Welcome everyone to our panel discussion today. And our goals are to discuss and learn about the current status of HPV disease burden and management strategies in different regions of the world. And we all know very well that this is a global disease and globalization. So what happens in one area affects the others. And that if we hope to eliminate hepatitis B someday, we need to work together. So I am from Stanford and chair of HPV. And my co-moderator today is Dr. Harry Jensen from Toronto and vice chair of HPVC. And this webinar, we are fortunate to have very distinguished faculty. We have Dr. Mark Sonderrup from South Africa, Dr. Zhidong Cha from Beijing, China, Dr. Shiv Sarin from New Delhi, India, Dr. George Papatheodoridis from Athens, Greece, Dr. Carla Coffin from Calgary, Canada, and Dr. Gadano from Buenos Aires. And I also want to acknowledge my co-organizer for this webinar, Dr. Holden Hsu from Ida University in Taiwan. So this webinar really illustrates the goals and missions. One of our major goals and mission is to advance science, education, and care for patients with chronic hepatitis B and an outreach approach to all different regions of the world. So I hope that this webinar will not only just inform us of what is going on, but also to help stimulate further research, collaboration, public health efforts in all different regions. So this panel discussion is open for questions, and I hope to receive questions from all participants as well as faculty, too, if any points that anyone would like to discuss. So while we wait for questions to come in among our participants, I would like to have the first question. So my first question would be for Dr. Sarin. Actually, I was very happy to see your slide set and one of your slide set that ticked off. And actually, that's exactly how I also feel, because despite all the guidelines that we have and we've had an oral drug since, at least in the U.S., since 1998 and since 2005, we have had one of the good first-line oral agents that's very well-pollinated. The diagnosis rate for hepatitis B in the U.S. at least is only 18 percent, and the treatment rate is less than 5 percent. And most of the guidelines are very complicated, even for hepatologists, even for gastroenterologists. So have we made it too complicated and contribute to one of the ongoing problems? You know, why can't we just, especially in many areas of the world, the prevalence is high enough that universal screening should be there, and the treat-on approach could be there, because we have safe drugs, and also we have very inexpensive generics now in many parts. So if you argue, you know, so we would like to hear what are your arguments for, in terms of, you know, not just hepatitis B medical care, but economics. And I would like to hear what would be the cons of it from the audience or among our faculty. Thank you. It's a pleasure to be and honor to join the ASLD. And the first question that you say, I'm very clear that one and one make 11. If you join and we join, we can succeed. Reasons, the only worry is if the drug is free, would everyone not treat? The question is reimbursement, money. So I think all of us would agree, and I'm sure all the experts would agree that it is much better that the person is without any HPV DNA detectable, and the drug is safe. And we have two drugs which are safe, there is no resistance. So why not use them? Why make it complicated? Except for the cost, except for reimbursement. So at least in India now, with our efforts and the government's generosity, every hepatitis B can get free drug and free diagnosis. And this is a large program. So I am happy that you also accept it. I have been saying it from 99. And I was able to slightly change her thinking in 2008. And she wrote a piece on our gastro paper and said, yes, she would be willing if the drugs are, you know, like affordable or are available without cost to the patient. But yes, that's a separate debate. And why don't I encourage you and ASLD to have a separate session on hepatitis B treat all or not. And let's hear everybody and try to understand everyone's point of view. Thank you. Thank you. So the other place with probably one of the largest reservoir of patients besides South Asia is probably East Asia. So Dr. Cheong Cha, I personally don't think, I mean, financial barriers is a big one. But I don't believe that it is the only one. And we may see this in other parts like North America, Canada, the U.S. and Europe. Because in our studies recently of insure people with private insurance in the U.S. So so all of the medications should be paid for. And the diagnosis rate is less than 20 percent. And even people who have HCC, only half of them are on medication. So it seems to be. And this is something I come back in just a little bit to get other opinions in other different areas. But we have one question from the audience. The question is that, do we really need functional cures to achieve HPV elimination or do we need to simply upscale our nuclear, our oral, our nuclear therapy? So this can be open to any of our faculty. Maybe we'll start in Europe. George, do you want to comment on that? First of all, thank you for the invitation to participate in this interesting hepatitis B SLDC webinar. So this is a question, a general question, I would say, a theoretical question. We all hope that the new drugs, when they are, they have been developed and they can be used in practice, they will offer high rates of what we call functional cure, which is now defined as HBS antigen seroclearance with