Alpha-fetoprotein (AFP) level and its changes in chronic hepatitis B (CHB) may influence the risk of future hepatocellular carcinoma (HCC). This study aims to evaluate the HCC risk in CHB patients with no overt HCC but with elevated AFP level and to explore the prognostic role of longitudinal changes in AFP and liver-related laboratory values. This multicentre cohort study included 10,639 CHB patients without a history of HCC from seven medical facilities in South Korea. Patients with a baseline serum AFP test and no HCC diagnosis on imaging within 3 months were included. Patients were categorised into high-AFP (≥ 10 ng/mL) and normal-AFP (< 10 ng/mL) groups. The primary outcome was the incidence of HCC within 2 years, with secondary outcomes focused on longitudinal changes in AFP and liver-related laboratory values. Propensity score matching (PSM) and Cox proportional hazard models were used to assess HCC risk. After 1:4 PSM, 1278 high-AFP and 3731 normal-AFP patients were analysed. The high-AFP group had a significantly higher 2-year incidence of HCC (HR: 4.29; 95% CI: 3.31-5.57). AFP levels increased in patients who developed HCC in both groups (p < 0.01). Among the high-AFP group, patients who did not develop HCC had elevated baseline alanine aminotransferase levels (p < 0.01), which decreased during follow-up (p < 0.01) unlike those who developed HCC. In conclusion, baseline AFP elevation in CHB patients is associated with an increased risk of developing HCC within 2 years. Longitudinal monitoring of AFP and liver-related laboratory values can help in risk stratification.

Current guidelines to prevent hepatocellular carcinoma (HCC) by chronic hepatitis B virus (HBV) infection are based on risk assessments that include age, sex, and virological and biochemical parameters. The study aim was to investigate the impact of predictive markers on long-term outcomes. The clinical outcomes of 100 patients with chronic hepatitis B were investigated 30 years after a baseline assessment that included liver biopsy. A favourable outcome-HBsAg loss or HBeAg-negative infection (ENI; previously termed 'inactive carrier')-was observed in 74% of all patients, whereas 7% developed HCC. HBsAg loss was observed in 75% of patients with genotype A, compared with 42%, 33% and 0% with genotypes D, B and C, respectively (p < 0.0001). HCC developed in 3 patients (33%) with genotype C as compared with 3 (17%), 1 (2%) and 0 patients with genotypes B, D and A, respectively (p < 0.0001). In multiple logistic regression analysis, both HBsAg loss and HCC were associated with HBV genotype and baseline HBV DNA level, and HCC also with histological score. The results suggest that genotyping and histological assessment may improve outcome prediction and help decisions about HCC screening, particularly in populations with HBV-infected individuals of mixed geographic origin.

Resistance-associated substitutions (RASs) are mutations within the hepatitis C (HCV) genome that may influence the likelihood of achieving a sustained virological response (SVR) with direct acting antiviral (DAA) treatment. Clinicians conduct RAS testing to adapt treatment regimens with the intent of improving the likelihood of cure. The Canadian Network Undertaking against Hepatitis C (CANUHC) prospective cohort consists of chronic HCV patients enrolled between 2015 and 2023 across 17 Canadian sites. Utilisation of RAS testing was assessed across demographics, clinical characteristics and years. SVR was described for the overall cohort and compared across populations of patients with historically negative predictors of SVR. The detection of key RASs and how this information influenced DAA selection were assessed. 2434 patients were identified with information on RAS testing. 98.3% achieved SVR. Out of the 227 patients tested for RAS, 147 (64.8%) had any detected RAS, and 84 (37.0%) had an NS5A RAS. The proportion of patients with SVR did not differ between RAS-tested (98.3%) and non-tested patients (98.3%; p = 0.99). SVR in those with an NS5a RAS was similar (98.6%) to the overall SVR proportion. Proportions with SVR did not differ between those with and without RAS testing in key subgroups (genotype 1a, genotype 3, prior treatment, cirrhosis). The specific DAA regimen and the addition of ribavirin were not associated with SVR outcome. RAS testing has a minimal influence on antiviral treatment selection. Going forward, there is a reduced role for RAS testing in most clinical scenarios.

