ABSTRACT

Chronic hepatitis B (CHB) remains a major public health challenge, particularly in the Asia-Pacific region. Despite effective antiviral therapy and World Health Organisation (WHO) targets to eliminate hepatitis B by 2030, gaps in screening and linkage to care persist globally. Community pharmacies, due to their accessibility and public trust, are increasingly recognized for their role in preventive care. This review explores international experiences in pharmacy-based hepatitis B screening and synthesizes key enablers for implementation. Case studies from the United States, Australia, the United Kingdom, and China illustrate varied levels of integration and policy support for pharmacy-led models. A 2024 systematic review further affirms the feasibility and acceptability of viral hepatitis testing in pharmacy settings, particularly when combined with outreach, training, and structured referral pathways. In Hong Kong, where CHB prevalence remains high, particularly among individuals aged over 35, screening is largely confined to opportunistic detection in hospital settings. Community pharmacies remain underutilized in hepatitis B care despite their widespread presence and emerging roles in chronic disease management. A recent pilot study demonstrates public receptiveness to pharmacist-linked point-of-care (POC) screening. Drawing on global evidence and local capacity, this article outlines a framework to expand the role of pharmacists in hepatitis B screening, vaccination, education, and linkage to care. Recommendations include pilot programs, regulatory reform, standardized protocols, and integration with the territory’s evolving primary healthcare system. Leveraging community pharmacies offers a scalable and person-centered pathway to address longstanding gaps in hepatitis B prevention and management in Hong Kong.

Keywords: Chronic Hepatitis B, Community Pharmacy, Community Pharmacist, Point-of-Care Testing, Primary Healthcare, Hong Kong

INTRODUCTION

Chronic hepatitis B (CHB) caused by hepatitis B virus (HBV) remains a significant public health challenge globally, particularly in the Asia-Pacific region. The World Health Organization (WHO) has set ambitious goals to eliminate viral hepatitis as a major public health threat by 2030, targeting a 90% reduction in new infections and a 65% reduction in related mortality.¹ Achieving these goals requires robust screening, early diagnosis, linkage to care, and long-term management, which are the components traditionally centered in specialist settings.² However, with the shift toward person-centered primary healthcare systems, there is growing interest in decentralizing aspects of CHB care to primary healthcare providers, including community pharmacists. Hong Kong has one of the highest CHB prevalence rates among high-income jurisdictions, with an estimated 5.6% of the population affected.³ Most of these individuals were born before the universal neonatal hepatitis B vaccination program was introduced in 1988, and many remain unaware of their infection status or are not engaged in ongoing care. While the public healthcare system provides antiviral treatment and specialist management through specialist clinics operated by the Hospital Authority, the gap in early-stage screening and community-based engagement limits the effectiveness of the current care cascade. Community pharmacies, as accessible and trusted healthcare touchpoints, are increasingly recognized for their potential role in public health interventions, including chronic disease management, medication management services and smoking cessation service.⁴ This review explores global models of hepatitis B management involving community pharmacies and proposes a locally adapted approach for Hong Kong within the context of its Primary Healthcare Blueprint.

 

GLOBAL EXPERIENCES IN COMMUNITY PHARMACY-BASED HEPATITIS B SCREENING

 

United States: From Risk-Based to Potential Universal Pharmacy Screening

 

In the United States, hepatitis B screening and vaccination have seen major policy advancements in recent years. In 2023, the Centers for Disease Control and Prevention (CDC) adopted a universal screening recommendation for all adults at least once in their lifetime, replacing the previous risk-based approach that often failed to identify asymptomatic carriers.⁵ Similarly, the Advisory Committee on Immunization Practices (ACIP) now recommends universal hepatitis B vaccination for all adults aged 19 to 59, regardless of risk factors.⁶  These changes present important opportunities to expand hepatitis B services beyond traditional healthcare settings. Community pharmacies, already established as key providers of vaccinations and chronic disease management, are well-positioned to support public health outreach. While pharmacists in many states are authorized to perform Clinical Laboratory Improvement Amendments (CLIA)-waived point-of-care (POC) testing through collaborative practice agreements, there are currently no FDA-cleared CLIA-waived tests for hepatitis B surface antigen (HBsAg).⁷ This regulatory limitation means that pharmacy-based screening for hepatitis B remains largely aspirational, in contrast to established roles in human immunodeficiency virus (HIV) and hepatitis C virus (HCV) testing. Despite some challenges, community pharmacies have emerged as accessible and acceptable primary healthcare service points, providing promising sites expanding hepatitis B services, especially for underserved and hard-to-reach populations.