antibody and the HBS. And this will be clinically important if it leads to improved outcomes and particularly decreasing or, I mean, I cannot expect zero rates, but decrease low rates of HCC. Because HCC remains the main problem of chronic hepatitis B patients today. So if we manage to decrease this endpoint and at the same time to stop treatment, because our patients may not be adherent to our recommendations for life, to receive nuclear therapy for life and to at the same time to remain under HCC surveillance and under several tests, not many, but some tests that they have to do every six or 12 months for securing the safety and the efficacy of the current drugs. So if we will be able to say the importance of the new drugs when they have been developed and when we know more about their long-term efficacy and safety and of course their cost. So it's a question that cannot be directly answered today, I think, but we all hope that the new drugs will bring additional benefits for our chronic HBB patients. Okay, that's interesting. But I would say that, I mean, the current drugs suppress the disease, don't really cure the disease, right? So for elimination, the curative treatment would be preferred, I think. Maybe we'll get the view from China, Dr. Jia from Beijing, because there's a lot of people with hepatitis B in China. What is your view on the current curing efforts that we have for hepatitis B? Thank you. Actually, in China, we have still over 80 million surface antigen positivity. Among them, about 20 to 30 million of them need urgent treatment. That means they have active disease. Yes, as you mentioned, that currently nukes can suppress the disease, prevent the disease progression. We can decrease but not eliminate the FCC. So that's why we still need the functional cure, which means the loss of surface antigen with or without surface antibody. In that way, we really further improve the clinical outcomes, especially the decrease in FCC, because we already have evidence showing loss of surface antigen will further decrease the incidence of FCC. So that's number one. Number two, as already discussed, the lifelong therapy is really difficult for most of the patients. Although the nukes in China, the generic version of antacovir, tenovir, TDF, I mean, are already very, very cheap. It's almost nothing. Every year, just every month, you need, wow, less than $2, $3 every month. So it's really a great improvement. But still, we want to have a functional cure to really, the patient can stop treatment. The last point is, if you could get a functional cure that psychologically, that gives the patient the confidence to eliminate that kind of discrimination or remove the stigma. So that's all my thought. Thank you. If I may add something, a comment about the elimination, because elimination is based on three major goals, decreased incidence, decreased morbidity, and mortality. So for hepatitis B, we don't actually need the treatment for decreased incidence, because we can rely on vaccination and our efforts for universal vaccination among the uninfected patients. It's not like hepatitis C. So for decreased morbidity and mortality, which comes from the existing chronic HPV infected patients, then that's why I said that we need to know more about the long-term outcomes of our patients when they receive the new drugs, and particularly if these drugs can decrease the ACC. It will be important to achieve the functional cure rates, but this should be combined with decreased ACC rates. Maybe I can ask Mark, who lives in Africa, where a lot of people cannot even afford long-term, like lifelong therapy potentially, and it's not available in several countries as well or very limited. So I would imagine for a continent like Africa, finite treatment might be very beneficial, because you could say, well, there's a vaccine, but again, we know that a lot of people don't receive, a lot of children don't receive vaccination at all or not in a proper way around the globe. So maybe Mark, can you comment from the African perspective? Yes, Harry, thank you very much, and thank you to AASLD for the invite to be on this eminent panel. I think the question being asked is really binary, but there's not a binary answer to It's not a yes, no kind of answer. The issue really comes down to what are you comparing finite cure against? Because obviously the aspiration of functional cure is a very laudable one, because it's going to imply some degree of finite treatment, and then hopefully clearance of surface antigen. But as Dr. Paptherodorus said, we're going to have to balance that against whether that's going to actually improve long-term outcomes, how's it going to influence ACC rates, and we currently have to then compare that to what we have at the moment, which is long-term oral antiviral therapy, which actually gives us pretty good results. It's not perfect, but it's pretty good results, and it's with pretty good drugs that are very effective. So I think the issue is a complex one. It's an aspirational outcome. Then what you've just touched on is certainly from the recent ILC meeting, there seems to be a suggestion that if we're going to achieve functional cure with hepatitis B, we may be looking at a fairly extended period of time of treatment. I think we all caught up in the 12 or 8 weeks of hep C curative therapy, which is just fantastic, but we're probably not going to be able to do that with functional cure for hep B. It's probably going to be much longer, and in my world, longer implies a lot more expensive, and so if we're