Hepatitis B elimination objectives can only be realised if new patient linkage to care is matched by long-term patient retention in care. We previously showed in adult chronic hepatitis B (CHB) patients that retention in care was inferior in younger patients and in patients from non-Asian ethnicities. The present study explores further the rates and determinants of loss to follow-up in a cohort of 271 young patients (aged 16-21 years at baseline). 16% of patients were lost to follow-up after a single consultation, and retention in care at 5 and 10 years was 53.7% and 45.9%, respectively. Retention in care was strongly associated with the source of patient referral and was superior for patients referred from the antenatal clinic and those transitioned from paediatric care (68% retention at 5 years for both sources) compared with those from "other" sources (36% at 5 years). In multivariate analyses, patient source of referral and distance of current residence from the Hepatitis Outpatient Clinic were the significant determinants of loss to follow-up. Retention in care may have been promoted by the transition process for those diagnosed in childhood and by the repeated referral from the antenatal clinic of women who had multiple pregnancies during the observation period. Only 20% of asylum seekers and referrals from genitourinary clinics were retained in follow-up at 10 years from baseline. This identifies a group of patients who do not access medical care, cannot benefit from treatment, and who may constitute a long-term public health risk.

Dendritic cells are the most potent antigen-presenting cells in immune therapeutic approaches for chronic hepatitis B (CHB) infection. Here, we developed a clinical trial to evaluate the efficacy and safety of autologous HBV vaccine-pulsed DCs and their induced T cells (HPDCT) in CHB patients. This was a randomised, prospective, open-label, multicentre, superiority study and 309 treatment-naive CHB patients were divided into HPDCT plus nucleos(t)ide analogues (NAs) group (n = 84), NAs mono-therapy group (n = 82), HPDCT plus Peg-interferon (Peg-IFN) group (n = 69), Peg-IFN mono-therapy group (n = 74). Twelve times of HPDCT vaccinations were given intravenously, and all the patients were followed up for 72 weeks. In total, 1836 HPDCT infusions were administered with no obvious toxicity and side effect although few patients had self-limited low fever. More patients got HBsAg loss in those receiving HPDCT therapy. Patients of HPDCT plus Peg-IFN group with HBV DNA < 1 × 10 IU/mL at baseline exhibited earlier, stronger and longer lasting of viral response, especially HBV DNA < 20 IU/mL, than those patients of Peg-IFN mono-therapy group, from week 24 till week 72 (p < 0.05). Comparable efficacy was observed between the patients of HPDCT plus NAs group and NAs mono-therapy groups. In addition, CD25 on CD8 T cells and HBV-specific CD8 T cell increased significantly in patients of HPDCT combined antiviral drugs therapy. HPDCT combined with antiviral drugs was safe and able to enhance T cell immunity. Furthermore, HPDCT combined with Peg-IFN could provide an incremental benefit to patients with baseline levels of lower HBV DNA. Trial Registration: ClinicalTrials.gov identifier: NCT01935635.

As the second most populated country in Africa, Ethiopia needs public health measures to control diseases that impact its population. The goal of this study is to analyse disease burdens of HBV and HCV, while also highlighting their estimated associated costs for the country. A literature review and a Delphi process reflecting input of Ethiopian experts and the National Viral Hepatitis Technical Working Group were used to complement mathematical modelling to estimate HBV and HCV disease and economic burdens. Two scenarios were created for HCV: 2023 base and WHO elimination. For HBV, three scenarios were created: 2023 base, WHO elimination and universal birth dose. Using current country costs, each scenario was also examined through an economic lens. There were an estimated 7.6 million HBV infections in 2023. To impact transmission, a universal birth dose and pregnant women screening program would allow Ethiopia to vaccinate approximately 3.9 million infants annually, with a budget of $4.68 million USD, meeting the WHO prevalence elimination target (≤ 0.1% in ≤ 5-year-olds) by 2043. Ethiopia had an estimated 690,000 HCV infections in 2023. To achieve HCV elimination, the country would need to expand screening and treatment to 74,000 individuals annually with a peak budget of $12 million USD per year until 2032, decreasing to less than $2 million USD in 2035. Ethiopia can begin making steps towards elimination of HBV through expansion of birth dose vaccination. However, larger investments will be needed to scale-up treatment and diagnosis interventions for both diseases.

