Hepatitis B Re-Engagement Hinges on How Systems Find Patients: Helen Nde, MPH

Finding approaches that bring patients back to hepatitis B care—whether proactive outreach or opportunistic screening—dramatically shifts re-engagement outcomes, but data gaps mask what's working in low- and middle-income countries, where the burden is greatest, according to a scoping review of re-engagement programs published in April 2024, conducted by Helen Nde, MPH, of the Center for Disease Analysis (CDA) Foundation, and colleagues.¹

Reaching out to individuals who have been diagnosed with hepatitis but who have gone untreated has been shown to increase linkage to treatment.² However, Nde’s analysis makes it clear that the outreach method used can make a big difference.

The research analyzed 11 studies tracking re-engagement rates for people living with hepatitis B (HBsAg+) who had been lost to follow-up—a critical gap that limits treatment access and drives mortality. Re-engagement rates ranged from as low as 2% in the Netherlands to 100% in Australia and Ireland, reflecting fundamentally different system approaches: active outreach programs that seek patients out versus passive programs that identify patients when they appear in emergency departments or primary care.

Nde also addressed a critical gap in the global evidence base: 10 of 11 studies came from high-income countries, masking what is—and is not—happening in the low- and middle-income settings where hepatitis B burden is highest

This interview was edited for clarity.

AJMC: Your scoping review found that re-engagement rates ranged from 2% in the Netherlands to 100% in Australia and Ireland. What drove such dramatic differences in outcomes across those countries?

Nde: That's a really great question to start with because it gives an overview of just the 2 main approaches to re-engagement, especially in the hepatitis context. If you look at the study that came out of the Netherlands, this was one of the largest hepatitis B patient re-engagement programs to be implemented. I believe this was in the Utrecht region, and this was a large program—a couple hundred patients were targeted—but the outreach was mainly to the patients’ GPs [general practitioners], so it was not outreach directly to the patients; it was with their GPs. This is because Dutch law doesn't allow for that kind of direct outreach. You reach out to their GPs, and then the GPs reach out to the patient. There's that layer between the outreach and the patient, and…that introduced some friction. A large number of people were just not reachable, and whether that's because of that layer of friction or because the patients themselves were just not available at that time. That's what I think was driving that low re-engagement rate in the Dutch study.

If you look at Australia and Ireland, those were small sample sizes to begin with, but the outreach was done in the emergency department setting. People were coming in for other reasons, sometimes hepatitis-related, sometimes not, and then they were picked up on the spot and linked to care within a short period of time. That speaks to the main approaches that re-engagement takes. There's the active approach, which involves finding people, figuring out how to reach them, and performing outreach, which has advantages and disadvantages. The advantage is it's more proactive. You have someone actively looking for these patients. Telephone calls—either directly to the patients, to their GPs, to primary care, or to some other provider they're connected to—are the main way. Phone calls, text messages, and letters have shown some promise. However, the most effective way to carry out that outreach we found is in-person outreach, peer-to-peer outreach, and outreach by navigators who have built trust in the community. The disadvantage is that if the phone number has changed, if it's inactive, if the address has changed, or if the patient has moved, then that outreach isn't as effective as you'd want it to be.

The other approach is more passive. Nobody is necessarily going out to look for the patient. It's more opportunistic. Patients come in for other reasons into primary care or into the emergency department, and then they're identified as individuals who need to be in care for hepatitis B or C. Sometimes these are alerts that go out when the patient's name triggers the system; sometimes it's just part of a standard screening process in the emergency department. This way, newly diagnosed patients are caught, and patients who have fallen out of care are also caught.

This passive approach has advantages and disadvantages as well. The advantage is the patient is right there, and they can be linked to care. Usually, if there's someone focused on them and they're available, there's that warm handoff, which really does help the process. The disadvantage is the patient has to come in. If they're not coming into the [emergency department] for any reason, they won't be caught. Sometimes they come in with more pressing issues, and they're not going to focus on hepatitis if they have another more pressing issue.

The outcomes point toward what works and what doesn't for each system, but I think the general theme that emerges is the closer you get to the patient, the better it is for successful re-engagement.

AJMC: Ten of the 11 studies you reviewed came from high-income countries. Does that gap tell us anything about where hepatitis B elimination efforts are or aren’t focused globally?

Nde: The one clear thing that gap illustrates is that outcomes for re-engagement efforts have been reported in formal peer-reviewed and indexable research in high-income countries. I had a conversation recently with a patient advocate from the African region who said, "We do re-engagement. We call people. We try to get them back in care. We just don’t publish the findings.” It's easy to look at a report and say nothing is happening, but things are happening; they're just not written up into formal papers and published.

But also, in the low- and middle-income context, a lot of the time the focus is on vaccination, because that's where a lot of transmission is happening. The focus is on vaccination and treating pregnant women. If you look at those studies, there are cultural vaccination programs that have happened, which is a re-engagement effort of sorts, finding people who should have been vaccinated but weren't. There's a lot of follow-up for pregnant women. It's happening; it's just not being reported in the way I chose to do this search, because my focus was on the general population.

But it also illustrates an actual gap: the fact that there are no formal peer-reviewed findings for efforts to re-engage with the general population of individuals who are chronically infected with hepatitis B says something as well. There are multiple ways to look at it, but I think the key point is that there's more that can definitely be done, especially since the treatment for hepatitis B [tenofovir] is not that expensive. It's very well known to be effective. It's accessible. More can be done in the parts of the world most affected by this virus.

AJMC: The WHO has set a target of 65% mortality reduction for people living with hepatitis B. How realistic is that target, and what has to change at the policy or health system level to get there?

Nde: It works better from a sense of hope and possibility to think of these targets as aspirational—something to reach toward and hopefully achieve in the timeline specified, or at the very least, to get as close as possible.

Fundamentally, what needs to change is how stakeholders think of hepatitis B relative to other chronic or infectious diseases. This is a disease that kills over 800,000 people every year, and it has a highly effective vaccine and highly effective treatment—not curative, but effective enough to prevent progression to severe disease and death. There's really no reason for hepatitis B to still be the problem it is in the US or in any country in the world.

The good news is that it's very well known what needs to happen: investing in vaccination, especially expanding access to the birth dose where it hasn't happened already, and not breaking what's already working in the US. Screen and treat pregnant women in endemic areas to prevent transmission, because if you acquire hepatitis B as an adult, odds are you're going to clear the virus. But if you acquire it as a child, your risk of becoming chronic is much higher, and that chronic disease progresses into serious disease by the time you're 30 or 40.

Screen and vaccinate people early enough; screen and treat pregnant women; and screen and treat the general population. A large number of adults have chronic hepatitis B and would benefit from treatment. Going with that is information—letting people know what they're dealing with, helping them understand this is not a disease to fear. It can be handled in a way that preserves quality of life. There is stigma that gets in the way of this happening, if not in the US, then in some communities in the US because of the foreign-born component, and elsewhere in the world, there's stigma associated with hepatitis B.

That information piece for providers and patients is key. Investing in what we already know works and making sure people have that information—I think that's the main thing that needs to happen.

References

1. Nde H, Eurich B, Razavi H. Re-engagement as a hepatitis B elimination strategy: a scoping review. Presented at the 2026 EASL Congress; May 27-30, 2026; Barcelona, Spain.
2. Wyatt B, Perumalswami PV, Mageras A, et al. A digital case-finding algorithm for diagnosed but untreated hepatitis C: a tool for increasing linkage to treatment and cure. Hepatology. 2021;74(6):2974-2987. doi:10.1002/hep.32086