going to do it, as I've maintained very often in platforms, it's a fantastic, laudable, noble objective, but it's going to have to be affordable, and I think that's where the problem is going to come in, and balanced against what we have as the benchmark at the moment. Harry, I wonder if I can just take on Dr. Sarin on a previous comment, because I think this testing treat-for-all issue is a crucial one that is clearly in need of important debate globally. I'm going to position myself in the camp at the moment of against treat-for-all for a number of reasons. The one being I think it just goes against a very simple principle of the practice of medicine, but I mean that's not going to solve the problem. I think we normally treat people who actually need treatment. We don't just treat people because we can, and I think my concern I have is probably both fundamentally just from a principle point of view, but certainly from our perspective within Africa, as people will well know, a large proportion of people are E antigen negative, and the million-dollar question literally is what proportion of those folk actually require treatment by all requisite levels of guidance, and so we could be treating a large number of people who may not warrant therapy, okay, if we do the test-and-treat approach, number one. Number two, we've got fantastic drugs, as I've just said, tenofovir, for example, but we can't sit here and say that it's not absolutely without potential for toxicity, and there is some rumors around telomere lengthening and other issues around tenofovir, which I think we have to be cognizant of, and that's kind of in the background, because the drug's effective and it works, but I think if we had to balance it economically, the number of people that we may be unnecessarily treating, even though the drugs are cheap, we could balance that against actually providing things like birth dose vaccination instead, and actually prevention. So I think the question is, again, not a simple answer, and I think it warrants a very important global debate. Thank you. Shaniv, do you want to comment? Thank you, Mark. I would like to comment, and I'm happy. We are starting with an aspiration to treat everybody, so the debate is what percentage should be treated and who is to be treated. I would like to say we actually made our algorithm so complicated, and I would ask anybody, any one of us, if we are hepatitis B positive, would we not like to be virus negative? Let's put ourselves in those shoes. Would you just like every six months for the next 20 years to go and just be declared inactive carrier? In fact, the only way we can get rid of hepatitis B is after the demise of the term inactive carrier. The inactive carrier term, we in fact wrote the first full piece in 99, that the term inactive carrier is not an appropriate term, it is chronic HPV infection, low replication or high replication. These terms come later, but if you have a term like you have 2,000 viral particles and they swing up and down as your immunity is, if your immunity is down, well, actually the virus might go up or vice versa. Every HPV patient produces 10 raised to power 13 viral particles a day and it is your T cells or it may be somewhat transitional B cells which will bring them down. So I have a feeling that the fact of inactive carrier is a misnomer and we have shown, many others have shown that 12% of them may have fibrosis. Now the issue is, should we treat or like our senior colleague from Africa, I would say that if the drugs are affordable by any mechanism, we would certainly be in a position. Are we treating them unnecessarily? Well, I do not think we are treating unnecessarily. Elimination word if you want to use as two parts as George has rightly said, every newborn from today is vaccinated properly and develops antibodies. Number two, that everyone who is harboring an infection cannot transmit to anybody, not one and for that it would be important that we make people who are suffering to be virus negative. Therefore if you take a normal, let's say in India, the normal life expectancy is 69-70 years. So if we take that, it will take us 70 years from today that is 2090 to be able to have an elimination of hepatitis B. So I think we have to plan a situation where no new infections can occur by transmission in any way and secondly everyone who is born is being protected. One more complex part of it is the efficacy of drugs or toxicity of drugs. I think efficacy is beyond doubt proven but yes we have to be careful that the drugs don't cause side effects and therefore people should be just told that when you take drugs, like for SARS-CoV-2 we are trying to treat everyone, Hep C we are treating everyone, HIV we are treating everyone. Therefore for Hep B, since the drugs may have side effects, our only job today as hepatologists should be in my opinion is that don't have side effects, don't break the treatment and remain virus negative till the new drugs come. This is my thought. Thank you Dr. Saran and I'm going to address another question to you from the audience from Live Well Initiative from Nigeria. So the question is that the group is glad to know that India diagnosed and treats Hep B free of fees. So at this rate will India achieve elimination of hepatitis B by 2030? And the same group also agreed with Dr. Sundararajan that birth no vaccine policy should be implemented in all continents and and I think that Dr. Saran and we all here also agree and hope that that will become reality very soon. Partly I have answered but I would like