A Quality Improvement Pilot to Increase Hepatitis B Screening and Optimize Patient Selection for Switch to Two-Drug Antiretroviral Regimens in People with HIV

Background Two-drug antiretroviral regimens (2DR) without tenofovir are increasingly prescribed for HIV; however, these regimens lack full activity against hepatitis B virus (HBV). An electronic health record (EHR)-based quality improvement (QI) project was developed to optimize switch to a 2DR within New York City HIV primary care clinics. Methods An EHR best practice advisory was linked to 2DR orders (dolutegravir-lamivudine, dolutegravir-rilpivirine, cabotegravir-rilpivirine) reminding clinicians to check HBV serologies prior to switch and providing guidance for prescribing 2DR to reduce risk of HBV reactivation in people with HIV (PWH). Prescribing patterns were monitored before and after implementation of the alert, including number of individuals screened for HBV (surface antigen (HBsAg), core antibody (HBcAb), and surface antibody (HBsAb)), and number of switches among individuals with HBsAg-positive (considered at highest risk) or isolated positive-HBcAb (elevated risk). Outcomes were compared for a one-year period before and after alert implementation on February 1, 2023. Results After alert implementation, 103/145 (71%) individuals had HBV screening prior to 2DR switch compared with 48/161 (30%) pre-implementation (p < .0001). Post-implementation there were fewer 2DR switches among individuals at increased risk for HBV reactivation (pre-QI 12, post-QI 1; p = .003). Conclusions HBV reactivation risk may be overlooked by clinicians when switching PWH to 2DR. In this study, an EHR-based intervention increased HBV screening rates and decreased switches in those at highest risk of HBV reactivation (HBsAg-positive or isolated positive-HBcAb). With the increasing uptake of 2DR, optimizing patient selection is vitally important to prevent HBV reactivation.