment in saving lives. Building on the insights from the pilot program, we expanded our efforts to lower-tier health facilities through different regions in Ethiopia, aiming to identify and treat a larger proportion of the undiagnosed HBV population. Achieving this goal requires a simplified and innovative approach to diagnostics and treatment.
To enhance our outreach, we integrated active screening programs with existing healthcare services, which proved to be an effective strategy. By utilizing resources from HIV and tuberculosis (TB) clinics, an integrated care will be able to share trained staff, counsel patients, and manage patient data more efficiently. We employed the same diagnostic platforms used for HBV viral load testing as those for TB programs, which improved the turn-around time significantly. The integration also fostered adherence to treatment counseling protocols and facilitated medication refills.
Challenges: One of the foremost issues is the lack of funding for hepatitis B initiatives, as the disease receives limited international attention. This constraint hinders major funding opportunities for governmental and non-governmental stakeholders.
Additionally, there remains a widespread lack of awareness regarding HBV status among the population, which slows participation in treatment programs that rely heavily on passive case finding.
Another significant barrier is the restricted access to HBV viral load testing, which is frequently limited to specialized research institutes and private laboratories, resulting in lengthy turnaround times that can extend to several months.
High lost-to-follow-up rates are notable among patients categorized as ineligible for treatment.
Key Lessons Learned
To effectively increase the uptake of HBV treatment, it is essential to focus on health education, community engagement, and the implementation of proactive screening campaigns.
Integrating hepatitis treatment with TB/HIV care and services for non-communicable diseases (NCDs) within “chronic care clinics” has shown promise in reducing stigma while enhancing service efficiency through the collective provision of services such as adherence counselling, side-effect monitoring, and patient tracking.
Facilitating quick access to laboratory results has emerged as a vital strategy for improving patient retention in care. The adoption of diagnostic tools like the Xpert® HBV viral load kit has significantly diminished turnaround times for laboratory results, thereby enhancing patient retention and treatment adherence.
The economic analysis of HBV and hepatitis C virus (HCV) treatments in Ethiopia has highlighted that the high expense associated with advanced laboratory tests constitutes a major driver of overall treatment costs. Therefore, implementing innovative diagnostic approaches or simplified criteria that reduce the dependency on extensive laboratory testing is critical for lowering treatment costs nationwide. As we move forward, we must continue our collective efforts to ensure hepatitis B no longer poses a significant threat to the health and well-being of our communities.
In light of the insufficient funding support for hepatitis B virus (HBV) initiatives and the recent U.S. decision to withdraw from the WHO and other international organizations, Africa must create an innovative funding mechanism to assist its citizens. Health should be prioritized, emphasizing awareness, screening, advanced diagnostic methods, simplified treatment protocols, and support for local drug manufacturers. Achieving this will require collaboration among the African CDC, the African Union, WHO AFRO, scientific societies, COLDA, national hepatology associations, HEPSANET, and civil society organizations in Africa, all working together towards a shared objective. |