to say that this we are a WHO collaborative center and we worked very hard, were able to develop this policy and the government of India has assigned X amount of money and for the next 10 years this should be available for a free HPV DNA, a free hepatitis B surface antigen and liver functions including a liver stiffness measurement which would be free in case the equipments are being procured. So that way hepatitis B program has got an impedance. I have two concerns which I have in my webinar session also and we showed this in two or three series of publications that the transmission of hepatitis B is not merely perinatal, I think dominantly is intrauterine and mother-baby transmission as is seen in China very often is also very common in other countries. So to be able to say that all vaccinations would be effective especially if the mothers are HBsAG positive is less likely. Occurred HPV and we have shown in 2011 and 30 in two studies that the anti-HBs in the babies born to HBsAG positive mothers sometimes 21% of them have anti-HBs which is less than 10 and therefore such babies may be a source of occult HPV we do not know or cause of chronic liver disease. To put it simply vaccination policies must be reassessed even HPV vaccine may not be as effective in babies born to HPsAG positive mothers if they are in a large scale. For treating all, thank you for appreciating the efforts. I wish all countries can follow and happy treatment should be free and affordable to everybody. So there are two issues that we kind of have been discussing together here is that screen on and treat all and you know I mean we say treat all you know but it's Dr. Serene who advocate for this also mentioned we don't mean to treat people who are HPCR negative and that is and and I think that I agree with with many of the faculty here this probably should be only the beginning of much more in-depth discussion but how about we just step back a little bit and just talk about something much simpler how about screen all how about universal screening so in places like East Asia or more high prevalence area like in Sub-Saharan Africa universal screening may be a lot easier to to be advocate for modern except for the financial resources but like in a place like Western Europe or Canada or the US the general population prevalence is very low like in the US it's like 0.02% however if you go to San Francisco or New York or Texas where we have a lot of immigrants from South America from Eastern Europe Southern Europe and East Asia then the prevalence is much more than that so so so there may have to be a more semi-universal strategy otherwise we could never convince policymaker that it is cost-effective and I have seen some work from from France and Germany trying this approach so I want to ask Dr. Papatheodoridis and Coffin what are your perspectives on this and and how to to do a quote-unquote semi or targeted universal approach for lower prevalence area. Thank you Dr. Nugent. The screening is the biggest challenge for the overall management of HPV patients and the efforts towards elimination so the screening policy probably should differ between among different countries and even among European countries there are differences in the epidemiology in the proportion of the high-risk groups within each population so I think many European countries now certainly Greece and other European countries have developed specific national plans for elimination in parallel with hepatitis C also for hepatitis B and these plans describe exactly which are the groups among the population of each country or if it is a total population specific age groups or high-risk groups for hepatitis B that should be screened for for HPV markers and which is the recommendations after screening depending on the findings. Of course the implementation of screening in a large proportion of the population is also very challenging so recommendation is one thing but implementing the recommendation into real life is is another issue and this is even more difficult to develop recommendation. It is scientific it is difficult to be to be accepted by the government and and the ministry because this can only help in the implementation but even if they accept the national plans the implementation remains difficult and remains challenging so we are in efforts of many European countries including Greece we are in the efforts of implementing screening policies for specific high-risk groups for hepatitis B. Having said that I have to admit that the the screening the under diagnosis rates remain very high in many European countries but I think this affects mainly the proportion of patients we diagnose with compensated subclinical cirrhosis because we still diagnose patients at first diagnosis with cirrhosis histological cirrhosis or by fibroscan cirrhosis but we don't see patients with decompensated cirrhosis. These have been very rare at first diagnosis and but still we need to decrease this number the patients we diagnose at first diagnosis with compensated cirrhosis because these are the patients who remain at risk for cancer even if they receive very effective treatment and they will remain at high risk for cancer for years. So I think screening is very challenging it's difficult and the policies should be individualized according to to each country. Maybe Carla Coffin from North America can share her thoughts. Yes thank you and it's been a very interesting discussion so far. I agree absolutely that we could be doing more even in Canada and the US like we're relatively wealthy