Epidemiology and impact of HIV coinfection with hepatitis B and hepatitis C viruses in Sub-Saharan Africa

Investigating factors associated to HBV/HIV co-infected patients in antiretroviral treatment clinic, in Northeast Ethiopia

BACKGROUND

Existing research in Ethiopia has primarily focused on the individual epidemiology of HIV and HBV, often overlooking the intricate dynamics of co-infection. This study aims to address this gap by comprehensively exploring the prevalence of HBV and HIV co-infection and the associated factors influencing co-infection rates within the specific context of ART clinics. The existing study provides limited insights into the unique challenges posed by this dual infection in the Ethiopian population receiving ART.

METHODS

An institutional-based cross-sectional study was conducted among people living with HIV aged 18 years and above attending ART clinics in northeast Ethiopia from April to May 2022. A sample size of 350(97% response rate) participants was selected by using a systematic random sampling method. Data were collected using a pre-tested interviewer-administered structured questionnaire. Data was entered into Epi Data version software and was exported to SPSS version 25 for further analysis. Descriptive statistics using Frequency, proportion, and summary measures were done. Binary logistic regressions were done to identify independent variables associated with HBV infection among HIV patients. A P-value less than 0.05 and adjusted odds ratio with a 95% confidence interval non-inclusive of one was considered statistically significant.

RESULTS

The prevalence of Hepatitis B Surface Antigen (HBsAg) was identified constituting 7.14% of the study population. Females [AOR] 0.14; 95% Confidence Interval [CI] [0.041-0.478]). Participants with an educational status of only reading and writing (AOR 8.7; 95% CI [1.143-66.5]). Single individuals (AOR 2.04; 95% CI [1.346-28.6]) were associated factors. Moreover, participants with a viral load exceeding 1000 copies/ml were 6.5 times more likely to be infected with HBV compared to those with undetectable viral loads (AOR 6.53, 95% CI [1.87-22.72]). Additionally, individuals with a CD4 count ranging from 351 to 500 cells/ml were 1.2 times more likely to be infected with HBV compared to those with a CD4 count of 500 cells/ml or above (AOR 10.4, 95% CI [1.28-85]).

CONCLUSION

The prevalence of HBV infection was found to be intermediate in HIV-infected patients in the study area. Being male, marital status of single and divorced, educational level was only read and written, current viral load of > 1000 copies/ml &<1000 copies/ml, and current CD4 < 250 cells/ml were found statistically associated factors for HBV infection. Thus, we recommend the provision of routine screening for HBsAg and appropriate treatment with accurate information on risk factors for HBV to improve quality of life and reduce morbidity.

Hepatitis B Virus Prevalence and Mother-to-Child Transmission Risk in an HIV Early Intervention Cohort in KwaZulu-Natal, South Africa

Background

HIV and hepatitis B virus (HBV) prevalence are both high in KwaZulu-Natal, South Africa. HIV coinfection negatively affects HBV prognosis and can increase the likelihood of HBV mother-to-child transmission (MTCT). In an early HIV infant treatment intervention cohort of HIV-transmitting mother-child pairs in KwaZulu-Natal, we characterized maternal HBV prevalence and screened infants at risk.

Methods

Infants were treated for HIV MTCT at birth, and combination regimens incidentally active against HBV were initiated within 21 days. Maternal samples (N = 175) were screened at birth for HBV infection (HBV surface antigen [HBsAg]), exposure to HBV (HBV anti-core IgG), and vaccination responses (HBV anti-S positive without other HBV markers). Infants of mothers who were HBV positive were screened for HBsAg at 1 and 12 months.

Results

Evidence of HBV infection was present in 8.6% (n = 15) of maternal samples. Biomarkers for HBV exposure were present in 31.4% (n = 55). Evidence of HBV vaccination was uncommon in mothers (8.0%; n = 14). Despite prescription of antiretroviral therapy (ART) active against HBV, HBV DNA was detectable in 46.7% (7/15) of mothers who were HBsAg positive. Three mothers had HBV viral loads >5.3 log10 IU/mL, making them high risk for HBV MTCT. Screening of available infant samples at 1 month (n = 14) revealed no cases of HBV MTCT. At 12 months, we identified 1 HBV infection (1/13), and serologic evidence of vaccination was present in 53.8% (7/13) of infants.

