Tenofovir for prevention of mother to child transmission of hepatitis B in migrant women in a resource-limited setting on the Thailand-Myanmar border: a commentary on challenges of implementation

Abstract

Background The aim of this manuscript is to highlight challenges in the implementation of maternal tenofovir disoproxil fumarate (tenofovir) for prevention of mother to child transmission (PMTCT) of hepatitis B virus (HBV) in resource limited setting. Current preventive strategies in resource-limited settings fail mainly due to prohibitive costs of hepatitis B immunoglobulin (HBIG) and a high proportion of homebirths, meaning both HBIG and hepatitis B birth dose vaccine are not given. A new strategy for PMTCT without the necessity of HBIG, could be daily tenofovir commenced early in gestation. Implementation challenges to early tenofovir for PMTCT can provide insight to elimination strategies of HBV as the burden of disease is high in resource-limited settings. Methods Challenges encountered during implementation of a study of tenofovir for PMTCT before 20 weeks gestation in rural and resource-limited areas on the Thailand-Myanmar border were identified informally from trial study logbooks and formally from comments from patients and staff at monthly visits. ClinicalTrials.gov Identifier: NCT02995005. Main body During implementation 171 pregnant women were hepatitis B surface antigen (HBsAg) positive by point of-care test over 19 months (May-2018 until Dec-2019). In this resource-limited setting where historically no clinic has provided tenofovir for PMTCT of HBV, information provided by staff resulted in a high uptake of study screening (95.5% (84/88) when offered to pregnant women. False positive point-of-care rapid tests hinder a test and treat policy for HBV and development of improved rapid tests that include HBeAg and/or HBV DNA would increase efficiency. Integrated care of HBV to antenatal care, transport assistance and local agreements to facilitate access, could increase healthcare at this critical stage of the life course. As safe storage of medication in households in resource-limited setting may not be ideal, interactive counseling about this must be a routine part of care. Conclusion Despite challenges, results from the study to date suggest tenofovir can be offered to HBV-infected women in resource-limited settings before 20 weeks gestation with a high uptake of screening, high drug accountability and follow-up, with provision of transportation support. This commentary has highlighted practical implementation issues with suggestions for strategies that support the objective of PMTCT and the World Health Organization goal of HBV elimination by 2030.

Prevalence of hepatitis B virus amongst refugees, asylum seekers and internally displaced persons in low‐ and middle‐income countries: A systematic review

“…Delivering hepatitis care is challenging in resource‐limited settings, particularly in conflict zones and humanitarian crises where health systems are fragile. However, it is feasible to provide treatment for HIV in conflict‐affected regions 59 and prevent mother‐to‐child transmission of HBV with tenofovir in resource‐limited settings 60 …”

“…However, it is feasible to provide treatment for HIV in conflict-affected regions 59 and prevent mother-to-child transmission of HBV with tenofovir in resource-limited settings. 60 In conclusion, hepatitis B is a significant public health issue with a high burden in LMIC, where service delivery is challenging in the…”

“…However, it is feasible to provide treatment for HIV in conflict‐affected regions 59 and prevent mother‐to‐child transmission of HBV with tenofovir in resource‐limited settings. 60 …”

Evidence-Based Strategies for Micro-elimination of Chronic Hepatitis B Virus Infection

“…Prophylactic treatment of pregnant mothers with antiviral treatment during gestation has previously been proposed as an alternative solution in eliminating mother-to-child-transmission in underserved populations [74]. In remote regions along the border of Thailand and Myanmar, Bierhoff et al demonstrated promise in prophylactic daily antiviral therapy started early in gestation as a substitute for mothers who are unable to access immunoglobulin or vaccines with a facility birth [75]. This indication for prophylactic tenofovir use was also used in Thompson et al [76].…”

Sustainability in Refugee Camps: A Systematic Review and Meta-Analysis

“…Forty percent of the existing studies (n = 10) were made in the Shoklo Malaria Research Unit (SMRU) on the Thai-Myanmar border that has a long and complicated history of conflict and human displacement. Shoklo Malaria Research Unit has provided humanitarian health care for refugees since 1986 and for migrants since 1997 [8,10,[21][22][23][24][25][26][27][28].…”