Universal testing for hepatitis B must be accompanied by better linkage with care

Comprehensive testing, monitoring, and treatment in primary care could save hundreds of Australian lives each year

Tens of thousands of Australians have undiagnosed chronic hepatitis B, most since infancy.1 Chronic hepatitis B is an important cause of cirrhosis, liver failure, and hepatocellular carcinoma. In eligible patients, antiviral therapy can prevent progressive liver disease and reduce the risk of hepatocellular carcinoma, but this potentially lifesaving therapy is not provided to people with clinically silent disease if a hepatitis B surface antigen (HBsAg) test is not undertaken. In 2012, liver cancer was the most rapidly increasing cause of cancer deaths in Australia.2

While the proportion of Australians with chronic hepatitis B who have been diagnosed is relatively large (about 70%),3,4 progress in increasing this proportion has been unacceptably slow over the past decade.1 The current risk‐based approach to testing, in which clinicians are expected to navigate sixteen indications and thirteen risk groups,5 must be transformed. One proposal is to offer HBsAg testing once to all people born before the year 2000 with unknown hepatitis B status.6 In United States, where an estimated 0.24% of people have undiagnosed chronic hepatitis B, a recent analysis found that universal one‐time HBsAg testing of adults would not only be cost‐effective, but probably cost‐saving compared with current practice.7

In this issue of the MJA, Xiao and colleagues8 report an Australian investigation of this question. Similar to the American study, their analysis assumed that testing would be opportunistic, undertaken during general practice consultations for other reasons. This is important, as adding a specific consultation for testing would render the intervention cost‐ineffective; in the most favourable scenario, the latitude for additional costs that did not eliminate cost‐effectiveness was limited ($4.02 per person tested). The authors estimated chronic hepatitis B prevalence among people eligible for universal testing to be 0.45%, nearly twice that in the United States.7 As noted by Xiao and colleagues, this estimate was conservative; by restricting testing to people born before 2000 (ie, those less likely to have been vaccinated as infants) and excluding people who had previously tested negative for HBsAg, the prevalence of undiagnosed chronic hepatitis B in the eligible population, and therefore the likelihood of testing being cost‐effective, were increased.8

All models are limited by uncertainty in the input data. The analysis by Xiao and colleagues is no exception. Contemporary serosurvey estimates of the prevalence of chronic hepatitis B in the general Australian population are unavailable, as is information about that of chronic infection among those not previously diagnosed. The latter parameter has substantial influence on the question of whether a universal testing approach is likely to be cost‐effective.8

Testing alone cannot achieve the desired individual or public health outcomes; what happens after a positive test result determines the benefits realised. Xiao and colleagues consequently found that undertaking universal testing in isolation was not cost‐effective. A strategy in which 50% of people with chronic hepatitis B were linked with appropriate care by 2030, however, was cost‐effective, and the larger this proportion, the greater the cost‐effectiveness. Like all member states of the World Health Assembly, Australia has committed to diagnosing 90% of people living with chronic hepatitis B and providing antiviral treatment to 80% of those diagnosed and eligible by 2030.4 These aims will require linking many more than 50% of people with hepatitis B diagnoses to care.

How can this transformation of diagnosis and care rates be achieved? In Australian primary care, increasing demand and declining access to affordable care for patients are already problems.9 Any addition to the workload of primary care physicians must deliver clear value for their patients, be supported by adequate resources and clear guidance, and ideally be accompanied by efficiency gains.

Simplifying testing criteria and clearly documenting results to avoid repeat discussions and testing can increase efficiency. In an earlier analysis,10 Xiao and colleagues found that achieving the World Health Organization hepatitis B targets would be highly cost‐effective in Australia were $500 million of public funds invested in program implementation, including clinician support and meaningful engagement with communities at the greatest risk. As most Australians with chronic hepatitis B were born overseas or are Aboriginal or Torres Strait Islander people,3 this critical investment would be directed to eliminating a condition with greatest impact in communities subject to inequitable health outcomes and barriers to health care. A cost‐effective program would thus improve both health equity and public health.

Comprehensive testing, monitoring, and treatment in primary care to achieve the WHO hepatitis B targets by 2030 will save hundreds of Australian lives each year.1 Reaching people who are undiagnosed and helping them make the vital first step into the chronic hepatitis B cascade of care is fundamental to this objective. The report by Xiao and colleagues provides important new information on how this might be attained cost‐effectively, a consideration never more important than it is today.