Discussion

This vulnerable cohort of HIV-transmitting mothers had a high prevalence of undiagnosed HBV. Early infant ART may have reduced the risk of MTCT in high-risk cases. Current HBV guidelines recommend ART prophylaxis, but these data underline the pressing need to increase availability of birth dose vaccines.

Prevalence of hepatitis-B virus co-infection among people living with HIV in Mthatha region of South Africa

BACKGROUND

Hepatitis-B virus (HBV) co-infection among people living with HIV (PLWH) is highly endemic in South Africa. Despite the availability of an effective vaccine for the last four decades, chronic HBV infection is a major cause of morbidity and mortality among PLWH. Although the incidence of most opportunistic infections has been reduced in individuals with HIV since the implementation of the universal test and treat program in South Africa, HBV co-infection among PLWH is still accounting for high morbidity and mortality.

METHODOLOGY

This cross-sectional descriptive survey was conducted in King Sabata Dalindyebo sub-district municipality in the Eastern Cape Province of South Africa to determine the prevalence of HBV co-infection among PLWH.

RESULTS

Two-thirds (65.5%) of the 602 PLWH who participated in the study had been screened for HBV co-infection. The mean age of the participants was 38.8±10.5 years and the majority (75.1%) were female. The prevalence of HBV co-infection among PLWH was 12.2%; among males were three times more frequently than females (OR=3, 95% CI 1.6-5.6, p=0.001). The median CD4 count of participants was 508 cell/mm3 (inter-quadrantile range = 307 to 715) and there was no significant association between HBV co-infection and CD4 count.

CONCLUSION

There is a high prevalence of HBV co-infection among PLWH in the Mthatha region of South Africa. The high prevalence of HBV co-infection indicates the need for routine screening for hepatitis B among PLWH in South Africa.

The burden of Hepatitis B virus infection in Kenya: A systematic review and meta-analysis

Background

Chronic Hepatitis B virus (HBV) infection causes liver cirrhosis and cancer and is a major public health concern in Kenya. However, so far no systematic review and meta-analysis has been conducted to estimate the burden of disease in the country. A better understanding of HBV infection prevalence will help the government implement efficient strategies at eliminating the disease. This systematic review and meta-analysis was therefore conducted to summarize and update the available information on the burden of HBV in Kenya.

Method

We systematically searched PubMed, Science Direct, Web of Science, Scopus, African Journals OnLine, and Google Scholar databases to retrieve primary studies conducted between January 1990 and June 2021 that assessed the prevalence of HBV infection in Kenya based on measurement of the Hepatitis B Surface Antigen (HBsAg). Meta-analysis was performed using the random effects model where HBsAg prevalence was estimated at a 95% confidence interval (CI) after simple pooling analysis. Potential sources of heterogeneity were also investigated.

Results

Fifty studies were included in the meta-analysis with a sample size of 108448. The overall pooled prevalence estimate of HBV in Kenya was 7.8% (95% CI: 5.8-10.1). Subgroup analysis revealed the highest prevalence among patients presenting with jaundice at 41.7% (95% CI: 13.5-73.3) whereas blood donors had the lowest prevalence at 4.1% (95% CI: 2.4-6.3). Prevalence in Human Immunodeficiency Virus (HIV)-infected individuals was 8.2% (95% CI: 5.8-11.0). An estimate of the total variation between studies revealed substantial heterogeneity (I² = 99%) which could be explained by the study type, the risk status of individuals, and the region of study.

Conclusion

We present the first systematic review and meta-analysis of the prevalence of HBV in Kenya. Our results show that the burden of HBV in Kenya is still enormous. This calls for an urgent need to implement public health intervention measures and strategic policies that will bring the disease under control and lead to final elimination.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=264859, identifier: CRD42021264859.

