Screen-and-treat for chronic hepatitis B: an overdue issue for sub-Saharan Africa
Authors: Jean-Pierre Allain
Journal: The Lancet Global Health (2016)

For more than a decade, WHO has focused its efforts against infectious diseases in Africa on HIV, tuberculosis, and malaria. HIV benefited from unprecedented efforts to enable diagnosis and prevention of transmission and to provide therapy at low cost. National networks of health clinics, transport of samples, centralised and—more recently—point-of-care testing, and monitoring of antiretroviral treatment (ART) by CD4 counts and viral load were put into place. External financial support from governments (eg, from the President's Emergency Plan for AIDS Relief and the European Union), international funding agencies, and numerous charities has allowed roughly 50% of HIV-infected people in sub-Saharan Africa to benefit from ART that is more than 90% effective.1WHOHIV/AIDS: data and statistics.http://www.who.int/hiv/data/en/Google Scholar In contrast to HIV, and as noted in an Article in The Lancet Global Health by Maud Lemoine and colleagues,2Lemoine M Shimakawa Y Njie R et al.Acceptability and feasibility of a screen-and-treat programme for hepatitis B virus infection in The Gambia: the Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) study.Lancet Glob Health. 2016; 4: e559-e567Summary Full Text Full Text PDF PubMed Scopus (107) Google Scholar little attention is being paid to chronic hepatitis B virus (HBV) infection, which affects 80–100 million people in sub-Saharan Africa and is a major cause of mortality from decompensated cirrhosis and hepatocellular carcinoma. Lemoine and colleagues and others have reported that 5–20%3Kramvis A Kew MC Epidemiology of hepatitis B virus in Africa, its genotypes and clinical associations of genotypes.Hepatol Res. 2007; 37: S9-19Crossref PubMed Scopus (226) Google Scholar of the 1 billion people living in sub-Saharan Africa are positive for hepatitis B surface antigen (HBsAg) and roughly 5% of them are at high risk of fatal complications. WHO has recently released a set of recommendations addressing chronic HBV infection, some of which are adapted to the low-income and middle-income countries that bear most of the burden.4WHOGuidelines for the Prevention, Care and Treatment of Persons with chronic Hepatitis B infection. World Health Organization, Geneva2015http://who.int/hiv/pub/hepatitis/hepatitis-b-guidelines/en/Google Scholar HBV infection is usually asymptomatic when acquired and remains clinically silent until it is too late for effective treatment. Lemoine and colleagues2Lemoine M Shimakawa Y Njie R et al.Acceptability and feasibility of a screen-and-treat programme for hepatitis B virus infection in The Gambia: the Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) study.Lancet Glob Health. 2016; 4: e559-e567Summary Full Text Full Text PDF PubMed Scopus (107) Google Scholar and—in an associated cost-effectiveness Article in The Lancet Global Health—Shevanthi Nayagam and colleagues5Nayagam S Conteh L Sicuri E et al.Cost-effectiveness of community-based screening and treatment for chronic hepatitis B in The Gambia: an economic modelling analysis.Lancet Glob Health. 2016; 4: e568-e578Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar propose and show that it is feasible to systematically and affordably screen, assess, and effectively treat chronic HBV infection in a sub-Saharan African setting. At present, the only infected but asymptomatic individuals identified are blood donors who are screened for HBsAg before they can donate. These people can then be assessed for chronic HBV infection and receive appropriate antiviral treatment. However, receipt of such treatment is uncommon in sub-Saharan Africa because, although HBsAg screening is mandatory, improving the donor's health is considered unaffordable.6Allain JP Opare-Sem O Sarkodie F Rahman R Owusu-Ofori S Deferred donor care in a regional hospital blood center in Ghana.Transfusion. 2009; 49: 669-675Crossref PubMed Scopus (18) Google Scholar Lemoine and colleagues show that, in a relatively large population representative of The Gambia, community HBsAg screening is feasible and well accepted by the population. Once appropriately informed and encouraged, individuals consented to be part of an effective diagnostic process to identify people with chronic HBV infection who, although still in good health, will probably be able to avoid cirrhosis and hepatocellular carcinoma if they can receive prolonged antiviral treatment. For departments of health in sub-Saharan Africa, especially those in the western half where the prevalence of genotype E chronic HBV infection is the highest in the world, prevention of HBV-related liver disease should become a priority, and the proposed screen-and-treat strategy should be the object of serious governmental consideration. The main challenge in low-resource countries is cost and allocation of resources. Can HBV control in sub-Saharan Africa be affordable beyond the systematic vaccination that is already implemented? Nayagam and colleagues carefully investigated this cost issue.5Nayagam S Conteh L Sicuri E et al.Cost-effectiveness of community-based screening and treatment for chronic hepatitis B in The Gambia: an economic modelling analysis.Lancet Glob Health. 