Patients in Africa are often unable to receive treatment according to WHO hepatitis B guidelines. Now researchers have found a way to improve the diagnosis and care of people living with hepatitis B. Credit: Charles Mpaka/IPS
  • by Charles Mpaka (blantyre)
  • Interpress service

In a study published in Nature communicationrecommends the researchers review the current World Health Organization (WHO) guidelines for managing the condition.

“Our data are important for informing clinical practice in and should be considered in the next revision of the WHO hepatitis B guidelines,” said the researchers who make up the Hepatitis B in Africa Collaborative Network (HEPSANET).

The lead author of the study, Asgeir Johannessen, tells IPS that clinics working in Africa have “repeatedly reported that very few patients in Africa” ​​qualify for treatment according to current WHO guidelines published in 2015.

“The lack of data from Africa is a major challenge, and we wanted to use African data from African patients to inform African treatment guidelines,” says Johannessen, a specialist in internal medicine and infectious diseases at the Institute of Clinical Medicine, University of Oslo in Norway.

According to the study, Africa represents one of the high burden regions for chronic hepatitis B virus. Of the estimated 316 million people living with chronic hepatitis B virus infection worldwide, 82 million are in Africa.

The research further states that antiviral therapy effectively reduces the risk of complications resulting from hepatitis B virus infection.

However, with current WHO-recommended guidelines, early diagnosis and treatment are affected because they are often only picked up when there is advanced liver damage.

The challenge in clinical practice in Africa has been to identify patients at risk of progressive liver disease who should start antiviral treatment in good time.

“In resource-limited settings, however, these fibrosis assessment tools are rarely available, and therefore antiviral treatment is often delayed until patients have developed symptoms of advanced chronic liver disease,” the research paper says.

So, the researchers set out to address this question: “Can we diagnose advanced liver fibrosis in the Africa region, using routinely available and inexpensive blood tests for hepatitis B patients?” says Alexander Stockdale, a member of the team and Senior Clinical Lecturer at the University of Liverpool and Malawi Liverpool Wellcome Programme.

In the study, the 23 researchers reviewed data for 3,548 patients with chronic hepatitis B living in eight sub-Saharan African countries, namely Burkina Faso, Ethiopia, Gambia, Malawi, Nigeria, Senegal, South Africa and Zambia.

They evaluated existing WHO treatment guidelines and a simple liver injury biomarker developed in West Africa.

They determined that the conventional hepatitis B standards of care are inappropriate for patient management in Africa. They found that, according to the WHO, the rate of diagnosis “is inappropriately high in sub-Saharan Africa”, which is often limited by a lack of resources.

The problem, say the researchers, is that the WHO’s existing guidelines are not adapted to the African population.

The study that informed these guidelines was conducted among active chronic hepatitis C patients in the United States, much older than Africa’s hepatitis B virus population and in a very different patient population compared to African chronic hepatitis B patients.

“Our data are important for informing clinical practice in SSA and should be considered in the next revision of the WHO hepatitis B guidelines,” says Johannessen.

He says they have shared their findings with the WHO and the Center for Disease Control (CDC) in Africa.

“We believe our findings will inspire the first hepatitis B treatment guidelines for the African world, and even the WHO is now changing its guidelines because of our work,” he told IPS.

“Africa is now the epicenter of the hepatitis B epidemic. In fact, 2 out of 3 new infections occur on the African continent. To combat the hepatitis B pandemic in Africa, we need African data to inform practice,” says Johannessen.

Initially, the researchers thought their main challenge would be getting people to share data.

“But in fact, everyone we reached out to was eager to participate. It’s clear that this is a topic that feels like a priority for colleagues working across Africa,” he says.

The study is the largest, most comprehensive and geographically representative analysis ever conducted in Africa.

“We therefore believe that our results are generalizable,” the researchers conclude.

However, they acknowledge some limitations of their study. For example, the method used to assess liver damage has been associated with technical limitations, including failed measurements reported in patients with certain health conditions such as obesity. The researchers were unable to determine the failure rate for these tests.

“This may affect the overall applicability of our results to the entire population with HBV,” they say.

But Adamson Muula, professor and head of community and environmental health at Kamuzu University of Health Sciences (KUHES) in Malawi, says that in terms of the methodology used in this study, the systematic review of data was relevant to answering the question.

“In the hierarchy of evidence, systematic reviews and meta-analyses rank high in terms of rigor of findings,” said Muula, who was not part of the research.

However, he noted that there are drawbacks to this approach, including the fact that in the interpretation of the results there is an implicit sense of Africa as a place. Muula argues that African health systems can be different even within the same country.

Within a country you can find a health system comparable to developed countries; others are more adapted to developing countries. The studies concerned more those with less sophisticated health systems.

Regardless, the study is vital, he admits.

Hepatitis B diagnosis on the continent has been a luxury. In Malawi, for example, where 5 percent of adults are estimated to be infected, virtually no screening or diagnostic system exists.

Individual patients can interact with healthcare, but more so when things are already out of hand when irreversible liver damage has already occurred.

“Efforts to reduce the time when diagnosis can take place are therefore commendable. This study provides guidance on when such an earlier diagnosis can be achieved.

“But research is one thing, strengthening health systems is another. Studies like this add momentum and arm policymakers to make the right decisions,” he says.

But he urges communities to take responsibility for these findings instead of leaving action in the hands of “sometimes incompetent decision makers.”

“The question should be what does society say about findings like these? If we wait for policymakers to decide when to invest in hepatitis B interventions, we will be waiting the rest of our lives.

“It is time for community groups to work with the duty bearers to the extent that hepatitis B is no longer a neglected tropical disease,” he says.

WHO’s goal is to have eliminated hepatitis by 2030.

IPS UN agency report

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