 

Australia: Growing Potential for Community Pharmacy in Hepatitis B Screening

Australia has laid foundational infrastructure for community-based hepatitis B services, although large-scale pharmacy-led screening is not yet mainstream. The country has experience in POC testing and community pharmacy–based harm reduction programs, including models for HIV and HCV.⁸ While dedicated hepatitis B screening pilots remain limited, several feasibility studies and policy discussions suggest pharmacies could expand into this space. In jurisdictions like Queensland and New South Wales, expanded pharmacist scope has already authorized pharmacists to deliver hepatitis B vaccination under an expanded scope of practice.^9,10 Although no formal national framework exists for HBV testing in pharmacies, the infrastructure, workforce readiness, and public trust suggest strong potential for pilot programs to be adapted for hepatitis B, especially in underserved and rural populations.

 

United Kingdom: Limited Pilots on Hepatitis B Screening in Community Pharmacies

In the United Kingdom, community pharmacy–based hepatitis B screening is not widely implemented, with only isolated pilot programs demonstrating feasibility. Screening efforts have been limited to small-scale pilots, often integrated within broader blood-borne virus (BBV) testing services. There is no universal or large-scale pharmacy-led HBV screening program in either country. In 2014, a dry blood spot testing pilot conducted across 22 community pharmacies on the Isle of Wight offered screening for HIV, HCV, syphilis, and HBsAg among people with risk factors. Over the nine‑month pilot, 186 tests were performed and 13 HCV-positive cases identified. Although HBV test results were not separately reported, the initiative demonstrated feasibility and the potential of community pharmacies as low-barrier access points for BBV screening within a broader testing framework.¹¹ This pilot targeted high-risk groups, such as people who inject drugs, and showed that community pharmacies can be effective low-barrier access points. However, HBV testing remains localized, with no national rollout or formal commissioning pathway.

 

China: Potential of Community Pharmacies for Hepatitis B Screening

China bears one of the heaviest global burdens of chronic hepatitis B, with an estimated 86 million people living with HBV, yet community pharmacy–based screening remains undeveloped.¹² Recent community-based initiatives, such as the Community-Based HBV Infection Detection and Vaccination (HBVIDV) programme in Beijing’s Chaoyang District, demonstrated feasibility of non-hospital vaccine and screening interventions.¹³ The programme was implemented in nearly 43 communities, significantly increasing HBV vaccination and immunity rates. However, the initiative was centrally managed by public health authorities, not via community pharmacy platforms. As of 2020, China boasted over 550,000 community pharmacy outlets, highlighting rapid expansion of retail pharmacy access nationwide.¹⁴ China’s extensive network of community pharmacies, which are highly accessible and trusted by the public, presents an underutilized but promising platform to support hepatitis B screening and management.

 

GLOBAL SYNTHESIS: THE CASE FOR PHARMACY-LED HEPATITIS B SCREENING

While hepatitis B screening through community pharmacies remains limited globally, emerging evidence supports the feasibility and acceptability of this approach in select settings. A 2024 systematic review synthesizing 42 studies on pharmacy-based viral hepatitis testing revealed that pharmacies are viable and acceptable venues for POC testing, particularly when integrated with outreach, education, and linkage-to-care services.¹⁵ Although most evidence centered on hepatitis C, four studies reported hepatitis B screening outcomes. These included pilots from England, Portugal, and Sierra Leone using dried blood spot (DBS) tests conducted among individuals with elevated risk. Program evaluations, primarily conducted in the context of hepatitis C, consistently highlighted high acceptability among both clients and pharmacy staff. Pharmacists expressed willingness to continue offering viral hepatitis services, provided they received appropriate training and system support. Clients found pharmacies accessible, convenient, and acceptable as testing venues, especially when confidentiality and trust were preserved. However, time constraints, workload, and stigma-related concerns were identified as barriers. Structured training programs enhanced pharmacists’ confidence in providing testing, counselling, and referrals. The experience of hepatitis C programs offers transferable insights. Core enablers such as pharmacist training, integration into existing workflows, availability of rapid diagnostic tools, and clear referral pathways are equally relevant to hepatitis B. As countries progress toward the WHO 2030 elimination targets, these findings underscore the untapped potential of community pharmacies in expanding equitable access to hepatitis B screening and early care, especially among underserved or stigmatized populations.