countries and there's a lot more that could be done to upscale surveillance and screening and a lot more that could be done even for simple things like birth dose vaccination and you know even though the argument is that you know prevalence of hepatitis B is low in North America the problem is we don't have a good surveillance or tracking system in Canada and you know there's significant change in the demographics in both Canada and in the US over the last several decades and they estimate that by 2030 up to a third of Canadians will have been born outside of Canada or born in a country that's highly endemic for hepatitis B. So definitely we need to be doing a lot more to increase screening because people present with very advanced liver disease you know they're presenting with too late with cancer and cirrhosis which could be entirely preventable with very cheap and very effective drugs and I completely agree with the with the the push for a birth dose vaccination. It makes no sense in fact it's I'm almost ashamed to say that we have 13 different vaccination programs in Canada and many of them don't even start until grade 7 or adolescence and this may have made sense a couple of decades ago when you know most Canadians were born into families of European or Scottish or French descent you know multi five generations but many Canadians are coming from families which are first or second generation from highly endemic areas and so all of the children you know it should be universal all of the children should get birth dose vaccination. Okay maybe last Dr. Jia from China and I have also a question for North for South America and Africa after that a different question. In China you know the prevalence currently is still around 6% is still much higher than that in North America and Europe but in younger generation less than 15 years old less than 1% already so we have already have age specific age group older than 20 years old then we also have some regional high endemic areas so now in China we routinely screen all the pregnant women for cervical angina, for HCV, for syphilis, for HIV or this kind of so-called triple elimination program that provide the free screening for all this and also provide a free HIV in addition to free HIV vaccine. In addition we have the screening routine screening for all those who will hospitalized for invasive procedures so at the moment we have no universal screening but we have a lot of screening program so we try to cover more and more. Of course at the moment still not covered all but one issue before several years ago money the economy burden is a was a big problem but now as I mentioned earlier the pricing for the TDF and Antakya become very very cheap almost nothing so that's no longer a barrier but another barrier would be the privacy the protection of the equal right for education for employment because it's kind of sensitive information so that's maybe one of the obstacles we need to overcome we need to come encourage people to come to screen at the same time we have to protect their privacy. Thank you. Okay so I want to follow up on the question hepatitis Delta and the continents which are hit most hard by that in our group are likely South America and Africa and it's very often a forgotten disease if we do have at least a suppressive treatment for hepatitis B which hardly or does not work for hepatitis Delta so particularly in in in the Amazon area in Brazil for instance Dr. Gaidano can you tell us a little bit on how that infection is is in any way conquered but with vaccination and there are actually now treatments on the horizon which might help at least suppress this disease myrtodex in particular long term it's been licensed down several countries can you tell a little bit about the problem of hepatitis Delta in your continent? Yes of course thank you Harry and thank you ASLD for inviting me it's a great discussion. Yes we have a huge problem in an area which is you know it's Amazon it's central of South America which is shared by 12 countries it's not only Brazil but other countries also like Colombia Bolivia Peru Ecuador Venezuela and a huge like 50 million people living there with very difficult access to that area so in in that region we the prevalence of hepatitis B is from I would say some areas of 2% HBs antigen 3% to almost 25% in some areas and some areas are co-infected with Delta 60% of patients for instance in the area of Peru, Colombia, Acre in Brazil 60% of patients of HB patients are co-infected with Delta. So we have a huge problem there if we measure fibrosis about almost 35 40% have F3 F4 fibrosis. The access is very difficult to the area so we definitely need of course universal vaccination we are far from getting that we have we don't have you know reliable data but we should be around 60% vaccination rate in those areas so we are far from getting 80 90 100% and of course in that area like in most other areas of South America you we should test and treat we are not doing we are not getting there and if we we have as I said as some of my colleagues said also less than 10% diagnosis people people diagnosed less than 10% and if we go with a diagnostic strategy we should go with a treatment strategy as well so we cannot diagnose just HBs antigen if we don't have tools for instance to have baseline serology, baseline HPV DNA, Fibroscan or whatever to measure fibrosis. So we are far from getting that and we are working together we need the collaboration of the WHO and you know it's our major task in the region and I think we are other