Sex and ethnic disparities in hepatitis B evaluation and treatment across the world

No Differences in Risk of Cirrhosis or Hepatocellular Carcinoma Among Treatment Naïve Chronic Hepatitis B Patients by Baseline Hepatitis B Viral Load: A Propensity Score Weighted Analysis

BACKGROUND AND OBJECTIVES

Previous studies among Korean adults with treatment-naïve chronic hepatitis B (CHB) observed paradoxical relationships between baseline hepatitis B virus (HBV) DNA and risk of hepatocellular carcinoma (HCC). However, these observations have not been validated in Western cohorts. We aim to evaluate the longitudinal risk of cirrhosis or HCC among a national cohort of treatment-naïve patients with noncirrhotic chronic HBV.

METHODS

Using a national cohort of U.S. Veterans with CHB (with baseline HBV DNA ≥2000 IU/mL) from 1/1/2020 to 3/31/2024, we evaluated the long-term risk of cirrhosis or HCC stratified by baseline high HBV DNA (>6.00 log10 IU/mL) or moderate HBV DNA (2000-6.00 log10 IU/mL). We applied propensity score weighting methods to adjust for baseline differences between the two groups.

RESULTS

A total of 1198 noncirrhotic treatment-naïve CHB patients with HBV DNA ≥2000 IU/mL were identified (90.7% were men, 41.7% African American, 29.6% non-Hispanic white, 18.2% Asian, mean age was 54.7 years, 27.9% were HBeAg positive). After propensity score weighting was applied, no significant differences in the incidence of cirrhosis or HCC were observed between CHB patients with moderate vs. high baseline HBV DNA (cirrhosis: 1.02 (95% CI: 0.83-1.25) vs. 1.19 per 100 person-years (95% CI: 0.94-1.51); HR 0.93, 95% CI: 0.68-1.28, P = 0.66; HCC: 0.34 (95% CI: 0.24-0.48) vs. 0.29 per 100 person-years (95% CI: 0.18-0.46); HR 1.02, 95% CI: 1.83, P = 0.95).

CONCLUSIONS

Among a national cohort of Western, predominantly non-Asian patients with treatment-naïve CHB, no significant differences in risk of cirrhosis or HCC were observed by baseline HBV DNA. These data suggest that some epidemiological trends and associations observed in Asian CHB populations may not necessarily be generalizable to non-Asian cohorts with different modes of transmission, risk factors, and virus-specific characteristics.

Differential Characteristics and Survival Outcomes of Patients With Cirrhosis According to Underlying Liver Aetiology

BACKGROUND AND AIMS

Updated data on the survival of patients with cirrhosis are limited, especially for subgroups by specific liver disease aetiology. To inform practice, future modelling studies, and public health planning, our study aimed to provide updated and granular data on survival outcomes of patients with cirrhosis stratified by liver disease aetiology. We also assessed their changes over time.

METHODS

We analysed 8726 consecutive adult patients with cirrhosis who presented at Stanford university medical center during 1/2005-1/2022.

RESULTS

8726 Patients had the following etiologies: hepatitis C virus (HCV) (28.1%), hepatitis B virus (HBV) (4.8%), alcohol-associated (ALD, 33.3%), metabolic-associated steatotic liver disease (MASLD) (9.5%), autoimmune (9.6%), cryptogenic (8.2%) and other etiologies (6.5%). Patients with cryptogenic cirrhosis had the lowest overall 5-, 10-, and 15-year cumulative survival (57.5%, 34.3% and 21.4%), as well as for liver and nonliver-related death, followed by ALD, MASLD, HCV, and autoimmune, while HBV patients had the best survival (86.0%, 70.1% and 65.1%), respectively. On multivariable Cox regression, cryptogenic cirrhosis (vs. HBV) was associated with the highest risk of all-cause death (aHR: 2.24, 95% CI 1.67-3.00), followed by MASLD and ALD (all p < 0.001). Post-2010 time was associated with a 33% lower risk of all-cause death (p = 0.0011); While in the post-2010 period, MASLD (vs. HBV) was associated with the highest risk of all-cause death (aHR: 1.92, 95% CI 1.32-2.80, p < 0.001) followed by cryptogenic and ALD.

