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Background The overall seroprevalence of HBsAg is estimated at 6.9% in adults in Madagascar. The most frequently used means of prevention remain screening and vaccination, but their implementation encounters structural and individual difficulties. An anthropological study was conducted in Madagascar in 2018-2019 in order to identify the care pathways of people with chronic HBV infection and the barriers to the vaccination, screening, and care. Methods Semi-directive interviews were conducted with twenty patients known to be chronically infected with HBV and three hepato-gastroenterologists at the central hospital in Antananarivo. Results None of the patients voluntarily got tested for HBV. Only two patients had known that there is a vaccine against this infection before they got the diagnosis of hepatitis B, and both were medical students. Patients' lack of knowledge about hepatitis B before the diagnosis (name of the disease, modes of transmission, signs, treatment, and prevention) influenced the therapeutic choice. For 16 patients, screening and vaccination of their entourage remained problematic; they do not have the financial resources for the screening and vaccination of their relatives. Moreover, it was difficult for them to make their relatives understand the interest of being screened and vaccinated because patients' entourages do not feel sick. To break the transmission, some patients prefer unofficial prevention methods. The significant costs related to medical follow-up (medical examinations and treatments) are entirely at the patient's own expense. Conclusions The low political commitment to hepatitis B in Madagascar leads to the inexistence of care policy and specific actions in terms of prevention. These results underline the urgency of developing a national plan and better communication strategies for the prevention of this infection in Madagascar. Key messages This study highlights the lack of knowledge about hepatitis B and the difficulties in access to care and vaccination. Priority is to develop a communication tool to raise the awareness about hepatitis B.

Barriers to the access to hepatitis B diagnosis and prevention in Madagascar: a qualitative approach