Hepatitis B Virus Screening and Vaccination in Patients Prescribed PrEP
Data from a commercial insurance claims database found that 38% of persons prescribed pre-exposure prophylaxis (PrEP) were screened for hepatitis B prior to PrEP initiation.1 The percentage is from a 2017 survey with data from 2011 to 2015. How would that percentage look today?
Melissa E. Badowski, PharmD, MPH, and her research team compared the rate of screening and vaccination for hepatitis B in adult patients receiving an initial prescription for oral PrEP between July 2014 and September 2018 with those receiving PrEP between October 2018 and October 2022.2
Dr Badowski presented the study "Guideline Adherence to Hepatitis B Virus (HBV) Screening and Vaccination in Patients Prescribed Human Immunodeficiency Virus (HIV) Pre-exposure Prophylaxis (PrEP)" at IDWeek 2023 in Boston, MA. She spoke with Consultant360 about the team's study findings and looked ahead to future research in the areas of HIV prevention and hepatitis B screening.
Consultant360: Can you please provide an overview of your presentation at ID Week 2023 titled, "Guideline Adherence to Hepatitis B Virus (HBV) Screening and Vaccination in Patients Prescribed Human Immunodeficiency Virus (HIV) Pre-exposure Prophylaxis (PrEP)."
Melissa E. Badowski, PharmD, MPH: We noticed that prior studies based on older literature (from 2013 and 2017) found that 60% of providers routinely screened for hepatitis B, and this was prior to the initiation of PrEP. Another study looked at the commercial insurance claims database between 2011 and 2015, and that found only about 38% of patients were being screened prior to initiation of PrEP. So we wanted to see where our numbers stood. We did a study around that time where at our institution we evaluated guideline adherence to screening for hepatitis B since oral medications for PreP also are used to treat HIV infection. And so we were hoping with the increased prescribing of PrEP and subsequent increased familiarity with PrEP around these times, we would see an improvement in adherence to guideline screening.
So based on all of that, the goal of our study was to assess appropriate screening for hepatitis B infection for the US Public Health Service Guidelines. And this is based on serologic testing. We were also looking to assess appropriate vaccination against hepatitis B, per CDC recommendations. Within our study, the secondary objectives looked to evaluate the immunity of vaccination against hepatitis A, HPV, as well as meningococcal vaccination.
We retrospectively evaluated adult patients receiving an initial prescription for oral pre-exposure prophylaxis at the University of Illinois (UI) Hospital and Health Sciences System in our outpatient clinics. As previously mentioned, we did have a historical group that we compared to, and so that we refer to as cohort 1, and that was between July 2014 and September 2018. And then this now most recent piece of evaluation, which we termed our second cohort, we evaluated between October 2018 and October 2022. Individuals were excluded if they tested positive for HIV when we were doing our screening for PrEP, receiving treatment for hepatitis C, were pregnant, or were in custody in a prison or jail during that time.
Consultant360: Can you provide the findings from your study?
Dr Badowski: In cohort 2, we screened 230 individuals, and we excluded 85 for reasons such as PrEP wasn't initially prescribed by one of our UI health providers, individuals tested positive for HIV infection, or they were prescribed oral PrEP essentially for post-exposure prophylaxis. So they coupled it with another antiretroviral agent. So we ended up with another 145 patients in cohort two, and that matched the same in cohort one. And our average age between these cohorts was 28 and 30 years. And a majority of males were prescribed PrEP in our study.
So our major findings were between cohort one and cohort two. So cohort one was the 2014 to 2018 group and cohort two included those from 2018 to 2022. There were significantly more individuals in the first cohort, 79%, who received screening for hepatitis B compared to cohort two, which was 68%. This was based on serologic testing. Similarly, there were significantly more individuals in the first cohort who received their first dose of the hepatitis B vaccine by or at the first follow-up. So that was 38% in cohort one compared to only 22% in cohort two. Finally, there was no difference between the cohorts that we found for hepatitis A immunity or vaccination, or meningococcal vaccination, but we did find significantly more individuals in cohort two that did have access or had documented hepatitis B vaccination. So that was 45% in cohort two compared to only 19% in cohort one.
Consultant360: How do those findings contribute to the existing literature about hepatitis B virus and HIV PrEP?
Dr Melissa Badowski: I think the take-home message is that there's so much more work to do in the area of HIV prevention, as well as those that we're screening for hepatitis B. For example, within the United States, there are millions of people who are living with hepatitis B that don't even know about it. And so while our rates of screening were higher than previously reported in the literature, we're nowhere near 100%. And in fact, we had a decrease in the number of individuals who were screened for hepatitis B.
And I think one of the things we think about within the cohorts that we studied, cohort one was in the area of infectious diseases and family medicine where we evaluated these individuals. Cohort two was basically anyone who had a receipt of an oral prescription. So I think just learning and tuning into additional educational endeavors is going to be essential, not only within our own institution, but I think nationally as well, just for the overall prevention.
And I don't think it's just a one-time educational effort. I think these have to be continuous messaging. I know within my institution, we are a large teaching hospital, so I think every year we get new prescribers, those who are new graduates from medical schools. I think we have to have continuous messaging and additional educational efforts for not only screening of Hepatitis B but also additional prevention efforts for HIV.
Consultant360: You mentioned some of the take-home messages there. Is there anything else that you'd like to talk about regarding what's next for research on this topic?
Dr Badowski: In terms of research, there are a lot of different avenues that we can take. The CDC recently recommended universal screening for hepatitis B. And so looking at all patients or individuals, it's not just those who are at risk, but at least once in their lifetime. So I think this would pair nicely with prevention efforts that we're looking to roll out as well. Although we're moving slowly, I think there's definitely a marked increase in PrEP prescribing. So I think we just need to make sure that we're taking the guidelines and adhering to the screening recommendations.
Additionally, I think we need to look beyond the interventions and focus on where they're needed. So I think about these missed screening opportunities. Are they more common outside of the area of infectious diseases? Is it for those who are seeking primary care, family medicine, or even internal medicine? We are used to these medications at baseline. We know what to be testing for. But I think additional educational endeavors and maybe evaluating a little bit more in comparing in those areas is needed.
And then, I know from a clinical pharmacist perspective, we also have collaborative practice agreements. So maybe is there a difference between those areas that have collaborative practice agreements compared to those that don't? I think another area that we're looking to evaluate is implementing an electronic order set that's available for screening to make sure that everything's checked appropriately. So I think that's another area that we'd like to focus on in terms of research.
References:
1. Huang Y-LA, Tao G, Samandari T, Hoover KW. Laboratory testing of a cohort of commercially insured users of HIV preexposure prophylaxis in the United States, 2011–2015. J Infec Dis. 2017;217(4):617-621
2. Awad R, Michienzi S, Badowski M. Guideline adherence to hepatitis b virus (HBV) screening and vaccination in patients prescribed human immunodeficiency virus (HIV) pre-exposure prophylaxis (PrEP). Talk presented at: IDWeek 2023. October 11-15, 2023. Accessed October 4, 2023. https://idweek.org/