Co-infection of HIV or HCV among HBsAg positive delivering mothers and its associated factors in governmental hospitals in Addis Ababa, Ethiopia: A cross-sectional study

Background

Blood borne viral infections such as Hepatitis B virus (HBV), Hepatitis C virus (HCV), and Human Immunodeficiency virus (HIV) cause substantial mortality and morbidity worldwide. Viral hepatitis during pregnancy is closely related to high risks of maternal and neonatal complications. In Ethiopia, only a little information is available on co-infection of HCV or HIV among Hepatitis B surface Antigen (HBsAg) positive pregnant mothers. Thus, the study aimed to determine HIV or HCV co-infection and associated risk factors among HBsAg positive delivering mothers.

Method

A health facility-based cross-sectional study was conducted in five governmental hospitals in Addis Ababa among 265 HBsAg positive delivering mothers in the year 2019 and 2020. A purposive sampling technique was used to select the study participants. Structured questionnaires and laboratory test results were used to collect the data. SPSS version 20 software was used to enter and analyze the data. Multivariable logistic regression was used to identify independent predictors of HIV or HCV co-infections.

Results

Of the HBsAg positive delivering mothers, 9 (3.4%) and 3 (1.1%) were co-infected with HIV and HCV, respectively. None of them were with triplex infection. All of the socio-demographic characteristics were not significantly associated with both HIV and HCV co-infections. Mothers who had a history of sexually transmitted diseases (STDs) were 9.3 times more likely to have HBV-HIV co-infection (AOR = 9.3; 95% CI: 1.84–47.1). Mothers who had multiple sexual partners were 5.96 times more likely to have HIV co-infection (AOR = 5.96; 95% CI: 1.074–33.104). The odds of having HBV-HIV co-infection were 5.5 times higher among mothers who had a history of sharing shavers, razors, and earrings (AOR = 5.5;95% CI: 1.014–29.69). HCV co-infection was not significantly associated with any of the potential risk factors.

Conclusion

This dual infection rate of HBsAg positive delivering mother with HIV or HCV indicates that a substantial number of infants born in Ethiopia are at high risk of mother-to-child transmission (MTCT) of HBV, HIV, and HCV. Thus, all pregnant mothers need to be screened for HBV, HCV, and HIV during antenatal care, and also need implementation of prevention mechanisms of MTCT of these viral infections.

Hepatitis B surface antigen and hepatitis B RNA changes in HIV/hepatitis B virus co-infected participants receiving hepatitis B virus-active antiretroviral therapy

INTRODUCTION

With advances in hepatitis B virus (HBV) therapies, there is a need to identify serum biomarkers that assess the HBV covalently closed circular DNA (cccDNA) reservoir and predict functional cure in HIV/HBV co-infection.

METHODS

In this retrospective study, combining samples from HIV/HBV co-infected participants enrolled in two ACTG interventional trials, proportions achieving HBsAg less than 0.05 log10 IU/ml and HBV RNA less than log10 1.65 U/ml or not detected (LLoQ/NEG) in response to DUAL [tenofovir TDF+emtricitabine (FTC)] vs. MONO [FTC or lamivudine (3TC)] HBV-active ART, were measured. Predictors of qHBsAg less than 0.05 log10 IU/ml were evaluated in logistic regression models.

RESULTS

There were 88 participants [58% women, median age 34; 47 on DUAL vs. 41 on MONO HBV-active ART]. Twenty-one percent achieved HBsAg less than 0.05 log10 IU/ml (30% DUAL vs. 10% MONO). Time to HBsAg less than 0.05 log10 IU/ml was lower (P  = 0.02) and the odds of achieving HBsAg less than 0.05 log10 IU/ml were higher (P = 0.07) in DUAL participants. HBV RNA became less than LLoQ/NEG in 47% (DUAL 60% vs. MONO 33%). qHBsAg less than 3 log10 IU/ml was the strongest predictor of HBsAg less than 0.05 log10 IU/ml.

CONCLUSION

This study supports current recommendations of TDF-based DUAL-HBV active ART for initial use in HIV/HBV co-infection. HBV RNA could be a useful marker of treatment response in HIV/HBV co-infected patients on HBV-active ART.

