From screening to care: a longitudinal implementation evaluation of a community-based hepatitis B program

Community-based hepatitis B virus (HBV) screening programs are widely used to identify chronic infection in high-risk immigrant populations in the United States. However, screening alone does not ensure engagement in care, and the processes that determine progression from diagnosis to sustained clinical management remain poorly characterized. In particular, there is limited longitudinal evidence evaluating real-world implementation across the full HBV care continuum. We conducted a RE-AIM–based implementation evaluation of a longstanding community-based HBV screening and education program among Korean American immigrant communities in the northeastern United States from 2009 to 2016. Through 152 outreach events, we delivered culturally and linguistically tailored education, venipuncture-based serologic testing, direct disclosure of results, and referral to care. Using prospectively collected programmatic data, we assessed reach, operational yield, and attrition across the care continuum among individuals testing positive for hepatitis B surface antigen (HBsAg), with longitudinal follow-up of up to eight years. Among 8,453 individuals screened, 204 (2.4%) were HBsAg positive. Of these, 121 (59.3%) had longitudinal follow-up data available, and 71 (58.7%) accessed clinical care, corresponding to 34.8% of all HBsAg-positive individuals. Most participants who accessed care received follow-up through private community-based outpatient practices (64/71; 90.1%) rather than centralized systems. Approximately 42 individuals required screening to identify one case, and 104 to achieve one confirmed linkage to care. Substantial attrition occurred between diagnosis and initial clinical engagement, representing the primary loss point in the care continuum. Lack of health insurance was the most frequently reported structural barrier. Community-based HBV screening effectively identifies individuals with chronic infection but does not ensure completion of the prevention pathway. This study provides longitudinal, real-world evidence quantifying attrition across the HBV care continuum and demonstrates that prevention is an implementation-dependent process requiring sustained engagement beyond initial screening. Strategies that integrate screening with patient navigation, longitudinal follow-up, and improved access to care are needed to enhance linkage to care and clinical outcomes in high-risk populations.