Black Patients Less Likely to Meet Hep B Treatment Criteria

While Black patients with chronic hepatitis B virus (HBV) infection were less likely to meet treatment criteria, race and socioeconomic factors were not associated with treatment initiation, a longitudinal observational study suggested.

In a cohort of 1,550 HBV-infected patients followed for approximately 7 years, just 14% of Black patients met American Association for the Study of Liver Diseases treatment criteria compared with 22% of Asian patients and 27% of white patients (P=0.01), reported Anna S. Lok, MD, of the University of Michigan in Ann Arbor, and colleagues in JAMA Network Open.

However, the cumulative probabilities of treatment initiation after meeting criteria were not significantly different among racial groups at 48 weeks and 72 weeks (P=0.68):

• Black patients: 0.45 and 0.45
• Asian patients: 0.38 and 0.51
• White patients: 0.40 and 0.51

Of note, the incidence of major adverse liver outcomes, including hepatic decompensation, hepatocellular carcinoma, liver transplant, and death, was 0.1 per 100 person-years and did not differ by race, they said.

"This study noted that African American or Black participants had a lower prevalence of HBeAg [hepatitis B e antigen] and lower HBV DNA levels among those who were HBeAg-negative, leading to a lower percentage meeting treatment criteria," Lok and team explained. Just 12% of Black patients were HBeAg-positive, compared with 30% of Asian and 15% of white patients (P<0.001).

"An important concern raised by some experts is whether thresholds for starting therapy should be lower in African American or Black individuals compared with those of other races," they added.

Factors associated with not being treated included gender and family history. Among eligible patients not treated, 70% were women and 80% had a family history of HBV. Clinicians may believe women have a lower risk of adverse outcomes, Lok and team suggested. Furthermore, previous research has found that some patients mistakenly believe that a family history means chronic HBV is an inherited disease and treatment will not make a difference.

In an accompanying editorial, H. Nina Kim, MD, MSc, of the University of Washington in Seattle, pointed out that Asian, Black, and Indigenous people, as well as immigrants, are disproportionately affected by HBV. According to the CDC's 2020 Viral Hepatitis Surveillance Report, Black people were 3.9 times more likely to have chronic HBV and 2.5 times more likely to die from the infection compared with white people, Kim noted.

"These data may be less surprising when we consider the lower rates of HBV screening, vaccination, and clinical evaluation reported among Black individuals compared with other groups in the United States," Kim wrote. "The fact that we have not observed racial disparities in treatment initiation does not mean none exist; it means we have to look harder to find them."

An important limitation to the study, noted by both Kim and the researchers, was that all participants were receiving care by a liver specialist. This may have enhanced treatment rates and obscured any differences in treatment initiation by race, they said. In addition, the small number of Black patients eligible for treatment may have underpowered the study to detect racial differences in treatment uptake, they added.

Furthermore, Kim noted, cohort participants were to some extent a self-selected group, and not representative of the general population, because they had consented to take part in the study. "Participants in this cohort were already engaged in specialty care at an academic health center when they consented to a study that might involve extra visits outside of their usual care or enrollment in a clinical trial. In other words, they were a selected group," she wrote.

"There may have been implicit exclusions from this study due to socioeconomic, cultural, and language barriers, as well as differing levels of trust in healthcare and research institutions," Kim explained. "Engagement in research has not historically been equitable or representative in the field of HBV."

For this study, Lok and team examined data from the Hepatitis B Research Network adult cohort study, which included 20 centers in the U.S. and one in Canada, and enrolled a racially diverse cohort of patients with chronic HBV. The majority of patients (75%) were Asian, 10% were white, and 12% were Black. Women comprised 51% of the cohort, and the median age was 41.2.

Data were collected from January 2011 to January 2018. The researchers used various statistical methods, including Kaplan-Meier estimates and multivariable Cox proportional hazard models, to look for factors associated with treatment initiation and outcomes, including age, sex, race, educational level, income, insurance type, and other factors.

During 5,727 person-years of follow-up, 504 participants initiated treatment, with incidences of 4.8 per 100 person-years in Black patients, 9.9 per 100 person-years in Asian patients, 6.6 per 100 person-years in white patients, and 7.9 per 100 person-years in those of other races (P<0.001)

An additional study limitation noted by Lok and colleagues was that they did not examine why eligible patients did not receive treatment.

"The reasons for lack of treatment initiation in eligible patients are complex and many unmeasured factors, such as health literacy, patient preference, and healthcare professional perspective, may have played a role in treatment decisions, but these data were not collected," they wrote.

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