Chronic hepatitis C virus (HCV) infection is associated with significant morbidity, mortality and health economic burden. Over 90% of HCV cases in England occur in people who inject drugs (PWID). Current treatments for HCV are effective but do not protect against reinfection. This research characterised HCV infection and reinfection risk in PWID in England using 2011-2021 data from the annual, cross-sectional, bio-behavioural survey of PWID, Unlinked Anonymous Monitoring. Risk factors for HCV infection were explored using multivariable logistic regression. Shared frailty models for the force of infection (FOI) were used to estimate the risk of HCV infection throughout injecting career with unmeasured risk variation modelled using gamma-shaped frailty distributions. HCV reinfection rates were derived using the frailty distributions of FOI models fitted to UAM data. Infection rates were highest in the first year of injecting (24 per 100 person-years) but fell to between 5 and 8 infections per 100 person-years subsequently. The estimated average annual risks of HCV primary infection and reinfection were 10.0% and 14.2%, indicating a 42% higher risk of reinfection compared to primary infection. Even those with no a priori risk factors were predicted to have high rates of reinfection if previously infected. These findings support the recognition of primary HCV infection as an independent risk factor for reinfection in PWID and emphasise the importance of reducing high-risk behaviours to prevent HCV reinfection following treatment of primary infection. Public health policies must recognise the importance of preventing reinfection in efforts to reduce HCV infection prevalence.

Acute hepatitis B (AHB) is generally a self-limiting illness in adults and most patients achieve hepatitis B surface antigen (HBsAg) clearance within 6 months. We aimed to investigate the proportion and influencing factors of chronic outcome in adult AHB patients. A total of 126 consecutive AHB patients were included between January 2013 and October 2018. Multivariate regression analysis was conducted to evaluate the influencing factor of HBsAg clearance. Fourteen (11.1%) patients failed to achieve HBsAg clearance within 6 months. Among them, nine patients achieved HBsAg clearance within 6-12 months, while five patients had persistent HBsAg positive over 1 year. Patients with HBsAg clearance had lower baseline antibody to hepatitis B core antigen (anti-HBc) (7.0 S/CO vs. 8.0 S/CO, p = 0.090) and HBsAg levels than those with chronicity of AHB. Multivariate analysis revealed that HBsAg ≤ 250 IU/mL (HR 3.008, IQR 1.877, 4.820, p < 0.001) and anti-HBc levels (HR 0.830, IQR 0.755, 0.912, p < 0.001) was significantly associated with HBsAg clearance. Anti-HBc remained an independent predictor of HBsAg clearance in different HBsAg subgroups. Patients with HBsAg > 250 IU/mL (p < 0.001) and high anti-HBc (p = 0.001) had lower cumulative HBsAg clearance rates than those with low HBsAg and anti-HBc. 11.1% of AHB patients did not achieve HBsAg clearance within 6 months, while the proportion of patients with persistent HBsAg positive decreased to 4.0% after 1 year. Combination of baseline HBsAg and anti-HBc levels could identify patients who might have a possible risk of chronicity following AHB.