countries with very low for instance Chile has 0.5% and some big cities Buenos Aires, Sao Paulo there is a problem but the huge problem is they are in central of the continent and we really need to go there together with universal vaccination and then diagnose and treat strategy yeah. Okay thank you very much. Mark can you comment on the Africans David? Yeah I mean as you will know Harry that Delta virus is more prevalent in in Africa as you move north towards the equator so the southern portion of the country is of the other continent is is less afflicted by Delta virus infection if you go to a country like Cameroon certainly northern Cameroon up to a third of people who are chronically be virus infected can be can in fact be co-infected with Delta virus so there is enormous burden. Some people access in the past some percolated interferon therapy but it's an absolute fraction and clearly there's a great need for for better therapies but the issues really remain around around access to to Mucludex and the newer therapies that are going to come so it's something that clearly needs to be eradicated but hopefully will be part of elimination of B which is everyone says that you'll be able to eliminate D in time. Harry can I just comment on on screening because I would like to see from some of my my fellow panelists whether some of these issues are transversal we spoke about screening and clearly that's the core of of moving towards elimination. The issue within Africa, of course, with screening is who's going to do it and where you're going to do it. But one cannot delink yourself from the issues of stigma because to get people to screen, you need to also address the stigma. Now, there's a big move towards integrating screening of B virus and C virus into the existing HIV services. Because as you know, I mean, 70% of the global burden of HIV is found in Sub-Saharan Africa. And that's one aspect that's been very well, in fact, handled in terms of developing services for managing HIV. So integrating and leveraging on those systems would be a sensible thing to do. But you have to address the stigma. That's the first issue, because people still have enormous stigma around hepatitis B and they're not going to screen unless you actually address that. Secondly, they're also not going to screen if you can't link them to care. So the treatment has to be available. And foundational to that, which has been shown beautifully in a country like Rwanda, which two decades ago was caught up in the most unbelievable internal strife, is in fact political will. Because there, the president and the government has put their absolute best behind upscaling screening for B and C virus in that country, where in certain instances, 4,000 people have been screened a day. So they are shining beacon on our continent. But I think those three issues are really important. But I wonder how others experience the issues of stigma around other parts of the globe. Maybe Carla, Coffin, can you comment on stigma in North America? Yeah, and I agree. This is a huge problem and it's quite unfortunate, especially seeing it in some children that are young people in my practice and how they've been affected growing up. And I think when we argue about the benefits of a functional cure, I mean, the psychological benefits of telling somebody, you know, you've cleared surface antigen, you know, this milestone, it can't be underestimated. You know, when we talk about costs and we talk about quality of life, this has tremendous impact. And I certainly agree that we should try and combine this with other screening programs. And, you know, there's so much that's being done and talked about, about COVID-19 screening and doing things like dried blood spot testing. And, you know, could we not try to integrate this with viral hepatitis screening in future? I think there's a lot more that could be done and certainly we need to address the stigma associated with hepatitis B. Harry? Yeah, go ahead. Yeah, I just want to mention about that. It's one of the advantages when you go through a strategy of universal screening. When you diagnose all of them, you eliminate at least part of the stigma because you are doing that in all the population and not the at-risk population like sexual or IBDU or whatever. Okay. Can I add on to the stigma part? 2016, Apostle passed the first statement on not having discrimination stigmatization about hepatitis B. In 2018, all four societies, ASLD, Easel, Apostle and Allay published a joint statement, both in hepatology and Hepatology International that we should have no stigma. In fact, that's a written statement published when Anna was also there as a president. So this has been a statement by all societies. What we, and this was also sent to WHO. What has not been done is that we all collect together and go to the United Nations General Assembly and get this passed. That anyone who discriminate will be, we have to give them equal rights. And so one part is the society and the policy makers movement. But the second part to which I vote for is that you say all my patients are virus negative. Why do you not allow them to get a government job? I have at least half a dozen doctors who one got an ophthalmology or other got another job. They are not allowed to change your specialty. So my clear conviction is that if you treat all, you make them virus negative, where is then a stigma? Where is then discrimination? So that is one part of stigma and discrimination to be eliminated. Now one another issue which Mark raised is about the screening. In