Originally published by our sister publication Pharmacy Practice News
By Ethan Covey
Due to multiple factors, immigrants living in the United States who have chronic hepatitis B virus (HBV) are vulnerable to gaps in antiviral use. This can increase their risk for serious outcomes, according to a study presented at IDWeek 2024, held in Los Angeles (poster P-2184).
“Liver disease and cancer due to hepatitis B are important health disparities affecting Asian, African and Latino immigrants in the U.S.,” said Lydia Tang, MBChB, an assistant professor of medicine, Institute of Human Virology, University of Maryland School of Medicine, in Baltimore.
“Currently, there is no effective cure for chronic hepatitis B,” Dr. Tang added. “We have oral antiviral medications, such as tenofovir alafenamide [TAF] and tenofovir disoproxil [TDF], which are great for chronic suppressive therapy and will reduce the risk of progression of liver disease including cirrhosis and liver cancer, … if taken consistently.”
Most people who take antivirals will need to take them for decades, or even for life. However, Dr. Tang said, “Any healthcare provider that takes care of patients with chronic hepatitis B will tell you that keeping their patients on antivirals can be challenging: Many insurances require annual prior authorizations, which creates a lot of administrative burden for the healthcare provider, and people with chronic hepatitis B are frequently confronted with high copays.”
And these significant challenges are only the tip of the iceberg for many individuals with chronic HBV.
“In the United States, the vast majority of people with chronic hepatitis B are immigrants,” Dr. Tang said. “Many immigrants face financial and language/cultural barriers, fear of stigma, and social isolation, which greatly affect access to care and information, and can prevent them from achieving healthcare self-efficacy.”
To shed light on these issues, this study aimed to describe antiviral use among a cohort of immigrants with chronic HBV, and to identify factors that could be associated with nonadherence with antivirals.
The study focused on people enrolled in the HOPE trial, a longitudinal natural history study enrolling people with chronic HBV infection, and TEMUL, a standard-of-care sub-study, which provides free TAF for two years.
From May 2017 to March 2024, 92 people received TAF through TEMUL, including 84 who were foreign-born. Eighty-one completed TEMUL with sustained adherence to TAF and were transitioned to receive ongoing antivirals through their regular healthcare provider. Fifty-eight completed a two-year follow-up. During the post-TEMUL follow-up period, antiviral switches were common, occurring in 22% of the cohort. Lapses in antiviral use were seen in one-fourth of the cohort, with 17% of the participants stopping antivirals altogether. Poor insurance coverage, high copays and communication issues with the pharmacy and healthcare providers were cited frequently as the reason for stopping medications.
Additionally, a higher proportion of non-English speakers and people without insurance experienced lapses in antivirals compared with those who adhered to antivirals. Having limited English proficiency was the most strongly associated with antiviral nonadherence .
“Our findings have real-world clinical import as it shows that to improve hepatitis B–related morbidity and mortality in the U.S.,” Dr. Tang said. “We need to develop interventions to improve access and adherence to antivirals tailored to non-English speakers.”
Dr. Tang noted that the biggest question raised by the study was how to develop and implement interventions to improve antiviral adherence among the immigrant population.
“Engagement of patients, community healthcare workers with expertise in these communities and community healthcare providers is key in future research,” she said. “Our study is important because to achieve the WHO and HHS’s [Department of Health and Human Services’] goals of eliminating viral hepatitis as a public health threat, we must understand the health behaviors of immigrants living with chronic hepatitis B in the U.S., and there is a paucity in literature on this subject.”
Dr. Tang received research funding for this study paid to her institution from Gilead Sciences.