Using a systematic review and meta-analytic approach, this study determined the durability of HBV immunity and the prevalence of anamnestic response to a booster HBV vaccine dose in individuals previously vaccinated with a 3-dose HBV vaccine series as children or adolescents. Two researchers independently searched PubMed, Embase and Cochrane from inception to 6/1/2023 and performed data extraction. Studies that included individuals with significant comorbidities or < 5 years of follow-up were excluded. Of 2517 potential studies, we analysed 91 eligible studies (193,359 individuals from 208 cohorts [some studies provided data for more than one cohort]). Median age at vaccination was 0 years (range: 0-20.00). After a median follow-up of 10.15 years (range: 5-35), 63.2% (95% CI: 59.3-67.0) retained HBV immunity. HBV immunity declined by 6.62% per follow-up year (Ptrend < 0.0001). In meta-regression adjusting for vaccine type, follow-up time and geographic location, age at vaccination was significantly associated with retaining HBV immunity (adjusted odds ratio [aOR] 1.12 per year, p < 0.0001). Anamnestic response rate (44 studies, 66 cohorts, 29,040 patients) was 90.34% (95% CI: 86.84-92.98), with highest rates in Europe and Asia, but only study setting (clinical versus community-based: aOR 2.21, p = 0.034) was an independent factor. HBV immunity prevalence was about 60% after 10 years following childhood vaccination. Anamnestic response rate was about 90% and varied by study setting. Testing for immunity should be considered in individuals with high exposure risk and distant vaccination history with booster as needed.

The World Health Organisation (WHO) has set goals to eliminate hepatitis C (HCV) as a global health threat by 2030. To meet this goal, Australia must increase testing and diagnosis, including expanding access to care through community pharmacists. This study aims to explore community pharmacists' preparedness to discuss and offer HCV testing and treatment. Australian community pharmacists from four states completed an online anonymous quantitative survey between August and October 2023. Pharmacists were asked about their experiences of, comfort discussing and willingness to host outreach HCV testing or treatment. Predictors of each outcome were examined using logistic regression. In total, 530 pharmacists participated in the study. One in five pharmacists stocked HCV medications (22%), half (48%) were willing/somewhat willing to host an outreach HCV testing and treatment team, while 36% strongly agreed/agreed they were comfortable discussing HCV testing and treatment. Willingness to host an outreach HCV team was associated with pharmacists working in rural/remote settings (95% CI: 1.04-2.35, p = 0.032), providing opioid agonist treatment (95% CI: 1.16-2.49, p = 0.006) and comfort discussing overdose prevention (95% CI: 1.31-2.80, p = 0.001). Pharmacists with ≥ 15 years' experience (95% CI: 0.44-0.94, p = 0.022) were less willing to host outreach HCV testing. Females were significantly less comfortable discussing HCV testing (95% CI: 0.45-0.98, p = 0.039) compared to males. This is the first Australian study to explore community pharmacists' preparedness to discuss and offer HCV testing and treatment. In light of research showing that community pharmacy models of care can help meet HCV elimination targets, ongoing engagement with pharmacists is needed to increase their preparedness to provide this care.

Hepatitis B virus (HBV)-hepatitis delta virus (HDV) coinfection is the most severe form of chronic viral hepatitis, but the factors that determine disease progression and severity are incompletely characterised. This long-term follow-up study aims to identify risk factors for severe liver-related outcomes. In this multicentre national cohort study, data from admission until the last visit between 2001 and 2023 was retrospectively collected from 162 HBV-HDV coinfected patients. The inclusion criteria were HBsAg or HBV DNA positivity, anti-HDV or HDV RNA positivity, and at least one follow-up visit. The median follow-up was 6.2 years (IQR 3.3-10.2). At baseline, 68/152 (44.7%) patients were diagnosed with advanced liver fibrosis. Forty patients (24.7%) had at least one severe liver-related outcome during follow-up. HDV viremia was detectable in 92 patients (64.3%) at last evaluation and was more frequently detectable in patients of European origin (p < 0.001). HDV RNA-positive patients had a 4.7-fold higher risk for severe liver-related outcomes (p < 0.001) and were more frequently diagnosed with advanced fibrosis at baseline (p = 0.007) compared to HDV RNA-negative patients. Multivariate analyses identified HDV RNA positivity, as well as several markers for liver disease severity, such as INR, platelet count, and advanced fibrosis at baseline, and age at admission as independent risk factors for severe liver-related outcomes. In conclusion, almost one in four HBV-HDV coinfected patients developed a severe liver-related outcome during follow-up. Several markers for liver disease severity and HDV RNA positivity were the strongest predictors for outcomes.

