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

M Bierhoff, M J Rijken, W Yotyingaphiram, M Pimanpanarak, M van Vugt, C Angkurawaranon, F Nosten, S Ehrhardt, C L Thio, R McGready, M Bierhoff, M J Rijken, W Yotyingaphiram, M Pimanpanarak, M van Vugt, C Angkurawaranon, F Nosten, S Ehrhardt, C L Thio, R McGready

Abstract

Background: The aim of this manuscript is to highlight challenges in the implementation of maternal tenofovir disoproxil fumarate (tenofovir) for prevention of mother to child transmission (PMTCT) of hepatitis B virus (HBV) in resource limited setting. Current preventive strategies in resource-limited settings fail mainly due to prohibitive costs of hepatitis B immunoglobulin (HBIG) and a high proportion of homebirths, meaning both HBIG and hepatitis B birth dose vaccine are not given. A new strategy for PMTCT without the necessity of HBIG, could be daily tenofovir commenced early in gestation. Implementation challenges to early tenofovir for PMTCT can provide insight to elimination strategies of HBV as the burden of disease is high in resource-limited settings.

Methods: Challenges encountered during implementation of a study of tenofovir for PMTCT before 20 weeks gestation in rural and resource-limited areas on the Thailand-Myanmar border were identified informally from trial study logbooks and formally from comments from patients and staff at monthly visits. ClinicalTrials.gov Identifier: NCT02995005.

Main body: During implementation 171 pregnant women were hepatitis B surface antigen (HBsAg) positive by point of-care test over 19 months (May-2018 until Dec-2019). In this resource-limited setting where historically no clinic has provided tenofovir for PMTCT of HBV, information provided by staff resulted in a high uptake of study screening (95.5% (84/88) when offered to pregnant women. False positive point-of-care rapid tests hinder a test and treat policy for HBV and development of improved rapid tests that include HBeAg and/or HBV DNA would increase efficiency. Integrated care of HBV to antenatal care, transport assistance and local agreements to facilitate access, could increase healthcare at this critical stage of the life course. As safe storage of medication in households in resource-limited setting may not be ideal, interactive counseling about this must be a routine part of care.

Conclusion: Despite challenges, results from the study to date suggest tenofovir can be offered to HBV-infected women in resource-limited settings before 20 weeks gestation with a high uptake of screening, high drug accountability and follow-up, with provision of transportation support. This commentary has highlighted practical implementation issues with suggestions for strategies that support the objective of PMTCT and the World Health Organization goal of HBV elimination by 2030.

Keywords: Antiviral therapy; Barriers; HBV; Inequality.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Map of study sites with Mae La Refugee camp (MLA), Wang Pha (WPA) and Mawker Thai (MKT) on the Moei river which demarcates the international border between Myanmar and Thailand [24]
Fig. 2
Fig. 2
Road leading to the clinic. a The distance between a village and the clinic is long and sometimes there is no possibility to use any form of mechanized transportation; b Dirt roads might be traversed with a tractor; c Most families need to walk many hours with their children to reach the clinic; d Tractor used for transportation of patients in Thailand-Myanmar rural border areas
Fig. 3
Fig. 3
Crossing a river. a flooding of the a river during the rainy season is frequent in this mountainous region making it almost impossible to cross which is problematic for scheduled antenatal visits, birth and childhood vaccinations; b typical crossing of the river by boat
Fig. 4
Fig. 4
Typical bamboo housing with a leaf roof and bamboo walls and floor
Fig. 5
Fig. 5
Storage areas for items such as Tenofovir Disoproxil Fumarate. Storage of goods on shelves out of reach of children but above a concrete slab frequently used for cooking increasing the temperature of items on the shelves

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