India, what we have done is just to share experience that even to the smallest village, they are detecting for diabetes, blood sugar by a capillary test. So detection for diabetes. And now we have piggybacked on that. So everywhere you are doing a blood test for diabetes, you do for hepatitis B and C. So we are able to do that. And that's how this program gels with diagnosis and treatment part. Another thing which we can do everywhere, and this has not been tested well, is that when we are using the NAC testing, we can pull six, 10 and test for hepatitis B. That will be cost effective. So I think a NAC testing, if it is used, can be very effective method for screening. So I think if we can screen and collectively have policies which are available, then I think treatment will become a necessity. As Adrian said very rightly, if you diagnose, and I think Dr. Jia would agree in China, this has been there. If you diagnose, certainly you should treat. And I think therefore screening and treatment cannot be separated. So we should treat and we should screen all. Mindy, do you have a question? Yeah, I would like to address some questions from our audience. So there are three questions and that they are related to each other. So I would like to summarize it. So we have one question regarding what is a DNA cutoff? Do we treat everyone above 2000? And if we treat the patients, how do we maintain the patients in care? And what would be reimbursement policy in certain areas like Taiwan? So I would like to ask if Dr. Hsu from Taiwan that has a pretty homogenous population and fairly small population with a very good socialized medicine, if you could address how does a government policy has helped or not helped in what the patients need in terms of antiviral medicine reimbursement? And I would like to, after that, if Dr. Coffin could address the issues on how we maintain patients in care, because it's hard enough to get the patient screen and started on a medicine, but once they are on a medicine, the problem doesn't end there. How do we maintain them in care, especially for a heterogeneous population like in Canada, which I think would be common to many populations in the US or in parts of Western Europe as well. Dr. Hsu. Thank you, Professor Mindy for giving me the honor to answer these questions. So in Taiwan, there is a national insurance healthcare policy. So if the patient fulfill the criteria for the treatment, the antiviral treatment, then the patient do not have to pay anything to get a drug. And the indication generally follows the international guidelines, mostly based on the Apostle guidelines. So the indication for treatment initiation, I think covers that ALT elevation and the viremia in addition to cirrhosis, chemoprevention, et cetera. However, there is a one unique feature for the reimbursement policy in Taiwan that according to the rule, most of the patient cannot continue the treatment indefinitely. So for example, for e-antigenic patients, unless the patient has liver cirrhosis, then he or she has to stop the treatment after three years. And there's a lot of debates about whether patient should try finite therapy. And I'm not going to bother the pros and cons here. Somehow, some of the patients relapse after discontinuation of treatments. And I think that there is something in Taiwan that hepatologists are trying to discuss with the government to make the criteria for treatment looser, to make more patients to keep on treatment. Thank you. So a good example of that, even when you have a government support to start the patient, that doesn't mean that it covers all the patients at need, even according to guidelines or long-term. So in Canada, Carla, how many percent do you think of the patients who get started actually stay on it long-term? And what is your reimbursement policy in Canada, another country that you also have much better government coverage than we do in the US? Well, actually, if our prime minister is listening to this webinar, I'd like him to know that we need a national drug care, national pharmaceutical coverage, because even though we have so-called universal healthcare, drugs are not covered. Out-of-hospital drugs and pharmaceuticals are not covered. So you need to apply to a provincial reimbursement program or you need to have private coverage. And one of the sad things that has happened during this pandemic is that people have lost their jobs and they've lost their drug coverage and they're stopping their medications. And we can say, well, all I can do is just monitor you, right? Monitor your, and hope that nothing bad happens. So a wealthy country, we don't have drug reimbursement and it's necessary. The nukes are cheap. We spend $260 billion a year on healthcare. We should be able to cover the cost of these nucleoside analogs for the relatively small percentage of people with hepatitis B in Canada. And I also understand and appreciate, and you can certainly speak to the challenges with pharmacare and an adherence to treatment and follow-up of patients in the US, even those with private insurance coverage are still lost to follow-up and still not able to continue with their treatment because it's all tied to their employment, if my understanding is correct. So it's difficult, if the answer to your question is how to maintain them on treatment. Well, you mentioned COVID and how much, I mean, we're here in this very strange situation, having a Zoom call with the rest of the world, but definitely in other continents, maybe Dr. Gardano can comment from South America, where