Hepatocellular carcinoma (HCC) is the most common primary liver cancer. Hepatitis B virus (HBV) is the main pathogen for HCC development. HBV covalently closed circular DNA (cccDNA) forms extra-host chromatin-like minichromosomes in the nucleus of hepatocytes with host histones, non-histones, HBV X protein (HBx) and HBV core protein (HBc). Epigenetic alterations are dynamic and reversible, which regulate gene expression without altering the DNA sequence and play a pivotal role in the regulation of HCC onset and progression. The aim of this review is to elucidate the deregulation of epigenetic mechanisms involved in the pathogenesis of HBV-related HCC (HBV-HCC), including post-translational histone and non-histone modifications, DNA hypermethylation and hypomethylation, non-coding RNA modification on HBV cccDNA minichromosomes and host factors, effecting the replication/transcription of HBV cccDNA and transcription/translation of host genes, and thus HBV-HCC progression. It is expected that the epigenetic regulation perspective provides new ways for more in-depth development of therapeutic control of HBV-HCC.

Steatotic liver disease is prevalent among people with hepatitis C virus (HCV). The new definition of metabolic dysfunction-associated steatotic liver disease (MASLD) emphasises the metabolic drivers of steatosis and recognises its frequent coexistence with other chronic liver diseases, including HCV. We aimed to evaluate the association of coexisting MASLD and HCV with liver fibrosis. Individuals with HCV who underwent transient elastography (TE) with associated controlled attenuation parameter (CAP) were included from two clinical centres. MASLD and significant liver fibrosis were defined as the presence of steatosis (CAP ≥ 275 dB/m) with at least one cardiometabolic risk factor, and liver stiffness measurement (LSM) ≥ 7.1 kPa measured by TE, respectively. Associated cofactors of significant liver fibrosis were determined using stepwise regression and cross-validation by LASSO models to select confounders. Among 590 participants, 31% were diagnosed with MASLD. The prevalence of significant liver fibrosis was the highest among people with MASLD (58%) followed by HCV-related steatosis (45%) and the non-steatosis group (39%). After adjusting for potential confounders, MASLD was associated with significant liver fibrosis (adjusted odds ratio [aOR] 2.29, 95% confidence interval [CI] 1.07-4.87). Furthermore, specific MASLD phenotypes including diabetes, hypertension and overweight were associated with significant liver fibrosis, with aORs of 4.76 (95% CI 2.16-10.49), 3.44 (95% CI 1.77-6.68) and 2.54 (95% CI 1.27-5.07), respectively. In conclusion, MASLD is associated with liver fibrosis in people with HCV, specifically the diabetes, overweight and hypertensive phenotypes. Beyond pursuing a virological cure, healthcare providers should prioritise managing metabolic conditions, particularly diabetes, hypertension and obesity.

This study aimed to evaluate the effectiveness of direct-acting antivirals (DAAs) on hepatitis C virus (HCV) hospitalisation trends in Italy, the country with not only the highest burden of HCV-related disease but also the highest number of patients treated for chronic HCV infection in Europe. Incident hospital discharge records in Italy from 2012 to 2019 that included a liver cirrhosis diagnosis without mention of alcohol, hepatocellular carcinoma (HCC), HCV and liver cirrhosis without mention of alcohol and/or HCC, cirrhosis with mention of alcohol, as defined by the International Classification of Diseases (ICD-9-CM) were reviewed. An interrupted time series analysis compared the incidence of cirrhosis and HCC before and after the introduction of DAAs (Year 2015). Overall, non-alcoholic cirrhosis significantly decreased after the introduction of DAAs (β = 0.03) and for those 40-59 years of age (β = 0.025). HCV with cirrhosis and/or HCC significantly reduced overall for those aged 40-59 and older than 60 ( ). HCC-related hospitalisation rates significantly decreased in patients younger than 60 ( ). Cirrhosis-related hospitalisations with mention of alcohol did not differ during the study period before and after the year 2015 ( ). There was a significant reduction in HCV-related hospitalisations throughout Italy after introducing DAAs.

