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NOhep Medical Visionaries Forum at AASLD 2022
While attending the 73rd AASLD Annual Meeting this year in Washington, DC, the World Hepatitis Alliance held a NOhep Medical Visionaries Forum, in partnership with the Hepatitis B Foundation and ICE-HBV.
The forum was titled 'Hepatitis B and an Undetectable=Untransmittable (U=U) campaign'. It was an exciting meeting that explored the impact that U=U messaging could have on those living with hepatitis B.
Speakers included:
Dr. Cami Graham, MD, MPH, Co-director of the Viral Hepatitis Center, Division of Infectious Disease, Beth Israel Deaconess Medical Center, Assistant Professor of Medicine at Harvard Medical School, Medical Director at Program RISE
Micheal Ighodaro, Director, Global Policy Advocacy at Prevention Access Campaign
Dr. Mark Sulkowski, MD, Professor of Medicine, Medical Director of the Viral Hepatitis Center, and Senior Associate Dean for Clinical Trial, Johns Hopkins University School of Medicine. Director, Division of Infectious Diseases at the Johns Hopkins Bayview Medical Center
Professor. Patrick Kennedy, MB BCh BAO BMedSci FRCP MD, Professor of Hepatology, Consultant Hepatologist & Gastroenterologist, Barts and The London School of Medicine & Dentistry, Queen Mary University of London, UK
Dr. Su Wang, MD, MPH, FACP Medical Director, Viral Hepatitis Programs and Center for Asian Health at Cooperman Barnabas Medical Center, RWJBH and Past-President World Hepatitis Alliance
Dr. Lewis Roberts, M.B., Ch.B., Ph.D., Professor in Gastroenterology Cancer Research and Consultant in Gastroenterology and Hepatology at the Mayo Clinic, Co-Principal Investigator of the Mayo Clinic Specialized Program of Research Excellence (SPORE) in Hepatobiliary Cancers
The forum was chaired by Dr. Chari Cohen, President at Hepatitis B Foundation and Jessica Hicks, Director at World Hepatitis Alliance. It explored the HIV U=U movement, how it came to be and how it has been transformative for people living with HIV. It then discussed three important questions about U=U for HBV:
Can we say U=U for HBV and if not, what data is needed?
How could U=U messaging help people living with HBV?
If not U=U, what similar messaging can we develop now for HBV?
The forum opened with an explanation of the origins of U=U in the HIV space and why it was important to have a bold statement like U=U and not something complex with many caveats as it would not be easily understood. Advocates, not medical experts, were the ones who decided on U=U because it provided a clearer message.
Insight was given into the community perspective on U=U. Many of those living with HIV thought they would always be infectious, leading to stigma and discrimination, and a fear of having intimate relationships. However, U=U has offered a powerful message that has changed and transformed patient lives. Prevention Access Campaign (PAC) and partners launched a U=U campaign in 2016 to build and communicate a consensus about the largely unknown fact: people living with HIV who are on treatment and have an undetectable viral load cannot sexually transmit HIV.
A breakthrough moment in the U=U movement was when Dr Anthony Fauci, Director of the National Institute of Allergy and Infectious Diseases (NIAID), highlighted it. Embracing the U=U messaging transformed the HIV field entirely. This breakthrough gave an incentive for those living with HIV to stay on treatment and sent an important message that they could lead live normal lives. It also served to motivate people with HIV to initiate and adhere to long-term antiviral treatment. U=U removed the constant worry of transmission that people had with sexual partners. Additionally, the U=U message has played a role in removing discriminatory policies and improving social and professional opportunities for people living with HIV globally.
The current hepatitis B guidelines and the data currently available for moving forward with a similar campaign for hepatitis B were explored. It was discussed that the current evidence and literature should be assembled along with the potential benefits and scenarios where U=U is important. Currently, treatment as prevention for hepatitis B is the approach in pregnancy in order to prevent mother-to-child transmission. Antiviral treatment is recommended for pregnant women with HBV DNA over 200,000 IU/ml by many societies, and there are many studies documenting effectiveness in the PMTCT field.[1] It was brought up that treatment to prevent transmission is also recommended for healthcare workers doing exposure prone procedures, such as surgeons.[2] [3]
Chronic hepatitis B is a dynamic disease and is always in a state of change. Unfortunately, the guidelines are likely to miss out on many of those who need treatment because they do not meet the current treatment criteria and are not able to receive regular follow-up. There was much discussion between delegates about the need to simplify hepatitis B guidelines and guidances, so that more frontline providers can provide care for people living with hepatitis B. Also, the need for flexibility in low resource settings is important as many people are unable to access HBV DNA testing and currently, it is a core part of treatment eligibility and many providers do not feel empowered to go outside of current guidelines.
