Editorial: Chronic Hepatitis B at the Intersection of Immigration, Acculturation, and Social Determinants of Health—Authors' Reply

We appreciate the commentary provided by Drs. Hoang and Ko on our study and appreciate the summary they have provided [1, 2]. We want to highlight and discuss several important considerations in our study. We acknowledge Drs. Hoang and Ko's comment that our FOCUS-HBV cohort was a highly selected cohort and potentially not generalisable to an unlinked immigrant chronic hepatitis B population in the United States (US). This is an important point. However, what is rather interesting and surprising is that although the majority of the patients were recruited from hepatology subspecialty clinics, only 43.5% had optimal medical adherence, which was defined as 100% adherence to annual testing for HBV DNA, ALT, and ultrasound for hepatocellular carcinoma surveillance if indicated. This leads us to believe—consistent with data on hepatocellular carcinoma surveillance in general [3]—that outside of the subspecialty context such as primary care, adherence is very likely to be even lower. With concerns around lack of generalisability due to a highly selected cohort skewed towards higher education and income, there are two things to keep in mind. One, an immigrant chronic HBV population will be predominantly Asian, and based on data from the Pew Research Center, a majority (56%) of Asian immigrants over the age of 25 have a bachelor's degree or more [4], underscoring the background of Asians that have immigrated here. Two, 36% of the cohort did not answer the survey question on income (with those that did not answer likely skewing towards lower incomes), and of those who did, 43% had an income less than $50,000, which is considered to be the cut-point differentiating between low income and middle-income households according to Pew Research Center. Overall, we feel that our cohort with respect to demographics is reasonably representative of the US foreign-born chronic HBV population. We also recognise that, not surprisingly, non-Asians were a minority in this cohort. African immigrants in the US have the second highest HBV prevalence (1.9%) but fewer were recruited into FOCUS-HBV than anticipated (only 2.6% of cohort). This highlights an important consideration and often challenge when ensuring diverse ethnic representation in research studies and when recruiting African American patients into clinical research. It has been shown from the Bronx West African HBV screening program that, despite attempts at linkage to care, only 37.8% diagnosed entered long-term care [5]. In a qualitative study where West African immigrants were interviewed to understand barriers to screening, vaccination, and treatment, themes that were most common were awareness and trust in US healthcare providers [6]. Although participants felt a high level of trust in US doctors, because becoming a doctor is more challenging in the US than in Africa, they also felt a lack of personal connection to their doctors; some of the participants felt that HBV was relatively “uncommon” in their community, and even before immigration, they were not aware of HBV [6]. Studies targeting foreign-born African HBV patients through culturally competent and community-engaged strategies are critical to address this remaining knowledge gap. The authors' declarations of personal and financial interests are unchanged from those in the original article [2]. Kali Zhou: writing – review and editing, conceptualization. Christine C. Hsu: writing – original draft, writing – review and editing, conceptualization. This article is linked to Zhou et al. papers. To view these articles, visit https://doi.org/10.1111/apt.70123 and https://doi.org/10.1111/apt.70156. The authors have nothing to report.