Barriers and enablers to people-centred viral hepatitis care in Vietnam and the Philippines: Results of a patient journey mapping study.

In Vietnam and the Philippines, viral hepatitis is the leading cause of cirrhosis and liver cancer. This study aims to understand the barriers and enablers of people receiving care for hepatitis B and C to support both countries' efforts to eliminate viral hepatitis as a public health threat by 2030. Retrospective, semi-structured interviews were conducted with a purposive, quota-based sample of 63 people living with hepatitis B or C in one province of Vietnam and one region of the Philippines. A rapid deductive approach to thematic analysis produced key findings among the three phases of care: (1) pre-awareness and testing, (2) linkage and treatment initiation and (3) ongoing treatment and recovery. The research found that participants followed five typical journeys, from a variety of entry points. Barriers during the pre-awareness and testing phase included limited awareness about hepatitis and its management, stigma and psychological impacts. Enablers included being familiar with the health system and/or patients benefiting from social connections within the health systems. During the linkage and treatment initiation phase, barriers included difficult physical access, complex navigation and inadequate counselling. In this phase, family support emerged as a critical enabler. During the ongoing treatment and recovery phase, the cost of care and socially and culturally informed perceptions of the disease and medication use were both barriers and enablers. Exploring peoples' journeys with hepatitis B and C in Vietnam and the Philippines revealed many similarities despite the different cultural and health system contexts. Insights from this study may help generate a contextualized, people-centred evidence base to inform the design and improvement of primary care services for hepatitis in both research sites.

Contextual and individual factors associated with knowledge, awareness and attitude on liver diseases: A large-scale Asian study.

There are limited data to provide better understanding of the knowledge/awareness of general population towards liver health in Asia. We sought to identify the knowledge gaps and attitudes towards liver health and liver diseases as well as evaluate associated individual-level and macro-level factors based on contextual analysis. An online survey assessing knowledge, awareness and attitudes towards liver health and disease was conducted among 7500 respondents across 11 countries/territories in Asia. A liver index was created to measure the respondents' knowledge level and the degree of awareness and attitudes. Multilevel logistic regression was performed to identify individual factors and contextual effects that were associated with liver index. The overall liver index (0-100-point scale) was 62.4 with 6 countries/territories' liver indices greater than this. In the multilevel model, the inclusion of geographical information could explain for 9.6% of the variation. Residing in a country/territory with higher HBV prevalence (80% IOR: 1.20-2.79) or higher HCV death rate (80% IOR: 1.35-3.13) increased the individual probability of obtaining a high overall liver index. Individual factors like age, gender, education, household income, disease history and health screening behaviour were also associated with liver index (all p-values<0.001). The overall liver index was positively associated with the two macro-level factors viz. HBV prevalence and HCV death rate. There is a need to formulate policies especially in regions of lower HBV prevalence and HCV death rate to further improve the knowledge, awareness and attitudes of the general public towards liver diseases.

Knowledge, attitude, and behaviors toward liver health and viral hepatitis-related liver diseases in Thailand.

ABSTRACT: This study aimed to quantify and evaluate the knowledge and awareness toward liver health and diseases as well as explore the attitudes and knowledge toward screening, diagnosis, and treatment of liver disease among the Thai population.This is a cross-sectional, self-reported and web-based questionnaire study. Awareness, perceptions and attitudes toward liver-related health and diseases as well as screening, diagnosis and treatment of liver diseases were assessed among 500 Thai adults.Respondents were mostly ≥35 years (62.0%) and females (52.0%). While there was an overall awareness regarding viral hepatitis as the main etiology of liver failure/cancer, respondents expressed misperceptions that hint at social stigmatization or discrimination toward infected individuals. A significant proportion lacked knowledge of liver screening tests and relevant diagnostic tests for viral hepatitis-related liver diseases. Screening or treatment costs and perception of being healthy were among reasons for not seeking medical consultation when exposed to risk factors or diagnosed. Treatment practices of hepatitis included prescription medication (59.1%), functional foods (51.8%) and traditional treatment (28.2%). Multivariate analysis identified income, recent health screening status and being diagnosed with liver disease(s) as significant predictors of the knowledge, attitude, and behaviors of the Thai population toward liver diseases.This study highlighted a degree of misperception and lack of in-depth understanding toward hepatitis-related liver diseases including poor attitudes and knowledge toward screening, diagnosis, and treatment of liver diseases. Factors identified suggest an unmet need to encourage proactive health-seeking behaviors to reduce transmission risks of hepatitis-related liver diseases within the community.