Persistent Hepatitis B Viraemia with Polymerase Mutations among HIV/HBV Co-Infected Patients on HBV-Active ART in KwaZulu-Natal, South Africa

To understand the problem of persistent Hepatitis B virus (HBV) viraemia in HIV/HBV co-infected patients on HBV-active antiretroviral therapy (ART), we assessed the rate of HBV virological response in patients on HBV-active ART in KwaZulu-Natal, South Africa, and analysed factors associated with persistent HBV viraemia. One hundred and fifty eligible participants with a chronic HBV diagnosis, with or without HIV coinfection, were enrolled and followed up after 6 months. The HBV pol gene was sequenced by next-generation sequencing and mutations were determined using the Stanford HBVseq database. Logistic regression analysis was used to assess factors associated with HBV viraemia at 6-month follow-up. The mean duration of HBV-active ART was 24 months. Thirty-seven of one hundred and six (35%) participants receiving HBV-active ART for longer than 6 months had virological failure. Advanced immunosuppression with CD4+ cell counts <200 cells/μL was independently associated with persistent HBV viraemia, aOR 5.276 (95% CI 1.575−17.670) p = 0.007. A high proportion of patients on HBV-active ART are unsuppressed, which will ultimately have an impact on global elimination goals. Better monitoring should be implemented, especially in HIV-coinfected patients with low CD4+ cell counts and followed by early HBV drug-resistance testing.

Molecular epidemiology of hepatitis B virus among HIV co-infected and mono-infected cohorts in Northwest Ethiopia

BACKGROUND

Hepatitis B virus (HBV) infection is a particular concern in human immunodeficiency virus (HIV) infected individuals. In Ethiopia, detailed clinical and virological descriptions of HBV prevailing during HIV co-infection and symptomatic liver disease patients are lacking. The aim of this study was to investigate HBV virological characteristics from Ethiopian HBV/HIV co-infected and HBV mono-infected individuals.

METHODS

A total of 4105 sera from HIV positive individuals, liver disease patients, and blood donors were screened serologically for HBV. The overlapping polymerase/surface genome region of HBV from 180 infected individuals was extracted, amplified, and sequenced for genotypic analysis.

RESULTS

The HBsAg seroprevalence was detected 43% in liver disease patients, 8.4% in blood donors, and 6.7% in HIV/HBV co-infected individuals. The occult HBV prevalence was 3.7% in HIV/HBV co-infected individuals and 2.8% in blood donors with an overall prevalence rate of 3.4%. A phylogenetic analysis showed three HBV genotypes; A (61.1%), D (38.3%) and E (0.6%). Genotype A belongs to subtypes A1 (99.1%) and A9 (0.9%), but genotype D showed heterogeneous subtypes; D2 (63.8%) followed by D4 (21.7%), D1 (8.7%), D3 (4.3%), and D10 (1.4%).

CONCLUSIONS

The HIV/HBV co-infected individuals and blood donors showed lower HBsAg seroprevalence compared to liver diseases patients. Occult HBV prevalence showed no difference between HIV/HBV co-infected and blood donor groups. This study demonstrated predominance distribution of HBV subtypes A1 and D2 in northwest Ethiopia. The observed virological characteristics could contribute for evidence-based management of viral hepatitis in Ethiopia where antiretroviral therapy guidelines do not cater for viral hepatitis screening during HIV co-infection.

Immunovirological discordance among female sex workers who start antiretroviral therapy in Burkina Faso

Background

In people living with HIV/AIDS (PLWHA), initiation of antiretroviral therapy (ART) leads to sustained effective suppression of viral replication and increasing CD4 + T cell count. However, a fraction of ART-treated patients still fail to reach adequate CD4 + T cell number despite a suppressed viral load (VL), and this phenomenon is defined as immunovirological discordance (IVD). In Africa, several studies have reported immunovirological outcomes of antiretroviral therapy, but little is known about IVD occurrence in Female sex workers (FSW). This study aimed to assess the prevalence of IVD and associated factors among a cohort of HIV infected FSW in Burkina Faso.

Methods

We conducted a cohort study from December 2003 to October 2016. Immunovirological discordance was defined as CD4 + T cell gain < 100 cells/µL despite a suppressed VL (VL < 1000 copies/mL) 12 months after ART initiation. The CD4 + T cells were counted using BD FACSCount™ System and point of care Pima™ CD4 + Analyzer. HIV-1 RNA was quantified by real-time polymerase-chain-reaction assay with the use of the ABI 7000 system. We conducted a logistic regression to identify factors associated with discordant responses.