CONCLUSIONS

Survival outcomes in patients with cirrhosis varied by aetiology and have changed over time, which should be taken into account for future practice guidelines and modelling studies.

Expanding treatment indications in chronic hepatitis B: Should we treat all patients?

Nucleos(t)ide analogues (NUCs) are first-line agents for chronic hepatitis B (CHB). Current guidelines provide recommendations for NUC initiation, yet the guidelines are complex and restrictive. Accumulating data on hepatitis B virus (HBV) replication and HBV integration suggests that there are no real quiescent disease phases in CHB, and treatment-ineligible patients in current guidelines still have substantial risks of cirrhosis and hepatocellular carcinoma. Expanding CHB treatment indications can effectively reduce the risks of liver-related complications. Furthermore, treatment indication expansion can be cost-effective, and can simplify care pathways to remove treatment barriers. Potential caveats for treatment expansion include risks of non-compliance, long-term side effects from NUCs, and poor patient acceptability. Nonetheless, these caveats are not insurmountable, and the benefits of treatment expansion outweigh the disadvantages. There is consensus among hepatologists in supporting treatment indication expansion, although expert panels have varying recommendations on treatment strategies. A treat-all approach, which involves treating all CHB patients, has also been proposed. A treat-all strategy is straightforward, and should yield the greatest benefits from a population health perspective. However, the feasibility of new treatment strategies, especially the treat-all approach, is influenced by multiple factors including local epidemiology, healthcare resource availability, and socioeconomic factors. A one-size-fits-all approach is not optimal, and treatment expansion strategies that are tailored based on local data should yield the greatest impact toward hepatitis elimination.

Diversity and inclusion in chronic hepatitis B randomised controlled trials: A systematic meta-epidemiological review

Background & Aims

Chronic hepatitis B (CHB) affects global populations unequally, with variable prevalence and pathophysiology. Clinical trials must balance efficiency with adequate representation of the populations most likely to benefit from the interventions they test. We aimed to investigate diversity and inclusion in CHB trials.

Methods

We performed a meta-epidemiological study of randomised controlled trials recruiting people with CHB published in MEDLINE and Embase, January 2010 to July 2023. We extracted participant age, sex, country of recruitment, race and ethnicity, and hepatitis B genotype. We calculated proportions of trials reporting participant demographics and results by demographics (transparency). We compared participants proportionately to global populations affected by CHB of different demographics (representation), and examined demographic-based trial exclusion criteria.

Results

Among 287 trials (81.9% single-country, 18.1% multinational) with 57,503 participants (median size: 102, IQR: 60-185), 97.9% tested drug interventions. Most trials reported participants' age distribution (285, 99.3%) and sex (278, 96.9%). However, only 37.3% (107) trials reported race and ethnicity, 84 (29.3%) reported genotype, and, among multinational trials, only 19 (36.5%) reported recruitment numbers by country. Less than 3% trials reported demography-stratified results. Female sex was under-represented (42.0% people with CHB, 28.7% trial participants). Geographic disparities between those affected by CHB and trial participation were marked for Africa (31.0% vs. 0.01%; under-representation), and Americas or Europe (5.7% vs. 14.0%; over-representation). Many trials had exclusion criteria based on age (71.4% children, 41.5% older adults) or sex-related (157, 54.7%), mostly excluding women who were pregnant, breastfeeding, or of reproduction potential.

Conclusions

Clinical trials for CHB are not inclusive of women and people in Africa. Researchers, funders, and publishers should actively consider diversity and inclusion of trials.

