The first global systematic review and meta-analysis of hepatitis B care has found critical patient losses at every step of care, calling for decentralised, integrated models to improve diagnosis, treatment, and patient retention.
Published in The Lancet Gastroenterology & Hepatology, the findings reveal that current hepatitis B service delivery models are failing to keep patients engaged in lifelong care - threatening the world's ability to meet the World Health Organisation (WHO) 2030 hepatitis B elimination goals.
The WHO-commissioned review was conducted by researchers from the University of Liverpool and Imperial College London in collaboration with colleagues from The Gambia, India, the Philippines, the USA, and Vietnam. It analysed data from more than 1.7 million people with chronic hepatitis B across 50 countries and found significant drop-offs in diagnosis, treatment initiation, and long-term retention, even in the best-performing systems.
Key findings of the review show that:
- Specialist-led hospital care achieved the best results but still showed major gaps: fewer than 75% of patients were assessed for treatment eligibility; of those eligible, only 78% began therapy. Retention plummeted among those not receiving treatment.
- Primary care, co-managed care, and passive referral models fared worse, with lower rates of assessment, initiation of care, and retention once in care.
- Postpartum care for women diagnosed during antenatal care had particularly low follow-up rates.
- Community screening with active linkage to specialist care achieved high treatment initiation rates for eligible patients.
Lead author Dr Alexander Stockdale from the University of Liverpool, said: "This is the first global review to map our progress across the hepatitis B care pathway. Without urgent changes, millions will miss out on lifesaving treatment. Many patients are not being fully assessed or being started on antivirals when they could benefit, and far too many are lost to follow-up over time. Strengthening primary care in low- and middle-income countries is essential to prevent hepatitis B-related deaths - already estimated at 1.1 million in 2022."
Senior author Professor Philippa Easterbrook (Imperial College London; formerly WHO Global Hepatitis Programme) added: "WHO's 2024 guidelines were a major step forward, expanding treatment eligibility to nearly half of all people living with chronic hepatitis B. But simplifying criteria alone is not enough. Too many still lack access to services, and even where clinics exist, patients often fall through the cracks.
"We need simple, decentralised models - integrating hepatitis B into primary care or existing HIV and chronic disease services. The HIV response has proven that streamlined care can achieve over 90% diagnosis, treatment initiation, and retention. It's time we applied those lessons to hepatitis B."
Professor Easterbrook added: "An integrated approach is even more pressing given the recent reductions in funding through USAID and the US President's Emergency Plan for AIDS Relief (PEPFAR) for health programmes in LMICs"
The researchers have made the following recommendations:
- Decentralise care into primary health facilities and integrate with HIV/non-communicable disease (NCD) clinics.
- Remove financial barriers by eliminating out-of-pocket costs for testing and treatment.
- Accelerate access through same-day assessment and treatment initiation.
- Improve long-term engagement using adherence and retention strategies from HIV care programmes.
Click here to read the full review.