 

HONG KONG: LOCAL BURDEN, SYSTEM GAPS, AND MISSED OPPORTUNITIES

Local Epidemiology and Care Landscape

Hong Kong bears a substantial burden of CHB, with an estimated prevalence of 5.6%, equating to over 400,000 affected individuals.² The disease burden is particularly concentrated among those born before 1988, prior to the introduction of universal neonatal hepatitis B vaccination. Notably, prevalence remains as high as 8.4% among individuals aged over 35, highlighting the priority of targeted interventions in this demographic.³ Other high-risk groups include immigrants, under-screened adults, and those with occupational exposure. At present, CHB management is primarily delivered through specialist outpatient clinics (SOPCs) under the Hospital Authority, offering confirmatory testing, liver function monitoring, antiviral therapy, and hepatocellular carcinoma (HCC) surveillance. However, this specialist-led model creates bottlenecks, with long waiting times and access barriers, particularly for those requiring follow-up or early-stage evaluation.^16,17 Conversely, primary healthcare settings remain underutilized in CHB screening and longitudinal care. Community pharmacies, despite being widely accessible and frequently visited by the public, currently lack a structured framework for offering POC testing, formal referral mechanisms, or systematic participation in hepatitis B care pathways. At present, no publicly commissioned programme or regulatory framework explicitly supports community pharmacists to conduct hepatitis B screening, reflecting a missed opportunity for broader community-based engagement.

 

Gaps in the Current Cascade of Care

Despite the high disease burden and the availability of effective antiviral treatment, many individuals living with hepatitis B in Hong Kong remain undiagnosed.³ The existing system relies heavily on opportunistic detection, such as through antenatal screening, blood donation, or pre-employment health checks, rather than proactive or population-based screening efforts.¹⁸ As a result, significant gaps persist across the cascade of care. Community-based screening remains limited thus missing opportunities to identify asymptomatic individuals. Public awareness also remains suboptimal, with ongoing misconceptions about transmission and social stigma associated with the condition, especially among older adults.¹⁹ Furthermore, there is a systemic overreliance on specialist clinics for diagnosis and follow-up, with little integration of primary healthcare professionals, including community pharmacists, into the broader management of chronic hepatitis B. These structural limitations result in late diagnoses, fragmented follow-up, and missed opportunities for prevention and early intervention.

A recent pilot study conducted at the primary healthcare setting in Hong Kong further illustrates the feasibility and public receptiveness of pharmacy-linked or community-based POC hepatitis B screening.²⁰ The study identified significant knowledge gaps, particularly regarding HBV transmission and chronicity. Nevertheless, low stigma and high acceptance were observed, with over 90% of participants reporting high satisfaction across convenience, cost, and disease management dimensions. Importantly, all participants expressed willingness to be screened if recommended by their family doctor. These findings highlight the value of patient education and demonstrate the readiness of the public to engage in POC hepatitis B screening within primary healthcare settings, such as community pharmacies.

 

Untapped Potential of Community Pharmacies in Hong Kong in Hepatitis B Screening

Community pharmacies in Hong Kong are well positioned to play a more active role in hepatitis B prevention and care. With over 600 registered community pharmacies across districts, they provide convenient, walk-in access to the public without the need for prior appointments. The ongoing expansion of service models under primary healthcare initiatives such as Jockey Club PHARM+ Community Medication Service Network has further demonstrated that community pharmacists can support chronic disease management, health promotion, and preventive care directly within the community setting.^21,22 However, to fully harness their potential in hepatitis B care, including screening, education, vaccination referral, and treatment adherence, further system integration and policy support are required. Community pharmacists already competent to deliver pharmaceutical services such as medication management services, vaccination and osteoporosis risk screening. There is a strong foundation upon which to build structured hepatitis B interventions within community pharmacy practice.

 

EXPANDED ROLE OF COMMUNITY PHARMACISTS IN HEPATITIS B PREVENTION AND MANAGEMENT

Building on the unmet needs and gaps identified in the local care landscape, community pharmacists in Hong Kong are well placed to contribute across the hepatitis B care continuum. Drawing on international models and local pilot evidence, the following core functions outline how community pharmacy–based services can be implemented and scaled up.

 

POC Testing and Linkage-to-Care

Community pharmacies can act as vital access points in the care cascade. Trained community pharmacists can provide risk-based hepatitis B screening using rapid HBsAg test kits under clear and pre-defined protocols. A pharmacist-led model can offer accessible, low-barrier testing, especially for individuals aged over 35 or those from high-risk groups. Testing could be accompanied by risk assessment, counselling, and built-in referral for follow-up care. Besides, community pharmacists can deliver structured pre- and post-test counselling, issue referrals to public or private providers, and support patients in navigating follow-up. Integration with Electronic Health Record Sharing System (eHealth) would further streamline these services.