Impact and implications

Clinical trials must balance the need to recruit homogenous participants to efficiently measure an intervention's effectiveness, with the need to produce evidence that can be applied to the whole population affected by a disease. We found chronic hepatitis B (CHB) clinical trials often failed to report basic demographic characteristics of participants, and had under-representation of women and people living in Africa. Given varied disease pathophysiology and treatment needs among different groups, this suggest a mismatch of evidence generation compared with the populations needing treatment, whereby the benefits and harms of different interventions across populations are not being adequately studied. We suggest relevant stakeholders, including researchers, funders, and publishers of CHB clinical trials, should actively recruit under-represented populations, target interventions to those most at need, and either consider demographic factors in results reporting and analysis, or make data easily available for interrogation.

Gaps and disparities in the treatment of chronic hepatitis B infection in the USA

Chronic hepatitis B (CHB) infection affects nearly 300 million individuals worldwide and is a leading cause of hepatocellular carcinoma and liver-related mortality. However, major gaps in the CHB cascade of care persist, with the majority of individuals with CHB not diagnosed and not linked to care and treatment. Even among individuals with known CHB, existing studies report on major gaps and disparities in timely linkage to care and timely access to CHB therapies. While the momentum to expand and simplify CHB treatment guidelines is promising, access to treatment still relies on individuals being effectively engaged in clinical care and liver disease monitoring. The contributing factors to the observed gaps and disparities in the CHB cascade of care are complex and multifactorial, and there is no one-size-fits-all solution than can be easily applied across all global regions. However, any serious approach towards addressing the existing gaps in the CHB cascade of care to improve patient outcomes requires a concerted investment from healthcare institutions, governments, policymakers, and industry partners to provide the necessary resources to be able to achieve this goal. Anything less than a comprehensive and collaborative approach that engages all stakeholders to invest effort and resources into tackling the global epidemic of CHB will continue to fall short in making progress towards global viral hepatitis elimination goals.

Health disparities in cirrhosis care and liver transplantation

Morbidity and mortality from cirrhosis are substantial and increasing. Health disparities in cirrhosis and liver transplantation are reflective of inequities along the entire spectrum of chronic liver disease care, from screening and diagnosis to prevention and treatment of liver-related complications. The key populations experiencing disparities in health status and healthcare delivery include racial and ethnic minority groups, sexual and gender minorities, people of lower socioeconomic status and underserved rural communities. These disparities lead to delayed diagnosis of chronic liver disease and complications of cirrhosis (for example, hepatocellular carcinoma), to differences in treatment of chronic liver disease and its complications, and ultimately to unequal access to transplantation for those with end-stage liver disease. Calling out these disparities is only the first step towards implementing solutions that can improve health equity and clinical outcomes for everyone. Multi-level interventions along the care continuum for chronic liver disease are needed to mitigate these disparities and provide equitable access to care.

Antiviral activity of HuaganJiedu decoction (HGJDD) against hepatitis B virus (HBV) through FOXO4/ERK/HNF4α signal pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Chronic hepatitis B virus (HBV) infection is still a widespread global health issue. HuaganJiedu Decoction (HGJDD) is a common prescription for treating HBV in China, which has the effect of enhancing antiviral efficacy and improving clinical efficacy. However, its precise mechanism of action remains unclear, warranting further investigation to elucidate its therapeutic potential and integration into standard medical practices.

AIM OF THE STUDY

This study aims to explore the therapeutic mechanism of HuaganJiedu Decoction (HGJDD) in HBV.

MATERIALS AND METHODS

We investigated the therapeutic potential of HGJDD, and LC-MS analysis characterized the chemical profile of HGJDD. In vitro, we utilized HepG2.2.15 cell line to assess cytotoxicity and treatment efficacy of HGJDD compared to Entecavir controls. In vivo, assessments included monitoring HBV-related biomarkers and viral load. Network pharmacology and RNA-seq analyses identified molecular pathways and targets influenced by HGJDD treatment. Immunofluorescence and Western blotting provided further insights into the therapeutic mechanisms underlying HGJDD for HBV.

