Barriers to longitudinal follow-up for hepatitis B treatment in rural Sierra Leone: A mixed methods study of retention in care.

HBV disproportionately affects resource-limited settings, and retaining patients in longitudinal care remains challenging. We conducted a mixed methods investigation to understand the causes of losses to follow-up within an HBV clinic in rural Sierra Leone. We developed a multivariable logistic regression model of baseline clinical and sociodemographic factors predicting losses to follow-up, defined as failing to present for a follow-up visit within 14 months of enrollment. We included patients enrolled between April 30, 2019 and March 1, 2020, permitting 14 months of follow-up by April 30, 2021. We then developed a survey to solicit patient perspectives on the challenges surrounding retention. We interviewed randomly selected patients absent from HBV care for at least 6 months. Among 271 patients enrolled in the Kono HBV clinic, 176 (64.9%) did not have a follow-up visit within 14 months of the study end point. Incomplete baseline workup (aOR 2.9; 95% CI: 1.6-4.8), lack of treatment at baseline (aOR 5.0; 95% CI: 1.7-14.4), and having cirrhosis at baseline (aOR 3.3; 95% CI: 0.99-10.8) were independently associated with being lost to follow-up. For the patient survey, 21 patients completed the interview (median age 34 years [IQR: 25-38]). Travel-related factors were the most frequently reported barrier to retention (57%). Almost 30% suggested improved customer care might support retention in care; 24% requested to be given medication. In our setting, factors that might reduce losses to follow-up included expanded criteria for treatment initiation, overcoming transportation barriers, reducing wait times, ensuring against stockouts, and scaling up point-of-care testing services.

Challenges of hepatitis B treatment in rural Sub-Saharan Africa: Treatment initiation and outcomes from a public hospital-based clinic in Kono, Sierra Leone.

Despite a high prevalence, there are few successful models for de-centralizing diagnosis and treatment of chronic hepatitis B virus (HBV) infection among rural communities in Sub-Saharan Africa. We report baseline characteristics and 1 year retention outcomes for patients enrolled in a HBV clinic integrated within chronic disease services in a rural district hospital in Sierra Leone. We conducted a retrospective cohort study of patients with HBV infection enrolled between 30 April 2019 and 30 April 2021. Patients were eligible for 1 year follow-up if enrolled before 28 February 2020. Treatment eligibility at baseline was defined as cirrhosis (diagnosed by clinical criteria of decompensated cirrhosis, ultrasonographic findings or aspartate-aminotransferase-to-platelet ratio >2) or co-infection with HIV or HCV. Retention in care was defined as a documented follow-up visit at least 1 year after enrolment. We enrolled 623 individuals in care, median age of 30 years (IQR 23-40). Of 617 patients with available data, 97 (15.7%) had cirrhosis. Treatment was indicated among 113 (18.3%) patients and initiated among 74 (65.5%). Of 39 patients eligible for 1 year follow-up on treatment at baseline, 20 (51.3%) were retained at 1 year, among whom 12 (60.0%) had documented viral suppression. Among the 232 patients not initiated on treatment eligible for 1 year follow-up, 75 (32.3%) were retained at 1 year. Although further interventions are required to improve outcomes, our findings demonstrated feasibility of retention and treatment of patients with HBV infection in a rural district in Sub-Saharan Africa, when integrated with other chronic disease services.

Screening and linkage to care for medical students with hepatitis B virus infection in Sierra Leone.

PURPOSE: Hepatitis B virus (HBV) infection is considered a major public health concern for Sierra Leone. Although medical students are at increased occupational risk for HBV infection, little is known about the burden of HBV infection amongst medical students in Sierra Leone. METHODS: As part of a screening and vaccination campaign, a cross-sectional study on prevalence of HBV among medical students in Freetown was conducted in December 2019. Antigen point of care test was used for HBV screening and data on students' risk history and demographics were collected. Additionally, for students diagnosed positive with HBV, linkage to care and initial assessment data after diagnosis was collected from the HBV clinic they were linked to. RESULTS: One hundred and fifty-seven medical students (77.3%) from year three to six were screened for HBV infection. Almost all students (98.1%) had never been vaccinated against HBV and more than half (56.7%) reported a history of needle stick injuries. The prevalence of HBV infection (Hepatitis B surface antigen (HBsAg) positivity) was 10.2% (n = 16). Among HBsAg positive students, 75% (n = 12) were successfully enrolled at chronic HBV clinic within three months of diagnosis. Only one student had evidence of liver cirrhosis and was started on treatment with Tenofovir diproxil fumarate. CONCLUSION: The prevalence of HBV infection is high among medical students in Sierra Leone. Despite the high prevalence, most of the students linked to care had no evidence of severe liver disease.