The exclusion of cirrhosis is important in chronic hepatitis B (CHB) patients with normal alanine aminotransferase (ALT). We aimed to optimise the performance of the aspartate aminotransferase to platelet ratio index (APRI) and fibrosis score based on four factors (FIB-4) to exclude cirrhosis in these patients. Five hundred and eighty four patients with normal ALT who underwent liver biopsy were included in the study. The patients were divided into derivation and external validation sets. A grid search method was used to identify new cut-offs with a negative predictive value (NPV) of > 95% and a sensitivity of > 90% for detecting cirrhosis. The proportion of patients with cirrhosis in the derivation and validation sets was 19.4% and 7.5%, respectively. The conventional cut-offs of APRI (77.6%) and FIB-4 (41.8%) had high rates of cirrhosis misclassification. A new APRI cut-off of 0.21 had a sensitivity of 97.0% and an NPV of 95.6%, and only two (3.0%) patients with cirrhosis were misclassified in the derivation set. Using a new FIB-4 cut-off of 0.53, with a sensitivity of 98.5% and NPV of 96.2%, only one (1.5%) patient with cirrhosis was misclassified. External validation showed similar results. Using the new cut-offs of APRI and FIB-4, cirrhosis could be completely excluded for HBeAg-positive patients or those aged > 40 years. The conventional cut-offs had high misclassification rates for cirrhosis. The new cut-offs of APRI (≤ 0.21) and FIB-4 (≤ 0.53) could be used to exclude cirrhosis in CHB patients with normal ALT levels with a low misclassification rate.

The prevalence of viral hepatitis among people in prisons is higher than in the general population. Screening, treatment and vaccination programmes exist within prisons to reduce the incidence of hepatitis, although lower uptake has often been reported compared to similar programmes outside of prisons. We conducted a systematic review of qualitative evidence to explore the barriers and facilitators to hepatitis B and C reduction programmes in prisons from the perspectives of people in prison, custodial staff and prison healthcare staff. Comprehensive searches of five databases (to November 2023) yielded 28 studies for review inclusion. Four synthesised findings were identified: (i) accurate, up-to-date knowledge of viral hepatitis disease and treatment among people in prison and staff is a facilitator to programme uptake, particularly when imparted by a trusted source; (ii) personal subjective and relative views have a bearing on participation with the programme; (iii) social interactions and relationships both within the community of people in prison and between them and staff groups influence participation in the programmes; and (iv) the organisational structure of the prison and healthcare services within it affect programme participation. Based on these findings, we make recommendations for the adaptation of viral hepatitis programmes to individual custodial settings thereby improving equitable programme access and hepatitis B and C reduction in this complex environment.

Hepatitis B virus (HBV) remains a critical public health issue in low- and middle-income countries (LMICs), particularly among pregnant women in Nigeria. Routine screening using rapid diagnostic kits is common in antenatal care, yet the accuracy of these tests can vary. This study aimed to determine the seroprevalencwe of HBV among pregnant women who had previously undergone screening using rapid diagnostic kits at Obafemi Awolowo Teaching Hospital, Ilesa, Osun State, Nigeria, to assess the effectiveness of initial screening and identify any missed cases. A cross-sectional study was conducted, involving 263 pregnant women. Blood samples were tested for HBV markers (HBsAg, HBsAb, and HBcAb) using ELISA. Sociodemographic data and potential risk factors were also analysed. The study found that 7.6% of women were HBsAg positive, indicating active HBV infection, and 49.6% were susceptible to HBV. There was a significant association between higher education levels and HBV seropositivity. Employment status also correlated with HBV prevalence, with self-employed women showing higher seroprevalence. Additionally, a history of blood transfusions was linked to higher HBV seropositivity. The findings highlight the limitations of rapid diagnostic kits in detecting HBV and underscore the need for enhanced infection prevention and control measures, including confirmatory testing, robust vaccination programmes and safe delivery practices to reduce HBV transmission in high-burden regions like Nigeria.

