A little over half of veterans with liver cirrhosis due to chronic hepatitis B are receiving antiviral therapy, according to study findings published in Clinical Infectious Diseases. People who identified as non-Asian, those with heavy alcohol consumption and those living in rural areas had lower treatment rates.

Around 2 million people in the United States are living with chronic hepatitis B, and veterans have a higher rate compared with the general population. Many people with chronic hepatitis B have no symptoms during early stages, but over time, it can lead to serious complications, including cirrhosis and liver cancer.

Hepatitis B can be treated with antivirals, including Viread (tenofovir disoproxil fumarate), Vemlidy (tenofovir alafenamide) and Baraclude (entecavir), sometimes used with pegylated interferon. These medications can suppress hepatitis B virus (HBV) replication indefinitely, but they seldom lead to a cure. There is controversy about who should be treated—some experts think current recommendations are too narrow—but guidelines agree that chronic hepatitis B patients with cirrhosis, who are at greatest risk for liver cancer and other complications, need treatment.

Robert Wong, MD, of the Veterans Affairs Palo Alto Healthcare System and Stanford University School of Medicine, and colleagues explored gaps in antiviral therapy and risk factors for lack of treatment using data from the Veteran Affairs Corporate Data Warehouse for the years 2010 through 2022. This is a national database of information on veterans receiving medical care at VA facilities across the country.

The study included 2,550 adults with chronic hepatitis B who had already progressed to cirrhosis. As is typical of a U.S. veteran population, most (98%) were men, and nearly half were at least 60 years old. About half (54%) were white, 33% were Black, 5% were Asian, 3% were Latino and just under 1% were American Indians or Alaska Natives. Comorbidities were common: 82% had high blood pressure, 46% had diabetes and 23% had hepatitis C virus coinfection. About 70% lived in urban areas, and 12% reported heavy alcohol use.

The researchers found that across the study population, only 52% started antiviral therapy. Asian people had the highest treatment rate (81%), followed by Latinos (64%), American Indians/Alaska Natives (57%), white people (51%) and Black people (47%).

People with higher levels of HBV DNA (greater than 2,000) at the start of the study had a higher treatment rate than those with lower levels (58% versus 51%, respectively). The American Association for the Study of Liver Diseases (AASLD) hepatitis B practice guidelines recommend treatment for people with a viral load above 2,000 (if HBeAg negative), an elevated ALT liver enzyme level and at least moderate liver inflammation or fibrosis, but people with cirrhosis should be treated even if HBV DNA or ALT levels fall below these thresholds.

Older individuals were significantly more likely to not be receiving treatment. Rural residents and people with high alcohol consumption also had lower treatment rates. The low rate among heavy drinkers is worrying, given their propensity to develop liver cancer and other complications, the researchers noted.

“In summary, our study of one of the largest non-Asian cohorts of patients with chronic hepatitis B in the United States demonstrates that only approximately half of patients with cirrhosis are currently on antiviral therapy,” wrote the study authors. “Novel interventions are needed to improve the comprehensive assessment and engagement of patients with chronic hepatitis B cirrhosis into care, particularly to ensure consistent antiviral therapy to reduce liver-related morbidity and mortality.”

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