Efficacy of entecavir in chronic hepatitis B patients with mildly elevated alanine aminotransferase and biopsy-proven histological damage.

UNLABELLED: Current guidelines for management of chronic hepatitis B recommend treatment for patients presenting with elevated hepatitis B virus (HBV) DNA and alanine aminotransferase (ALT) >2 x upper limit of normal (ULN) or histological evidence of liver disease. Retrospective analyses have demonstrated that significant hepatic necroinflammation and fibrosis were present in a substantial proportion of patients with ALT 1 to 2 x ULN. To assess therapeutic efficacy in this clinical setting, we retrospectively examined treatment endpoints among the subset of nucleoside-naïve chronic hepatitis B (CHB) patients treated in phase 3 clinical trials of entecavir who had both screening and baseline serum ALT 1.3 to 2 x ULN. A total of 1347 patients were randomized to treatment with entecavir or lamivudine. Three hundred thirty-six patients, constituting 25% of the total study population, had screening and baseline ALT 1.3 to 2 x ULN. Clinically significant necroinflammation (Knodell necroinflammation score > or =7) was observed in 60% and 72% of hepatitis B e antigen (HBeAg)-positive and HBeAg-negative patients, respectively, whereas marked fibrosis (Ishak fibrosis score > or =4) was observed in 8% and 15% of HBeAg-positive and HBeAg-negative patients, respectively. Among entecavir-treated HBeAg-negative patients, the proportions of patients achieving histological improvement, HBV DNA <300 copies/mL, and ALT normalization were similar between patients with mildly elevated ALT and those with ALT >2 x ULN. However, entecavir-treated HBeAg-positive patients with mildly elevated ALT had lower response rates for histological improvement, HBV DNA less than 300 copies/mL, ALT normalization, and HBeAg seroconversion than those with ALT greater than 2 x ULN. CONCLUSION: This retrospective analysis demonstrated that HBeAg-negative CHB patients treated with entecavir responded similarly irrespective of baseline ALT level. However, HBeAg-positive patients with mildly elevated ALT responded less well to treatment with entecavir than did those with ALT greater than 2 x ULN.

Patterns of managing chronic hepatitis B treatment-related drug resistance: a survey of physicians in Mainland China, South Korea, Taiwan, and Thailand.

PURPOSE: The emergence of antiviral resistance can negate the benefits of antiviral therapy in patients with chronic hepatitis B (CHB). This study aimed to assess how physicians in Asia manage suspected antiviral resistance. METHODS: Randomly selected CHB-treating physicians in Mainland China, South Korea, Taiwan, and Thailand underwent a face-to-face interview. A standardized questionnaire was used to assess how physicians identify, monitor, and manage suspected resistance and its associated medical costs. RESULTS: We interviewed 575 physicians from January to May 2008. Most physicians preferred a "prevention-of-antiviral resistance" strategy over a "rescue-once-resistance-develops" strategy. Physicians had encountered lamivudine resistance most frequently (96-100% of respondents), followed by the resistance to adefovir (18-58%) and entecavir (3-7%). While physicians in South Korea and Taiwan have access to resistance testing, physicians in Mainland China and Thailand have limited access to resistance testing but rely on HBV DNA and alanine aminotransferase (ALT) tests to identify resistance. Once resistance is suspected, 60% of the physicians in Mainland China, South Korea, and Thailand monitored these patients quarterly and the remaining 40% opted for monthly follow-up. In comparison, 70% of the Taiwanese physicians monitored these patients monthly. The average total direct medical costs, excluding antiviral costs, to manage a patient during the first year after suspected resistance is identified ranged from USD $319 to USD $709. CONCLUSIONS: Limited access to HBV resistance tests causes physicians in Asia to manage suspected resistance by various HBV DNA assays and ALT tests. This raises concerns that resistance may not be detected early enough to be rescued efficiently.