Most individuals are unaware of their HBV and HCV infection status.10
Guidelines written by the American Association for the Study of Liver Diseases (AASLD) recommend that HBV screening be performed prior to starting immunosuppressive therapy and in people born in endemic areas, such as Asia, South America, and the Caribbean; US-born individuals who were not vaccinated during infancy and whose parents are from highly HBV-endemic areas; people with chronically elevated liver enzyme levels; men who have sex with other men; people with multiple sexual partners or a history of sexually transmitted disease; inmates of correctional facilities; pregnant women; and people who have used injecting drugs, are on dialysis, are infected with HIV or HCV, or are in close contact with people infected with HBV.3
AASLD guidelines also recommend HCV screening in individuals with hemophilia who have received clotting factor concentrates prior to 1987, recipients of blood transfusions or organ transplants before 1992, children born to HCV-infected mothers, and healthcare workers who have had a needle stick injury or mucosal exposure to HCV-positive blood.4
The Centers for Disease Control and Prevention (CDC) recommend routine HBV testing for all individuals born in regions with an intermediate or high population seroprevalence of HBsAg, as well as US-born individuals who were not vaccinated during infancy and whose parents were born in regions in which HBsAg sero-prevalence is high.11
The CDC also recommends that anyone born from 1945 through 1965—otherwise known as the “baby boomer” generation—should be tested for HCV because these people are 5 times more likely to be infected and are at greater risk for the development of serious, life-threatening liver disease due to HCV.12
Yet despite these recommendations, barriers to screening still exist and are related to challenges regarding patients, healthcare providers, and the healthcare system.13
Barriers in relation to patients include the lack of awareness of the risk for and progression of liver disease, language and cultural differences, and fear of social stigma.13
In a study surveying those with viral hepatitis, 45% of survey respondents perceived language to be the chief barrier, whereas the lack of knowledge of available treatment options was reported by 40%.14
In addition, 53% of the survey respondents reported fear of discrimination or stigma about having a liver disease, while 22% reported cultural barriers to accessing adequate healthcare.
Other patient-reported barriers to seeking care are the misperception that HCV infection is a relatively benign disease, fear of investigations and treatment, and feeling well overall.15
On further inquiry about these particular misperceptions, it was learned that they were shaped by conversations that the surveyed patients had had with peers about viral hepatitis, including “horror stories” about liver biopsies and treatments.15
Patients also cited difficulties in accessing healthcare, which included limited knowledge of testing sites, not being referred for specialist investigations, and ineligibility for treatment.15
Patients’ relationships with their healthcare providers in relation to trust in the provider, concern from the provider, and continuity of care also influenced their commitment to medical care.15
In addition, patients often did not seek medical care because other priorities, such as employment, education, and addiction behavior, took greater precedence.15
Therefore, education on HBV and HCV infections and their associated testing and treatment options, as well as patients’ determination to improve their health, appear to drive whether a patient will take advantage of screening and medical intervention for hepatitis infection.15
Major barriers in relation to healthcare providers include their level of knowledge about viral hepatitis with regard to risk factors, interpretation of laboratory results, and treatment.13
Primary care physicians are often the point of entry into the US healthcare system; therefore, they are essential to identifying at-risk individuals, providing screening, and making the necessary referrals to special-ists.13
Still, in a survey of general practitioners (GPs), 42% reported that they lacked confidence in interpreting HCV serology, and 20% reported that they lacked confidence in interpreting HBV serology.16
Likewise, 22% and 18% did not recognize HCC as a complication of HBV and HCV infections, respectively. Further, 20% of GPs were unaware of treatment for HBV infection, whereas 47% were uncertain whether pregnant women could receive treatment for HCV infection. In addition, 89% of GPs also identified language difficulties as the main barrier to treatment among the immigrant population.16
In another study that surveyed GPs, it was learned that, although 83% perceived chronic HBV infection to be a serious disease, 62% reported that they were not familiar with the treatment guidelines.17
The complexity of the existing US healthcare system poses other challenges for both patients and provid-ers.13
More specifically, navigating this system can be challenging, especially for those patients without adequate health insurance or knowledge of how the system works.13
The lack of knowledge about health benefits and available health and social services, language barriers within the clinic setting, and the lack of appropriate and timely referrals to specialists are also limiting factors.10
Furthermore, underutilization of healthcare services has been noted among high-risk groups, regardless of their health insurance status.18
Identifying these disparities is vital to providing optimal healthcare. Recommendations to address these deficits have strongly emphasized the importance of disseminating educational materials about viral hepatitis, including information about pathogenesis and available treatments, in both culturally and linguistically tailored mediums for both patients and healthcare providers.14
Effective screening programs are also recommended to include culturally sensitive educational outreach efforts to promote awareness, screening, and vaccination and should also include a counseling component with connections to healthcare services and follow-up care.13
Efforts to bridge disparities about hepatitis education, screening, and care were not embraced through the 2-year screening initiative at a cultural fair. The presence of healthcare specialists did not ignite much interest or inquiry. In fact, most festival attendees rushed past the exhibit after an initial glance. When verbally approached to participate, several attendees replied that they had been screened by their primary care physicians “last week” and were waiting to hear about the results of their blood work. When verbally approached in their native languages, some festival-goers still shielded themselves from further contact, refusing to be persuaded to participate even by family members.
Despite monetary incentives, such as free souvenir bags and a raffle for professional basketball tickets, most at-risk individuals at the festival declined the opportunity to receive free screening for HBV or HCV serology status. Those who did participate were influenced by secondary gains. Some already had some knowledge of HBV or HCV or had personal or family history of HBV or HCV. Some of the study participants were persuaded after hearing that they were at risk based on their country of origin and comorbidities. Others were best persuaded by supportive and encouraging family members who were also willing participants. A few reported that they simply wanted to know their status, and even fewer volunteered to be screened because they wanted to take advantage of the free medical advice and intervention being offered.
Our study had limitations. First, we participated in a festival that was aimed at providing recreation and entertainment, not healthcare. The endeavor of drawing blood may have appeared to be intrusive and disruptive to the festival-goers’ pursuit of merriment. Second, the written consent form and subsequent questionnaire were offered only in the English language. Although the volunteers present were fluent in various languages such as Creole, Cantonese, and Thai, language barriers still persisted, which may have hindered the willingness of festival attendees to participate. Third, our goals were to build awareness about and screen for HBV and HCV in high-risk individuals in our community. Our study objectives did not include assessing barriers to screening. The attitudes and behaviors of those who rejected free screening during the festival are based on conjecture. Given the infrastructure of our booth, questionnaires and detailed interviews with those who rejected free screening could not be conducted for confirmation and validation about reasons for rejection. Finally, testing for anti-HBs for all of the study participants was not performed due to laboratory costs. This added information would be helpful in distinguishing those individuals with immunity from those without immunity for HBV.