A Big Step Forward for Liver Health

Danjuma Adda

JALINGO – In late March, the World Health Organization released new guidelines on the prevention, diagnosis, and treatment of chronic hepatitis B (HBV) infection. As a person living with HBV, I welcome the changes, which could significantly reduce deaths from liver cancer in Africa.

The story of Wisdom, a father and the founder of one of the best private schools in his hometown in Nigeria, demonstrates the need for a new approach to treating HBV. After trying to donate blood to his sick cousin, Wisdom was shocked to learn that he had HBV. But medical staff told him to go home and return in six months, because his viral load was too low to treat based on the 2015 WHO guidelines.

Wisdom never felt the need to return to the hospital, because he appeared healthy, and the doctor had not seemed concerned about his infection. But 13 weeks later, while working on his farm, Wisdom felt a sharp pain in his upper right abdomen, had nausea, and nearly fainted. After weeks of tests, he was diagnosed with advanced liver cancer. Last August, a mere five months after his initial diagnosis, Wisdom passed away, leaving behind his wife, daughter, and a pile of medical bills.

Outcomes for cases of liver cancer are poor across Africa. Like Wisdom, the majority of Africans are diagnosed late, leaving little time to initiate treatment. The median survival rate in Sub-Saharan Africa (SSA), where 95% of patients with liver cancer present with advanced or terminal disease, is 2.5 months. By contrast, around 40% of patients in high-income countries are diagnosed at an early stage, when curative or life-prolonging interventions are still possible.

All hepatitis infections cause inflammation in the liver. So it is no surprise that, according to recent cancer statistics, 70% of liver cancer cases are related to HBV and hepatitis C viral infections. More worrying, the data show a 25% increase in global deaths caused by liver cancer between 2010 and 2019. In 2020, 830,200 people died from liver cancer, and nearly half of those cases were due to HBV.

I was diagnosed with HBV in 2004. As was the case for Wisdom, several tests showed that I had a low viral load, and my clinicians, using protocols developed by liver specialists in Nigeria, Europe, and the United States, did not recommend treatment. The 2015 WHO guidelines would later call for the same approach to patients like me: run a series of diagnostic tests, and forgo treatment if the viral load is low. I felt powerless to make decisions about my own health.

Despite doctors’ assurances that I was healthy, I lived in constant fear of liver cancer; each day I monitored my body for signs of it developing. My anxiety only increased when I read about the disease and attended scientific meetings on the subject, especially once I learned that men with HBV in Africa are more likely to develop liver cancer, even with low viral loads. So, some years ago, I started taking the daily oral medication that the WHO recommends for treating HBV. While these drugs have kept me healthy so far, I pay for them out of pocket – a privilege that not everyone can afford.

Most people with HBV have neither the scientific knowledge nor the financial resources to advocate for themselves, which is why the new WHO guidelines will help save lives. Under the four new options for meeting treatment eligibility, up to half of people with HBV will be able to receive potentially life-saving antivirals, whereas previously only one-fifth could.

Moreover, the guidelines also identify additional circumstances in which a patient may demand treatment, such as to prevent transmission to family members or sexual partners, and to reduce the risk of liver cancer. That means almost all patients with HBV could potentially be eligible for antivirals, a sharp contrast to the previous guidelines, which called for treating only those patients with advanced liver disease.

The new guidelines represent a leap forward by expanding treatment eligibility and allowing for co-decision-making between clinicians and patients, which will undoubtedly lead to more people being treated for HBV. Nevertheless, there is room for improvement. For example, the recommended use of HBV DNA tests for continued monitoring fails to account for the fact that such tests are not widely available in Africa.

The next step is for governments, especially in SSA, to train health-care workers and patient advocates on the new guidelines to ensure their implementation. They must also ramp up testing to detect people with HBV earlier in the disease’s progression and treat as many cases as possible.

To that end, I urge national hepatitis programs and ministries of health not to let these guidelines gather dust, but rather to act immediately to implement them, which necessitates scaling up testing and treatment. Swift action is the only way to reduce deaths from liver cancer in Africa and achieve the WHO’s goal of eliminating hepatitis B by 2030.