A new global systematic review and meta-analysis reveals the urgent need to overhaul hepatitis B care delivery to meet the WHO 2030 elimination goals.
Millions of people living with chronic hepatitis B are being lost at every step of the care pathway, threatening global efforts to eliminate the disease by 2030, despite effective low-cost antiviral therapy according to a major new study published in The Lancet Gastroenterology & Hepatology.
The review, commissioned by the World Health Organization, analysed data from more than 1.7 million patients across 50 countries. It found that while hospital-based specialist care models performed best, still fewer than three-quarters of patients were properly assessed for treatment. Around one quarter were lost at each step of the care pathway from testing, initial assessment, starting treatment if eligible and retention in care.
Patients identified through community testing programmes when there was no formal linkage arrangements for care, or those diagnosed during pregnancy, and those looked after in primary care were especially likely to fall through the cracks, with just one-third of those tested in community campaigns, and less than half of women referred after antenatal screening making it into care.
“Without urgent changes, millions will miss out on lifesaving treatment,” said lead author Dr Alexander Stockdale, from the University of Liverpool. “Many patients never get assessed for treatment, and even when they do, too many do not start treatment, and are lost to follow-up. We urgently need to strengthen care at the primary care level, especially in low- and middle-income countries, where most of the global burden lies.”
Globally, hepatitis B remains a leading cause of cirrhosis and liver cancer, claiming an estimated 1.1 million lives in 2022. Yet only 13% of people with the infection are diagnosed, and just 3% are on treatment. Effective antiviral medicines can prevent disease progression, but treatment is lifelong, making retention in care critical.
The study found that some community-based models with active screening and direct linkage to specialist care achieved good results for starting eligible patients on treatment, with greater than 90% initiation. However, long-term follow-up data for these models were lacking. Retention in care was also strongly linked to treatment status: nearly 88% of patients on therapy remained in care after 1-4 years, compared with less than half of those not treated.
Senior author Professor Philippa Easterbrook of Imperial College London, who was previously at WHO’s Global Hepatitis Programme and led the 2024 WHO guidelines for hepatitis B care1 2, that substantially simplify and expand eligibility for treatment, said the findings show a need to rethink service delivery models.
“The guidelines recommend expanded eligibility for treatment, but this alone is not enough,” she said. “Too many people still lack access to services, and even where clinics exist, patients are not being linked or kept in care. We must promote access by decentralising hepatitis B care out of specialist centres and integrating it with existing primary care, HIV or chronic disease services. The HIV response has shown that simplified models can work – now we need to apply those lessons to hepatitis B.”
Professor Easterbrook added: “An integrated approach is even more pressing given the recent reductions in funding through USAID and the US President’s Emergency Plan for AIDS Relief (PEPFAR) for health programmes in LMICs.”
The authors urge governments and health systems to:
- Expand decentralised care into primary care and HIV/NCD clinics
- Remove out-of-pocket costs for testing and treatment
- Introduce same-day assessment and treatment initiation
- Apply retention and adherence strategies used successfully in HIV care
With an estimated 257 million people worldwide living with chronic hepatitis B, the researchers say that without a shift in how care is delivered, WHO’s 2030 elimination goals will remain out of reach.
Service delivery models and care cascade outcomes for people living with chronic hepatitis B: a global systematic review and meta-analysis. Alexander J Stockdale, Bethany Holt, Ajeet Singh Bhadoria, Abhishek Sadasivan, Daniel Ikeda, Todd Pollack, Janus P Ong, Thuy Pham, Prof David B Duong, Vy Nguyen, Gibril Ndow, Prof Roger Chou, Prof Philippa Easterbrook. The Lancet Gastroenterology & Hepatology,
Source : Imperial College London
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