Black people are less likely to meet the criteria for chronic hepatitis B treatment, but among those who do, the likelihood of starting therapy did not differ significantly by race or socioeconomic factors, according to study results reported in JAMA Network Open.
An estimated 2.4 million people in the United States have chronic hepatitis B, and people of African or Asian descent are disproportionately affected. Over time, chronic hepatitis B virus (HBV) infection can lead to serious complications, including cirrhosis, liver cancer and liver failure. Studies suggest that Black people are about four times more likely to have chronic HBV and more than twice as likely to die from it compared with their white counterparts. These groups also have a higher incidence of hepatocellular carcinoma (HCC), the most common type of primary liver cancer.
Differences in access to hepatitis B treatment can impact clinical outcomes. It is unclear whether racial discrepancies in outcomes are due to differences in the duration of infection, HBV genotypes, social determinants of health, treatment access or other factors.
Anna Lok, MD, of the University of Michigan at Ann Arbor, and colleagues with the Hepatitis B Research Network assessed disparities in hepatitis B treatment initiation and related clinical outcomes across racial groups in North America.
The study population consisted of 1,550 adults with chronic HBV. Just over half were women, and the average age was 41 years. About 75% were Asian, 12% were African American or Black, 10% were white and the remaining 3% were other races. While all participants tested positive for hepatitis B surface antigen, they were not receiving treatment at baseline. Follow-up was done at weeks 12, 24 and every 24 weeks after that. People with acute rather than chronic HBV infection and those with HIV, hepatitis C or hepatitis D coinfection were excluded.
Over the course of the study, 504 individuals began treatment for hepatitis B. Black people had the lowest likelihood of treatment initiation, at 4.8 per 100 person-years, while Asians had the highest likelihood, at 9.9 per 100 person-years; white individuals fell in between, at 6.6 per 100 person-years.
A lower proportion of Black participants (14%) met treatment eligibility criteria compared with Asian people (22%) and white people (27%). However, the probability of treatment initiation after meeting the criteria was not significantly different. Around 50% of participants who met the criteria received treatment by week 72—a proportion that was statistically similar across racial groups. Moreover, major adverse liver outcomes—such as liver cancer, transplantation and death—were uncommon and did not differ by race.
“We observed a treatment gap between participants eligible for and those receiving treatment, suggesting that efforts to increase awareness of HBV and training of health care professionals, along with simplifying treatment guidelines, will be necessary to achieve the World Health Organization’s goals of HBV elimination by 2030,” the study authors concluded.
Antiviral treatment using medications such as Viread (tenofovir disoproxil fumarate), Vemlidy (tenofovir alafenamide) or Baraclude (entecavir) usually does not cure hepatitis B, but it can slow disease progression and reduce the risk for liver-related complications. Unlike HIV or hepatitis C, treatment is not recommended for everyone with chronic hepatitis B; instead, it is reserved for those with more advanced disease. According to the American Association for the Study of Liver Diseases, treatment is recommended for people with cirrhosis, sustained liver inflammation and/or persistent viral replication, as indicated by HBV DNA levels.
Assessing treatment eligibility requires ongoing follow-up and laboratory monitoring, H. Nina Kim, MD, of the University of Washington in Seattle, noted in an accompanying commentary.
“Participants in this cohort were already engaged in specialty care at an academic health center when they consented to a study that might involve extra visits outside of their usual care or enrollment in a clinical trial,” she wrote. “In other words, they were a selected group. There may have been implicit exclusions from this study due to socioeconomic, cultural and language barriers as well as differing levels of trust in health care and research institutions. Engagement in research has not historically been equitable or representative in the field of HBV.”
“A critical aspect of examining the HBV care cascade through the lens of equity is acknowledging the role that health systems play in perpetuating inequities,” Kim continued. “We need to examine whether our guidelines for HBV treatment are so complex that it becomes the purview of specialists, thereby restricting access and deepening inequities…. We should assess whether the HBV care pathway is unduly burdensome for patients with more limited socioeconomic means who cannot miss work, arrange transportation or meet out-of-pocket costs. We need to understand how racial bias and stigma can influence the progression of HBV care for those who have historically been marginalized. Ultimately, we need to build trust and partner with communities most impacted by HBV as we strive to bridge gaps in the cascade.”
Click here to read the study in JAMA Network Open.
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