Direct-acting antiviral (DAA) therapy is associated with a significant reduction in hepatocellular carcinoma (HCC) incidence among patients with cirrhosis, but data are conflicting about the risk of recurrence following DAA therapy. DAA-PASS was a prospective, pragmatic, observational study designed to estimate the risk of HCC recurrence associated with DAA therapy exposure during routine clinical care. Eligible patients were DAA treatment naive with Barcelona Clinic Liver Cancer (BCLC) stage A. Patients were followed at regular intervals for up to 24 months. To provide additional data, outcomes were compared to the Italian Liver Cancer Group (ITA.LI.CA) cohort. Of 42 patients enrolled, 24 were treated with DAA therapy. Ten HCC recurrence events were observed during the study, with 5 each in DAA-treated and DAA-untreated patients (cumulative incidences of 23 and 37 per 100 PY, respectively). The overall crude hazard ratio (HR) for HCC recurrence associated with DAA therapy was 0.6 (95% CI, 0.2-2.2). In the ITA.LI.CA cohort, HCC recurrence was observed in 193 patients during 24 months of follow-up, resulting in a cumulative incidence rate of 28 per 100 PY. Although limited by small sample size, this prospective study suggests DAA therapy is not associated with increased HCC recurrence risk among patients with a history of complete response to prior HCC therapy.

The objective of this report is to provide clarification on the interaction among hepatitis B virus (HBV), hepatitis C virus (HCV) and alcohol in the development of hepatocellular carcinoma (HCC). A systematic search was performed in PubMed, Web of Science and Scopus databases up to July 18, 2023. The inclusion criteria involved observational studies that examined the relationship between HBV, HCV, alcohol use and the development of HCC. To assess between-study heterogeneity, the I statistics were employed. Publication bias was evaluated using the Begg and Egger tests. The effect sizes were estimated as odds ratios (ORs) with 95% confidence intervals (CIs) utilising a random-effects model. Among the initial pool of 31,021 studies identified, 28 studies involving 42,406 participants met the inclusion criteria. Through our meta-analysis, we found that the combined effect of HBV and alcohol was associated with an OR of 14.56 (95% CI: 9.80, 21.65). The combined impact of HCV and alcohol showed an OR of 42.44 (95% CI: 20.11, 89.56). Coinfection with both HBV and HCV was associated with an OR of 32.58 (95% CI: 20.57, 51.60). These results emphasising the importance of reducing alcohol consumption and implementing effective viral hepatitis prevention and treatment.

Hepatitis B is an infectious disease that inflicts high health and economic costs on the healthcare system. Poor adherence to treatment increases that cost. We aimed to assess the levels of knowledge, attitudes and practices (KAP) among patients in the West Bank, Palestine, and identify factors associated with good adherence. We conducted a cross-sectional study surveying hepatitis B patients visiting primary healthcare during October 2022 until June 2023 using an interviewer-administered questionnaire covering qualitative and quantitative aspects regarding hepatitis B. We considered adherence as good if participants received > 90% of their monthly prescription antiviral doses. Among 386 participants, the median age was 45 years (range 20-81); 80% had good adherence to treatment. Mean knowledge score was 11.4 (on a 13-point scale), mean attitude score was 3.4 (on a 4-point scale), mean practices score was 6 (on a 7-point scale) and the mean overall KAP score was 21.8 (on a 24-point scale). KAP components (Cronbach alpha = 0.820) were correlated with good adherence (p < 0.001). After adjustment for other factors, participants with good KAP scores had better adherence to treatment than those without (prevalence ratio: 1.41, 95% CI: 1.10-1.84, p-value = 0.011). We recommend investment in education and awareness campaigns to improve adherence.