Results

Among the 123 HIV-1 infected FSW having at least 12 months follow-up on ART, 105 (85.4%) achieved HIV-1 RNA suppression. Among the latter 25 gained less than 100 CD4 + T cells within 12 months follow-up. The IVD rate was 23.8% (95%CI 16.04%–33.11%). After adjustment for age, WHO clinical stage and ART regimen including nucleoside/nucleotide reverse transcriptase inhibitors, only baseline CD4 + T cell count between 200 to 350 cells/µL (adjusted OR: 4.15; 95%CI 1.13–15.22) and 350 to 500 cells/µL (adjusted OR: 17.50; 95%CI 2.68–114.31) remain significantly associated with IVD occurrence.

Conclusions

Immunovirological discordance response was common in FSW with proportions close to those observed in the general population. A diagnosis and personalized follow-up of patients who do not achieve full immune reconstitution would make it possible to avoid complications in terms of morbidity and mortality.

Global Disparities in Hepatitis B Elimination-A Focus on Africa

In 2016, WHO member states at the World Health Assembly adopted a Global Health Sector Strategy that included a policy of eliminating viral hepatitis. Clear targets were established to assist in achieving this by 2030. The strategy, while achievable, has exposed existing global disparities in healthcare systems and their ability to implement such policies. Compounding this, the regions with most disparity are also those where the hepatitis B prevalence and disease burden are the greatest. Foundational to hepatitis B elimination is the identification of both those with chronic infection and crucially pregnant women, and primary prevention through vaccination. Vaccination, including the birth dose and full three-dose coverage, is key, but complete mother-to-child transmission prevention includes reducing the maternal hepatitis B viral load in the third trimester where appropriate. Innovations and simplified tools exist in order to achieve elimination, but what is desperately required is the will to implement these strategies through the support of appropriate investment and funding. Without this, disparities will continue.

Genotype E: The neglected genotype of hepatitis B virus

Hepatitis B virus (HBV) (sub)genotypes A1, D3 and E circulate in sub-Saharan Africa, the region with one of the highest incidences of HBV-associated hepatocellular carcinoma globally. Although genotype E was identified more than 20 years ago, and is the most widespread genotype in Africa, it has not been extensively studied. The current knowledge status and gaps in its origin and evolution, natural history of infection, disease progression, response to antiviral therapy and vaccination are discussed. Genotype E is an African genotype, with unique molecular characteristics that is found mainly in Western and Central Africa and rarely outside Africa except in individuals of African descent. The low prevalence of this genotype in the African descendant populations in the New World, phylogeographic analyses, the low genetic diversity and evidence of remnants of genotype E in ancient HBV samples suggests the relatively recent re-introduction into the population. There is scarcity of information on the clinical and virological characteristics of genotype E-infected patients, disease progression and outcomes and efficacy of anti-HBV drugs. Individuals infected with genotype E have been characterised with high hepatitis B e antigen-positivity and high viral load with a lower end of treatment response to interferon-alpha. A minority of genotype E-infected participants have been included in studies in which treatment response was monitored. Of concern is that current guidelines do not consider patients infected with genotype E. Thus, there is an urgent need for further large-scale investigations into genotype E, the neglected genotype of HBV.

Predictors of All-Cause Mortality among People with HIV in a Prospective Cohort Study in East Africa and Nigeria

Background

Introduction of antiretroviral therapy (ART) has been associated with a decline in human immunodeficiency virus (HIV)-related mortality, although HIV remains a leading cause of death in sub-Saharan Africa. We describe all-cause mortality and its predictors in people living with HIV (PLWH) in the African Cohort Study (AFRICOS).

Methods

AFRICOS enrolls participants with or without HIV at 12 sites in Kenya, Uganda, Tanzania, and Nigeria. Evaluations every 6 months include sociobehavioral questionnaires, medical history, physical examination, and laboratory tests. Mortality data are collected from medical records and survivor interviews. Multivariable Cox proportional hazards models were used to calculate adjusted hazard ratios (aHRs) and 95% confidence intervals (CIs) for factors associated with mortality.