RESULTS

HGJDD showed no toxicity on HepG2.2.15 cells at 10%, 20%, 40%, and 80% serum concentrations. In vitro, HGJDD reduced HBsAg, HBeAg, and HBV DNA levels by dose-dependently and time-dependently. HGJDD can decrease the levels of HBsAg, HBeAg, and HBV DNA in serum and liver levels, meanwhile the therapeutic effect of high-dose HGJDD approach to EVT's in HBV Tg mice. According to intersection of network pharmacology and transcriptome, FOXO signal pathway was highlighted as potential targets and Immunofluorescence find that FOXO4D protein expression lever was increased in three HGJDD group, especially in high-dose HGJDD group. Western blotting confirmed increased level of FOXO4, ERK, and p-ERK and decreased levels of HNF4α, which reflected that the therapeutic effect was closely to FOXO4/ERK/HNF4α signal pathway.

CONCLUSIONS

Traditional Chinese medicine (TCM) offers diverse herbal treatments for HBV, with HGJDD showing efficacy in reducing HBsAg, HBeAg, and HBV DNA levels at cellular and animal levels. This study identified that FOXO4/ERK/HNF4α signal pathway played an important role in HGJDD's therapeutic effects. These findings support HGJDD's potential in HBV treatment, providing a scientific basis for clinical use.

Hepatitis B virus-induced cirrhosis: Mechanisms, global variations, and treatment advances

We focus on hepatitis B virus (HBV)-induced cirrhosis, global differences, and the evolution of antiviral treatment strategies. Chronic HBV (CHB) infection affects more than 250 million people globally, leading to cirrhosis and hepatocellular carcinoma. The aim of this article was to synthesize the current understanding of the pathophysiological mechanisms and clinical consequences of HBV-induced cirrhosis, and explore differences in disease progression between geographic regions. Disease progression varies across regions due to differences in HBV subtypes, transmission routes, and immune responses. The challenge of late diagnosis and treatment, particularly in resource-limited areas, highlights the urgency and importance of CHB service expansion. Modern nucleos(t)ide analogues, such as tenofovir and entecavir, have emerged as the main therapeutic regimens to improve clinical outcomes in patients by suppressing viral replication and attenuating liver fibrosis. However, drug resistance challenges highlight the need for ongoing research and personalized treatment strategies. This article highlights the mechanisms and impact of cirrhosis progression in the context of CHB infection, aiming to reduce the incidence of cirrhosis and its serious consequences, thereby improving the long-term health of CHB patients worldwide, especially in Africa.

Liver diseases and hepatocellular carcinoma in the Asia-Pacific region: burden, trends, challenges and future directions

Globally, nearly half of deaths from cirrhosis and chronic liver diseases (CLD) and three-quarters of deaths from hepatocellular carcinoma (HCC) occur in the Asia-Pacific region. Chronic hepatitis B is responsible for the vast majority of liver-related deaths in the region. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the most common form of CLD, affecting an estimated 30% of the adult population. Compared with people of European descent, people from the Asia-Pacific region carry more genetic variants associated with MASLD and its progression. Alcohol is a fast-growing cause of CLD and HCC in Asia as a result of the rising per-capita consumption of alcohol. Drug-induced liver injury is under-recognized and probably has a high prevalence in this region. The epidemiological and outcome data of acute-on-chronic liver failure are heterogeneous, and non-unified definitions across regions contribute to this heterogeneity. CLDs are severely underdiagnosed, and effective treatments and vaccinations are underutilized. In this Review, we highlight trends in the burden of CLD and HCC in the Asia-Pacific region and discuss the rapidly changing aetiologies of liver disease. We examine the multiple gaps in the care cascade and propose mitigating strategies and future directions.

Trends in Hepatocellular Carcinoma Mortality Rates in the US and Projections Through 2040

IMPORTANCE

The burden of liver cancer varies worldwide. An upward trend in both hepatocellular carcinoma (HCC) incidence and mortality in the past 2 decades has been observed.