again, Brazil is hit very hard. COVID has in a major way hampered our efforts to screen and also to treat. And so hopefully we'll get over that quite soon, but this will definitely, or potentially I would say, jeopardize our elimination strategy by 2030, which will be extremely difficult to reach anyway. Can you comment on some experience of that within South America? Yes, Harry, if things were difficult before, they are much more difficult now. And as you all know, for instance, I'm sure you share this, we don't know what is going to be the scenario in the region for next year or next years. But for sure, access will be more difficult as it is now. We used to go to some regions to have blood tests with the FibroScan and to FibroScan a whole population, we cannot do it now. Brazil is the same, for instance, Raimundo Paraná, who is in Salvador, he's the president of Ale. He has a program to go to Amazona and he's not getting there now. People cannot go to big cities. So this is complicating even more the strategies, even if we had limited strategies on the problem of COVID is complicating it all. So we should maybe recreate strategies in these new scenarios. And this will depend on each of the regions. Maybe a question, because we're ending the one hour Q&A. If you allow me, if it's fine, I mean, to the group in general, because definitely Hepatitis B is not as much on the radar as many other disease, infectious diseases, as we all know, like HIV, like malaria, like tuberculosis, et cetera. So what would we need to do in the current era? And let's pretend that we are in next year, in 2022, when COVID is over. What effort should we undertake to really get this disease higher on the ladder of the politicians, really? Is there any like, Mark, can you comment that from an African perspective? Yes, Harry, thank you. I mean, I just want to pick up very briefly. The issues of COVID are clearly negative, but I think we have to look at the positives. And the positives is that the world suddenly knows that vaccines are really important. The world suddenly also knows that if you need to upscale PCR testing for a virus quickly, you can. And governments know that as well. And yet we have a virus for which there's been an effective vaccine for 40 years. And we seem to have dragging of our feet generally around the globe. So I think we should use COVID-19 to remind those in decision-making roles that this can be done, and that issues around birth dose vaccination and vaccination are crucial. And this is an entirely preventable illness. And then we need to actually go and find those folk who need treatment. And we need to use the gold standard, which is HPV DNA viral load testing. And that needs to be available to everyone, not just the selected few. Thank you. Other comments from other continents? Yeah, that's a good point. I agree completely. And I think that on one side, we may anticipate that maybe we have less access to budgets because of the pandemic and because the budgets are destinated to other virus, but I don't think so. I think, as Mark said, that the health will be in the center of the governments and of the world organizations. So we have to take advantage of that and say, well, we need vaccine to this, we need treatment for this, affordable access. And that may be a possibility or maybe a good thing when we get out of the pandemic. Okay, I think we're approaching the end of this session. Right, Wendy? Yes, we have two minutes left. Very quick, Shiv. Very quick. WHO recommends that in populations where you have up to 5% or even 3% SARS-CoV-2, we need to do an antibody screening. And we are not doing a screening for HBV in places where the prevalence is about 3% or so. I think we need to debate in another webinar or so that populations where there is a low prevalence, how do we handle the screening programs in those low prevalence places? And also, I think the non-relevance of ALT should also be discussed in our program so that we can move forward. Otherwise, we'll be treating only 1% of the infected. Thank you. Okay, all right. With that, I would like to close this Q&A session. It's very nice to see how the epidemiology treatment and diagnosis in the different continents is evolving slowly but steadily. And hopefully, indeed, COVID will not hamper our preventive and diagnostic and therapeutic activities too much in this, and that we can still move on in trying to reach the elimination deadline of 2030. I really would like to thank, first of all, the audience from around the globe, all the speakers. I would like to thank the ASOB. I would like to thank my co-moderator, Mindy Nguyen, and Dominic Clayton and John Lingerfeld. And then to announce our next webinars, I think the HPV SIG has been quite active, and there's some very interesting webinars coming up. So I really invite you to participate in the next ones, which is the Stop Nucleoside Analog webinar, which will be held in January 2021. Then there is the Young Investigators webinar in February 2021. And we have a much bigger meeting, the Emerging Topic Conference on Elimination, which is truly, I would say, an outstanding program with very good speakers from around the globe, which is about to happen in March 2021. Obviously, all of this online. Thank you very much. Good morning, good afternoon, good evening, good night, wherever you are, and have a nice week. Thank you. Bye-bye.

HPV disease burden

management strategies

different regions

universal screening

affordable treatment

stigma

functional cures

further research

global scale