Table 2 Call to action and future directions in HBV elimination

Prevention of mother-to-child transmission

 • NMoH must ensure access to birth dose HBV vaccine

 • Gavi should support countries with birth dose HBV vaccine

 • HBV DNA needs to be made universally available to assess need for TDF prophylaxis and to monitor ongoing antiviral therapy

 • Pregnant women need access to education, diagnosis and risk-stratification

 • Antiviral prophylaxis must be available in pregnancy when HBV DNA is high

Set up national treatment programs for HBV

 • NMoH cannot wait for external funding. Treatment of HBV is cost-effective and should be an urgent priority [96].

African HBV treatment guidelines

 • Africa CDC should take the lead in driving the development of African Guidelines

 • Given the diversity of healthcare services in Africa, guidelines cannot take a one-size-fits-all approach but should be tiered to available resources (e.g. with or without access to HBV DNA)

 • Lack of laboratory facilities should not disqualify patients from treatment

 • We propose a new paradigm in HBV therapy in LMICs: ‘Treat-all-except’. This approach will ensure that most patients with or at high risk of significant liver disease are treated and could save costs compared to a ‘Treat-all’ strategy

Integration, simplification, task sharing, decentralization

 • These were success factors in HIV programs and NMoH do not need to reinvent the wheel when setting up HBV care and treatment services

 • Integration will further promote triple elimination goals for HIV, syphilis, and hepatitis B

 • Simplified treatment guidelines with task sharing from physicians to nurses/health officers and decentralization outside specialized hospitals

 • Training of peer supporters and community advocacy is essential

Awareness, screening, and linkage-to-care

 • NMoH must prioritize active screening campaigns; reliance on passive case finding will not have significant public health impact

For hepatitis B, screening might be done only once for the whole adult population; there is no need for repeated mass screening in countries where transmission mainly occurs in childhood

Industry

 • Access to drugs: Although TDF is off-patent, access for HBV mono-infected patients is still restricted in many countries since it is only registered as an HIV drug. Pharmaceutical companies must take on this responsibility and remove bureaucratic obstacles to scaling up HBV treatment in Africa. Affordable access to Entecavir and TAF is also important in PLWHB who have renal impairment or are at risk of osteoporosis

 • Access to diagnostics:Industry should be prompted to set up access programmes in LMICs for affordable and reliable POC assays for HBsAg and HBV DNA viral load testing; and transient elastography machines. The HIV sector managed to develop a range of POC assays for CD4 cell counts and HIV viral load [97]; these technologies could be modified to test for HBV DNA. It is essential to validate tools that can be utilized in decentralized settings. For instance, investing in the improvement and prequalification of a rapid test for hepatitis B e antigen is an area deserving attention

Academia

 • Share data from Africa: HBV data from Africa are scarce, and clinicians/researchers on the continent working with PLWHB should be encouraged to share their data, preferably via larger registries like the HEPSANET collaboration (https://www.hepsanet.org or Research platforms such as PROLIFICA (https://www.prolifica.africa/team-partners/the-team)

 • Prioritize high-impact studies: There are urgent research gaps that need to be prioritized to inform guidelines and influence policy in Africa. These include:

  ◦ Large longitudinal cohort studies to highlight the following: (i) the natural history in untreated patients, (ii) risk factors for HCC and cirrhosis, (iii) optimal threshold for initiating antiviral therapy, and (iv) treatment efficacy, resistance, and long-term toxicity

  ◦ Studies on the feasibility and cost-effectiveness of different models of care: (i) Treat-all, (ii) Treat-all except…, (iii) Treat only if…

  ◦ Study strategies to integrate HBV testing and treatment into existing healthcare systems

  ◦ PMTCT implementation research as part of the WHO triple elimination strategy

  ◦ Surveillance strategies and low-cost diagnostic markers for HCC