 

Health Education and Stigma Reduction

As frontline primary healthcare professionals, community pharmacists can correct misconceptions about hepatitis B transmission and promote prevention through culturally sensitive education. Pharmacy-based health promotion by public education talks, counselling, leaflets, or online platforms can enhance disease literacy, normalize screening, and reduce stigma, especially among older adults and immigrant populations.

 

Hepatitis B Vaccination Services

As the government plans to launch pharmacist-led vaccination programmes, expanding hepatitis B immunization to include trained community pharmacists is a logical and feasible next step. Community pharmacists in Hong Kong already receive vaccination-related training through accredited programmes offered by local universities, equipping them with the necessary clinical skills and knowledge. With formal authorization, community pharmacists would be well positioned to assess patient eligibility, administer the full vaccine series, monitor for adverse events, and contribute to improving adult vaccination coverage, particularly among under-immunized or high-risk populations.

 

Adherence and Monitoring Support

For patients on long-term antiviral therapy, community pharmacists can offer adherence counselling, side effect monitoring, and support tools including drug refill reminders. Their routine interaction with patients creates opportunities to reinforce follow-up schedules and improve treatment outcomes. This aligns with community pharmacists’ established role in chronic disease management and medication therapy review.

 

PRACTICE RECOMMENDATIONS FOR HONG KONG

 

To fully leverage the potential of community pharmacists in hepatitis B screening and management, the following operational enablers are recommended:

 

Launch Pilot Programs for Pharmacist-Led Screening and Vaccination

Pilot initiatives and commissioned programmes should be implemented in qualified community pharmacies in collaboration with the Hospital Authority and DHCs. These pilots should focus on adults aged over 35 and other high-risk populations, offering point-of-care testing and vaccination services.

 

Capacity Building by Standardized Protocols and Training

Clear and standardized service protocols should be established for hepatitis B screening, informed consent, counselling, documentation, vaccination, and referral. These protocols must align with existing clinical and infection control guidelines and be supported by consistent patient education materials. In parallel, accredited training programmes should be provided to ensure community pharmacists are equipped with the necessary competencies to deliver these services safely and effectively. To fully enable pharmacist-led care, policymakers should also explore regulatory mechanisms to expand the scope of practice under relevant ordinances.

 

Enable Sustainable Infrastructure and Integrated Care Pathways

To ensure the long-term viability and effectiveness of pharmacist-led hepatitis B services, a supportive infrastructure must be established. This includes the development of sustainable reimbursement models to incentivize pharmacist participation, such as public-private partnerships, DHC-linked subsidies, per-service reimbursement, or bundled payment schemes. Digital tools should be integrated into pharmacy workflows to facilitate data collection and service monitoring. Key indicators, including screening uptake, positivity rates, referral completion, vaccination coverage, and patient satisfaction, should be routinely tracked to inform quality assurance and continuous improvement. Furthermore, strong cross-sector collaboration is essential. Formal referral and feedback systems should be established between community pharmacists, family doctors, and DHCs. Integration with the eHealth platform would enable real-time communication, shared care planning, and outcome tracking across providers, helping to build a coordinated and person-centered hepatitis B care pathway.

 

CONCLUSION

Chronic hepatitis B remains a major public health challenge, particularly in high-prevalence regions like the Asia-Pacific. Despite WHO’s 2030 elimination goals, persistent gaps in early detection, vaccination, and linkage to care hinder progress. Community pharmacies, as trusted, convenient, and accessible healthcare providers, remain an underutilized resource in the hepatitis B care cascade. Global evidence supports pharmacy-led models in screening, education, and vaccination as effective complements to traditional healthcare, especially for underserved populations. In Hong Kong, primary healthcare reform presents a timely opportunity to expand the role of pharmacists in hepatitis B services. With the right policy support, training, and integration, community pharmacies can help close critical gaps in the care cascade, reduce stigma, and improve continuity of care. Importantly, this is not only a pragmatic approach, but also an equity-driven one. Embedding hepatitis B services into community pharmacies can engage populations who face barriers to formal care, promoting a more inclusive and person-centered healthcare system. As Hong Kong advances its Primary Healthcare Blueprint, activating the pharmacy sector will be key to achieving hepatitis B elimination and strengthening long-term public health resilience.

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