2016; 4: e568-e578Summary Full Text Full Text PDF PubMed Scopus (62) Google Scholar From a health economist's viewpoint, a cost of about US$511 per quality-adjusted life-year gained or $540 per disability-adjusted life-year averted would seem low, but these sums are roughly the same as the annual income per capita in The Gambia and many other countries in sub-Saharan Africa. Most governments in sub-Saharan Africa do not support health-care costs through insurance systems, although such schemes have been initiated in several countries and successful in a few. In the next 5–10 years, community financial support is unlikely to be available. External funding, such as that distributed to control HIV is unlikely to be made available, since chronic HBV infection is not yet considered a health priority, is not in the eye of the media, and is not perceived as important by the public. Apparently healthy patients will be reluctant to pay for treatment of a disease that will only affect them in the distant future. Willingness to pay will lie with individuals. Most likely, only educated people who are relatively better off financially will be both willing and able to pay. These two Articles on the feasibility of screen-and-treat interventions for chronic HBV infection in sub-Saharan Africa have some weaknesses. The strategy of combining vaccination with the screen-and-treat approach is theoretically suitable for the control of chronic HBV infection in sub-Saharan Africa, but will lose effectiveness due to poor compliance. Data from reports on generalised vaccination in sub-Saharan Africa suggest that poor adherence is common.7Bekondi C Zanchi R Seck A et al.HBV immunization and vaccine coverage among hospitalized children in Cameroon, Central African Republic and Senegal: a cross-sectional study.BMC Infect Dis. 2015; 15: 267Crossref Scopus (21) Google Scholar, 8Peto TJ Mendy ME Lowe Y Webb EL Whittle HC Hall AJ Efficacy and effectiveness of infant vaccination against chronic hepatitis B in the Gambia Hepatitis Intervention Study (1986–90) and in the nationwide immunisation program.BMC Infect Dis. 2014; 14: 7Crossref PubMed Scopus (78) Google Scholar In the Article by Lemoine and colleagues, compliance with screening was 73–81%, with 81% of HBsAg-positive people in the community and 42% of those screened at the blood bank subsequently attending a specialist clinic for HBV diagnosis and assessment of whether antiviral treatment was needed. Individuals in the community were reminded about attending the clinic up to three times, whereas those at the blood bank were not reminded, hence the much poorer compliance. Another problem with these studies is the inclusion of quantitative HBV DNA assays in the therapeutic decision making. These assays are not only expensive and technically demanding, but are also unavailable in most tertiary hospitals in sub-Saharan Africa and would therefore require centralised testing. Experience with the deployment of HIV viral load testing has showed that the delays created by centralised testing generate substantial loss to follow-up.9Phelps BR Ahmed S Amzel A et al.Linkage, initiation and retention of children in the antiretroviral therapy cascade: an overview.AIDS. 2013; 27: S207-S213Crossref Google Scholar Until simple, affordable, point-of-care HBV DNA testing is available, indication for antiviral treatment should rely on simpler and less costly criteria such as alanine aminotransferase, transient elastography, aspartate aminotransferase-platelet ratio index, or γ-glutamyl transpeptidase-platelet ratio index. The inclusion of chronic HBV infection in health priorities is long overdue and these two Articles provide evidence of feasibility and potential solutions. This issue can no longer be avoided; the ball has started rolling and WHO, governments, charities, the media, and the public need to embrace the need to tackle HBV infection at both the public health and economic level. I declare no competing interests. Acceptability and feasibility of a screen-and-treat programme for hepatitis B virus infection in The Gambia: the Prevention of Liver Fibrosis and Cancer in Africa (PROLIFICA) studyHBV infection remains highly prevalent in The Gambia. The high coverage of community-based screening, good linkage into care, and the small proportion of HBsAg carriers who need treatment suggest that large-scale screening and treatment programmes are feasible in sub-Saharan Africa. Full-Text PDF Open AccessCost-effectiveness of community-based screening and treatment for chronic hepatitis B in The Gambia: an economic modelling analysisAdult community-based screening and treatment for HBV in The Gambia is likely to be a cost-effective intervention. Higher cost-effectiveness might be achievable with targeted facility-based screening, price reductions of drugs and diagnostics, and integration of HBV screening with other public health interventions. Full-Text PDF Open Access