Table 1 Expanded access to treatment in the WHO Africa region: The arguments for and against

Financial implications

Potential long-term cost-effectiveness, based on reduction of complications and transmission

Avoid potentially unnecessary treatment that may represent an excessive financial impact on healthcare systems with conflicting priorities and scarce resources

Expanded treatment may not be cost-effective in all settings

Retention in care

Avoid the need for HBV DNA testing with its inherent complexities (stock-outs, out of pocket costs, capital and maintenance costs) in resource-limited settings. May enhance the initiation of antiviral treatment which is associated with improved retention in care, relative to deferral and monitoring

Investigations such as HBV DNA and ALT may reduce the uptake of initiating antiviral therapy; but can help patients to understand their disease stage, and therefore may enhance the retention in care for those initiated

Risk of liver complications in low-risk groups

A more inclusive model might be pertinent in Africa, given limited natural history data from the region and the high incidence of HBV-related cirrhosis

A more restrictive model reflects the uncertain benefit of treatment for patients with normal ALT and low HBV DNA, and reduces exposure to unnecessary costs and side-effects

HCC incidence

Young age of HCC and poor prognosis at time of diagnosis in real-world cohort studies from Africa

Age-standardized HCC incidence do not show an excess of cases for WHO Africa; age of onset might be explained by population age distribution

HBV transmission

Expanded treatment access reduces risk of horizontal and vertical transmission

HBV DNA quantification can inform transmission risk

Longitudinal outcome data

Less loss to follow up in treated compared to untreated populations

Longitudinal monitoring of untreated patients can refine and optimize treatment criteria specific to WHO Africa