Results

From 2013 through 2020, 2724 PLWH completed at least 1 follow-up visit or experienced death. Of these 58.4% were females, 25.8% were aged ≥ 50 years, and 98.3% were ART-experienced. We observed 11.42 deaths per 1000 person-years (95% CI: 9.53–13.68) with causes ascertained in 54% of participants. Deaths were caused by malignancy (28.1%), infections (29.7%), and other non-HIV related conditions. Predictors of mortality included CD4 ≤ 350 cells/µL (aHR 2.01 [95% CI: 1.31–3.08]), a log₁₀copies/mL increase of viral load (aHR 1.36 [95% CI: 1.22–1.51]), recent fever (aHR 1.85[95% CI: 1.22–2.81]), body mass index < 18.5 kg/m2 (aHR 2.20 [95% CI: 1.44–3.38]), clinical depression (aHR 2.42 [95% CI: 1.40–4.18]), World Health Organization (WHO) stage III (aHR 2.18 [95% CI: 1.31–3.61]), a g/dL increase in hemoglobin (aHR 0.79 [95% CI: .72–.85]), and every year on ART (aHR 0.67 [95% CI: .56–.81]).

Conclusions

The mortality rate was low in this cohort of mostly virally suppressed PLWH. Patterns of deaths and identified predictors suggest multiple targets for interventions to reduce mortality.

Infection courses, virological features and IFN-α responses of HBV genotypes in cell culture and animal models

BACKGROUND & AIMS

HBV consists of 9 major genotypes (A to I), 1 minor strain (designated J) and multiple subtypes, which may be associated with different clinical characteristics. As only cell lines expressing genotype D3 have been established, herein, we aimed to establish stable cell lines producing high-titer cell culture-generated HBV (HBVcc) of different genotypes and to explore their infectivity, virological features and responses to treatment.

METHODS

Stable cell lines producing high titers of HBV genotype A2, B2, C1, E, F1b and H were generated by transfecting plasmids containing a replication-competent 1.3x length HBV genome and an antibiotic marker into HepG2 cells that can support HBV replication. Clones with the highest levels of HBV DNA and/or HBeAg were selected and expanded for large-scale purification of HBVcc. HBVcc of different genotypes were tested in cells and a humanized chimeric mouse model.

RESULTS

HBVcc genotypes were infectious in mouse-passaged primary human hepatocytes (PXB cells) and responded differently to human interferon (IFN)-α with variable kinetics of reduction in HBV DNA, HBeAg and HBsAg. HBVcc of all genotypes were infectious in humanized chimeric mice but with variable kinetics of viremia and viral antigen production. Treatment of infected mice with human IFN-α resulted in modest and variable reductions of viremia and viral antigenemia. HBVcc passaged in humanized chimeric mice (HBVmp) infected PXB cells much more efficiently than that of the original HBVcc viral stock.

CONCLUSIONS

Herein, we generated stable cell lines producing HBV of various genotypes that are infectious in vitro and in vivo. We observe genotype-associated variations in viral antigen production, infection kinetics and responses to human IFN-α treatment in these models.

LAY SUMMARY

Stable cell lines producing high-titer cell culture-generated hepatitis B virus (HBV) of various genotypes were established. HBV genotypes showed stable infectivity in both in vitro and in vivo models, which are valuable tools for antiviral development.

Hepatitis B virus infection and hepatocellular carcinoma in sub-Saharan Africa: Implications for elimination of viral hepatitis by 2030?

Elimination of viral hepatitis in sub-Saharan Africa by 2030 is an ambitious feat. However, as stated by the World Health Organization, there are unprecedented opportunities to act and make significant contributions to the elimination target. With 60 million people chronically infected with hepatitis B virus (HBV) of whom 38800 are at risk of developing highly fatal hepatocellular carcinoma (HCC) every year, sub-Saharan Africa faces one of the greatest battles towards elimination of viral hepatitis. There is a need to examine progress in controlling the disproportionate burden of HBV-associated HCC in sub-Saharan Africa within the context of this elimination target. By scaling-up coverage of hepatitis B birth dose and early childhood vaccination, we can significantly reduce new cases of HCC by as much as 50% within the next three to five decades. Given the substantial reservoir of chronic HBV carriers however, projections show that HCC incidence and mortality rates in sub-Saharan Africa will double by 2040. This warrants urgent public health attention. The trends in the burden of HCC over the next two decades, will be determined to a large extent by progress in achieving early diagnosis and appropriate linkage to care for high-risk chronic HBV infected persons.

