Decentralization of hepatitis B care in sub-Saharan Africa

An estimated 296 million people live with chronic hepatitis B (CHB) globally. In the absence of treatment, 15-40% of these will die from its complications. Antiviral therapy effectively prevents disease progression and death in CHB. In low-income countries, however, antiviral treatment is rarely available due to complex treatment guidelines, poor laboratory capacity, and lack of public funding. In 2015, our group set up a pilot treatment program for CHB at a referral hospital in Addis Ababa, Ethiopia. In 2021/22, this program was extended to four district hospitals to study simplified CHB care in a low-income country. With the present application we aim to decentralize CHB therapy to rural settings, which will be essential to achieve universal access to antiviral therapy in Africa. This project is a research collaboration between partners in Norway (Vestfold Hospital, University of Oslo) and Ethiopia (Addis Ababa University, St. Paul's Hospital Millennium Medical College). We will study different treatment models, each of which has its theoretical pros and cons: i) Standard model (“treat only if…”): This is the conventional model where we try to identify and treat only those at highest risk of disease progression and death. ii) Inclusive model (“treat all except…”): This is a novel approach. It is generally easier to identify patients at low risk of disease progression, and with this model all patients will receive treatment unless they fall in the low-risk category. iii) Test-and-treat (“treat all”): This is the easiest model where all people with CHB receive treatment without any need for laboratory testing. The primary endpoint will be death or liver decompensation. Moreover, we will study the cost-effectiveness of these decentralized models and compare with the hospital-based models. Implementation research, such as our study, is of vital importance to respond to the research gaps identified by the World Health Organization in hepatitis B care. Our study is expected to directly inform international hepatitis B guidelines and will be a major contribution to the efforts to eliminate viral hepatitis as a public health threat by 2030.

An estimated 296 million people live with chronic hepatitis B (CHB) globally. In the absence of treatment, 15-40% of these will die from its complications. Antiviral therapy effectively prevents disease progression and death in CHB. In low-income countries, however, antiviral treatment is rarely available due to complex treatment guidelines, poor laboratory capacity, and lack of public funding. In 2015, our group set up a pilot treatment program for CHB at a tertiary hospital in Addis Ababa, Ethiopia. In 2021/22, this program was extended to four regional secondary hospitals to study simplified CHB care in a low-income country. With the present application we aim to decentralize CHB therapy to rural settings, which will be essential to achieve universal access to antiviral therapy in Africa. We will study different treatment models, each of which has its theoretical pros and cons: i) standard model (“treat only if…”), ii) inclusive model (“treat all except…”), and iii) test-and-treat (“treat all”). The primary endpoint will be death or liver decompensation, and secondary endpoints will be programmatic and laboratory success indicators. Finally, we will study the cost-effectiveness of these decentralized models and compare with the tertiary/secondary hospital-based model. Implementation research, such as our study, is of vital importance to respond to the research gaps identified by the World Health Organization in hepatitis B care. Our study is expected to directly inform international hepatitis B guidelines and will be a major contribution to the efforts to eliminate viral hepatitis as a public health threat by 2030.