The African perspective was also explored, and it was explained that a large proportion of those who are diagnosed with liver cancer in Sub-Saharan Africa do not meet any guidelines for treatment. Many individuals develop liver cancer at a much earlier age in Africa than in other parts of the world, and antiviral treatment likely needs to be initiated earlier to prevent these outcomes. It was also stated that the global community has failed these disproportionately affected communities and that political will is needed to make a bigger difference.
A primary care provider and person living with hepatitis B gave insight into how impactful the U=U messaging could have on those living with hepatitis B. She shared her story of being diagnosed as a college student and how she realizes now that her hepatitis B status could have potentially hampered her training. There are numerous reports of students and trainees living with hepatitis B not being allowed to continue their training and in the US, this has been deemed discriminatory,[4] However around the world, many with hepatitis B still face discrimination in their education, training and employment.
People living with hepatitis B are very concerned about transmitting the virus to others, their family members and partners, yet are not comfortable speaking with doctors about this. She highlighted how the fear of spreading the virus and the stigma that comes with it, comes up quite a bit in the discussions in the HepB Community (www.hepbcommunity.org) online forum which is a global peer-led, volunteer-driven forum to support those living with and affected by hepatitis B. On the chat boards, people ask a lot about whether they are able to date or marry, when to bring up their hepatitis B diagnose with those whom they are in a relationship, and even how to manage blood cleanup (when they are bleeding from a cut, etc.). It is clear that all these issues are a source of distress for people living with hepatitis B.
She concluded by saying even as a healthcare professional, that a U=U type messaging would have helped her through her journey as someone navigating living with hepatitis B for both her personal and professional life. We need to be aware of how important these psychosocial factors are and how the worry over transmission can greatly impact a persons' quality of life and the community around them. These concerns need to be front and center for those living with hepatitis B.
Following the presentations and throughout the forum, there was very engaging discussion amongst the attendees It was expressed that these conversations are long overdue and much needed. There was discussion about how the U=U movement also brings up the concern of whether we should be treating people earlier for hepatitis B. There is growing evidence that HBV DNA integration happens early in life and could be linked to increase risk of not only liver cancer, but other cancers. One hepatologist indicated that if her children had hepatitis B, she would have them on antiviral at a young age.
It was stated by one attendee that he believes that enough evidence already exists with published data to support a U=U movement for hepatitis B. The HIV U=U campaign was not supported by all at the beginning and it may be there not be consensus at the beginning for hepatitis B as well. One point of discussion what organizations would be helpful to having lead and support the hepatitis B message. Hepatitis community groups, physicians, researchers, and also public health agencies would be important (such as the Center for Disease Control who have supported the HIV U=U campaign in the US). This meeting was an important first step and further efforts are needed to assemble and collate evidence, gather clinical and patient perspectives, and develop an appropriate and accurate messaging campaign to improve the lives of people living with hepatitis B.
[1] https://apps.who.int/iris/bitstream/handle/10665/333391/9789240002708-eng.pdf
[2] https://www.cdc.gov/mmwr/preview/mmwrhtml/rr6103a1.htm
[3] https://shea-online.org/guidance/management-of-healthcare-personnel-living-with-hepatitis-b-hepatitis-c-or-hiv-in-us-healthcare-institutions/
[4] Moraras K, Block J, Shiroma N, Cannizzo A, Cohen C. Protecting the Rights of Health Care Students Living With Hepatitis B Under the Americans With Disabilities Act. Public Health Rep. 2020 Jul/Aug;135(1_suppl):13S-18S. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7407047/
Watch the full video here – Hepatitis B and an Undetectable=Untransmittable (U=U) campaign
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