OBJECTIVE

To assess observed HCC-related age-standardized mortality rates (ASMRs) in the US for 2006 to 2022 and provide ASMR projections through 2040.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used data from the National Vital Statistics System, which is accessible through the Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research website. Data on deaths attributed to HCC (from January 1, 2006, to December 31, 2022) were obtained for adults 25 years or older and were stratified by liver disease etiology, age, sex, and race and ethnicity. Etiologies included alcohol-associated liver disease (ALD), hepatitis B virus (HBV), hepatitis C virus (HCV), and metabolic dysfunction-associated steatotic liver disease (MASLD).

MAIN OUTCOMES AND MEASURES

The main outcomes were (1) observed ASMRs of HCC per 100 000 persons using Joinpoint regression (National Cancer Institute) to assess trends during 2006 to 2022 and (2) ASMRs projected for 2023 to 2040 using Prophet and AutoARIMA modeling.

RESULTS

This study included 188 280 HCC-related deaths from 2006 to 2022. Most deaths occurred among males (77.4%). The annual percentage change was 4.1% (95% CI, 2.2% to 7.7%) for 2006 to 2009 and decreased to 1.8% (95% CI, 0.7% to 2.0%) for 2009 to 2022, with an overall observed ASMR of 5.03 per 100 000 persons in 2022 and a projected ASMR of 6.39 per 100 000 persons by 2040, with consistent trends for both sexes. By etiology, ASMRs decreased for HCV- and HBV-related mortality but increased for ALD- and MASLD-related mortality. In 2022, MASLD surpassed HBV as the third-leading cause of HCC-related death and was projected to overtake HCV in 2032 as the second-leading cause; ALD was projected to be the leading cause of HCC-related death in 2026. In 2022, the ASMR was higher among individuals aged 65 years or older compared with those aged 25 to 64 years (18.37 vs 1.79 per 100 000 persons). The American Indian or Alaska Native population had the largest increase in projected ASMR by 2040 (14.71 per 100 000 persons) compared with the Asian population (3.03 per 100 000 persons).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, ASMRs for ALD- and MASLD-related HCC death increased rapidly from 2006 to 2022; ALD-related HCC was projected to be the leading cause by 2026, with MASLD as the second-leading cause by 2032. These findings may serve as a reference for public health decision-making and timely identification of groups at high risk of HCC death.

Sociodemographic Disparities in Hepatitis B Treatment: A Real-World Analysis of 3 Safety-Net Health Systems in the United States

Background

Timely treatment of chronic hepatitis B (CHB) reduces risks of cirrhosis and hepatocellular carcinoma. Gaps in timely treatment persist, especially among underserved safety-net populations. We aim to evaluate gaps and disparities in CHB treatment in the United States.

Methods

Adults with treatment-naive CHB without human immunodeficiency virus were identified from 2010 to 2018 across 3 safety-net health systems. CHB treatment eligibility was assessed using American Association for the Study of Liver Diseases (AASLD) criteria and alternative criteria, including the Simplified Approach for Hepatitis B Algorithm. Differences in CHB treatment between groups were evaluated using χ2 methods, adjusted Kaplan-Meier methods, and adjusted Cox proportional hazards models.

Results

Among 3749 patients with treatment-naive CHB (51.5% women, 38.7% White, 33.7% African American, 19.6% Asian, 24.6% cirrhosis), 30.0% were AASLD treatment eligible, among whom 31.0% were treated. Men were more likely than women to be treated (33.5% vs 26.6%, P < .01). On multivariable regression, there remained a trend toward greater treatment in men versus women (adjusted hazard ratio [aHR], 1.21 [95% confidence interval {CI}, .96-1.54]). Disparities by race/ethnicity and insurance status were observed. When exploring outcomes using SABA criteria, similar trends were observed. Among treatment-eligible patients, greater likelihood of treatment was observed in men versus women (aHR, 1.40 [95% CI, 1.14-1.70]) and in Asians versus Whites (aHR, 1.50 [95% CI, 1.16-1.94]).

Conclusions

Among an ethnically diverse multicenter safety-net cohort of CHB patients, less than one-third of treatment-eligible patients received antiviral treatment. Significant disparities in CHB treatment were observed by sociodemographic characteristics.