Beyond the Exam Room: Perspectives on Barriers to HBV Care in Japan

Key Takeaways:

• Barriers to hepatitis B virus (HBV) care in Japan include lack of awareness, lack of transparency regarding HBV testing results, and low rates of linkage to care.
• Key calls to action to help eliminate barriers to HBV care within Japan include patient and healthcare professional education, increasing lines of communication between healthcare professionals and patients regarding positive tests, and improving linkage to care.

Yuri Sakakibara is a medical social worker at Nagoya University Hospital in Japan. He provides support for patients with hepatitis as a hepatitis medical coordinator and consults on patient transfers, provides support for hospital discharge, and assists patients with managing medical fees. In this discussion, he and Hidenori Toyoda, MD, PhD, FACP, a hepatitis specialist at the Ogaki Municipal Hospital In Ogaki, Japan, discuss their experiences with barriers to hepatitis B virus (HBV) care and key action items to reduce those barriers in Japan.

Testing

Hidenori Toyoda, MD, PhD, FACP:
I would like to begin our discussion with the state of HBV medical care in Japan. First, unlike in the United States, Japan has national health insurance, and all citizens have the same health insurance. There is a subsidy system for HBV, and the cost for testing and treatment is very low or free, so the economic barrier is largely removed. Another feature is that, although Japan is an Asian country, HBV is not endemic to Japan like it is to South Korea and China, so overall the prevalence has been fairly low.

This is all good news. The bad news is that the HBV testing rate is only approximately 70%, so not everyone is tested for HBV, despite these tests being free to the public. Yuri, could you discuss barriers to HBV testing from your perspective?

Yuri Sakakibara:
I think one of the biggest issues we have to tackle is lack of public education on HBV. To encourage testing for individuals who have not yet taken a hepatitis test, we must disseminate accurate information about the virus. I think it is necessary to let the public know that HBV is a disease that can progress to liver cirrhosis and liver cancer, and that if an early diagnosis is made and appropriate treatment is received, its progress can be suppressed or delayed. At our hospital, we offer liver disease classes for patients and public lectures free of charge.

Hidenori Toyoda, MD, PhD, FACP:
I completely agree that patient education is important—people need to understand that they should be tested because HBV infection can lead to many adverse outcomes, but that these can be largely prevented.

Linkage to Care

Hidenori Toyoda, MD, PhD, FACP:
Next, I would like to consider the barriers to linkage to a hospital or clinic after receiving a positive HBV test. Indeed, many patients who are diagnosed with HBV are not linked to care. Can you offer some perspective on this as a hepatitis coordinator?

Yuri Sakakibara:
Yes. Many of the patients with HBV are in the workforce, and the fear of workplace discrimination is thought to be a large contributor to this lack of linkage to care. In the past, there have been cases where an employee who was found to be infected with HBV at the time of employment was not hired by the company or was treated unfavorably at times of promotions. Although it is said that this is no longer the case, there are still concerns about discrimination and prejudice in the workplace. Therefore, patients still feel that they are unable to talk to their workplace about their illness and perhaps unable to take time off to see a doctor.

Hidenori Toyoda, MD, PhD, FACP:
Another reason may be that entire families may be shunned in some way if their HBV status becomes known. Indeed, vertical transmission was the main way HBV is transmitted in Japan previously, and if the infection is known within the family, people may want to avoid marrying or getting engaged to a member of this family.

Yuri Sakakibara:
Another major concern is that many people who test positive for HBV in Japan via tests for work, prenatal checkups, blood tests before surgery, etc, are unfortunately not informed of their positive status. If the test is performed, it is important to provide a thorough explanation of the test result, especially if it is positive. Do you have opinions on this, Dr Toyoda, given that you see many patients as a specialist?

Hidenori Toyoda, MD, PhD, FACP:
The main reason for testing for HBV or hepatitis C should be for the benefit of the patient. However, testing is often done before surgery or invasive testing to protect oneself or to ensure that doctors and healthcare professionals don’t become infected. In such circumstances, when patients test positive, it is very common for them not to be told they have HBV. By law now in Japan, these test results—whether positive or negative—must be communicated to the patient, although this does not always happen.

Furthermore, even if patients are diagnosed with HBV, if the transaminase is normal or patients are undergoing seroconversion, they will be told that they already have recovered and neither tests nor treatment is necessary. This is a major problem, because patients are being told by doctors that they have been cured before they have been seen in a specialist facility. I believe this is happening because the general physician, or family doctor, who is getting these results does not have sufficient education on HBV. We must do a better job of educating general physicians and strengthening the collaboration between nonspecialists, family practitioners, and liver specialists. This is particularly important given that, unlike for hepatitis C patients, liver cancer may develop in patients with hepatitis B and a normal liver.

Treatment

Hidenori Toyoda, MD, PhD, FACP:
Finally, I would like to ask about barriers to treatment. Japan offers HBV treatment subsidy programs and health insurance, but many patients are unaware of these systems and perceive treatment as an economic problem. In addition, these subsidy systems are application oriented, so you cannot receive the subsidy unless you follow the procedures, which often are considered complex. Could you comment on this?

Yuri Sakakibara:
Although we have health insurance and a hepatitis medical expense subsidy system in Japan, the economic burden still may be difficult to bear depending on the region. For example, if there are no specialized medical institutions nearby, one would need to pay transportation costs, which may be difficult for certain people, such as older patients and those with low income. To this end, we believe it is necessary to promote smooth follow-up by having hepatitis medical coordinators at hospitals and government offices to guide people and provide appropriate support systems and contact points at the right times.

Hidenori Toyoda, MD, PhD, FACP:
Yes. Another barrier to treatment is that people seem to be resistant to taking medications for the long term. To combat this, we try to relate their HBV medications to other medications, such as those for blood pressure. We explain that by continuing to take a blood pressure medicine, it is possible to suppress arteriosclerosis, just like taking HBV medications will suppress liver disease progression. However, future medications for HBV may help eliminate this barrier.