Prevalence and predictors of hepatitis B virus (HBV) infection in east Africa: evidence from a systematic review and meta-analysis of epidemiological studies published from 2005 to 2020

BACKGROUND

The epidemiology of hepatitis B virus (HBV) in the general population in east Africa is not well documented. In this meta-analysis, we examined 37 full published research articles to synthesise up-to-date data on the prevalence and predictors of the HBV burden for the effective prevention and management of the virus in our region.

METHODS

We examined 37 full published research articles found using PubMed, Scopus, African Journal Online (AJOL), and Google Scholar between May and October 2020. Dichotomous data on HBV prevalence and predictors of infection were extracted from the individual studies. The HBV prevalence, test of proportion, relative risk, and I2 statistics for heterogeneity were calculated using MedCalc software version 19.1.3. Begg's tests was used to test for publication bias. Sources of heterogeneity were analysed through sensitivity analysis, meta-regression, and sub-group analysis at 95% CI. P < 0.05 was considered significant for all analyses.

RESULTS

The prevalence of HBV was generally high (6.025%), with publications from Kenya (8.54%), Uganda (8.454%) and those from between 2011 and 2015 (8.759%) reporting the highest prevalence (P < 0.05). Blood transfusion, scarification, promiscuity, HIV seropositivity, and being male were independent predictors significantly associated with HBV infection (P < 0.05), with the male sex being the most strongly associated predictor of HBV infection. Meta-regressions for the pooled HBV prevalence and sample size, as well as the year of publication, lacked statistical significance (P > 0.05). Omitting the study with the largest sample size slightly increased pooled HBV prevalence to 6.149%, suggesting that the studies are robust. Begg's test showed no evidence of publication bias for overall meta-analysis (p > 0.05).

CONCLUSION

The burden of HBV is still high, with the male sex, blood transfusion, body scarification, and HIV seropositivity being potential predictors of infection. Thus, it is important to scale up control and prevention measures targeting persons at high risk.

Challenges for hepatitis B virus cure in resource-limited settings in sub-Saharan Africa

PURPOSE OF REVIEW

The aim of this article is to highlight the unique challenges for hepatitis B virus (HBV) cure faced in resource-limited settings (RLS) in sub-Saharan Africa (SSA), where access to disease prevention measures, medical testing, and treatment are limited.

RECENT FINDINGS

SSA RLS face challenges, which need to be anticipated as HBV cure research advances. There is a paucity of data because of lack of HBV surveillance and limited access to laboratories. Interruption of transfusion-transmitted infections, perinatal mother-to-child-transmissions, and transmission in people-who-infect-drug networks has not been achieved fully. Although RLS in SSA are within the epicenter of the HIV pandemic, unlike for HIV, there is no population-based testing for HBV. Public health response to HBV is inadequate with concomitant political inertia in combatting HBV infection.

SUMMARY

A functional HBV cure will improve the diagnosis/treatment cascade, decrease costs and accelerate HBV elimination. There is a concerted effort to find a HBV cure, which will be finite, not require life-long treatment, adherence, and continued monitoring. Increased research, improved financial, infrastructural and human resources will positively impact on implementation of HBV cure, when available. We can emulate major strides made in tackling HIV and the strength of advocacy groups in soliciting policymakers to take action.

Prevalence of HIV/hepatitis B and HIV/hepatitis C coinfection among people of East, South, Central and West African ancestry in the United Kingdom

Regional variability in the prevalence of hepatitis B (HBV) and C (HCV) is reported in sub-Saharan Africa, although data for people with HIV are sparse. We determined the prevalence of HBV/HCV in 2473 people of African ancestry with HIV in the UK. Overall, 6.2% were co-infected with HBV and 1.3% with HCV. Central [adjusted odds ratio (aOR) 2.40 (95% confidence interval (CI) 1.23--4.67) and West [2.10 (1.29-3.41)] African ancestry was associated with HBV and Central [6.98 (2.00-24.43)] African ancestry with HCV.

Hepatitis B, C and D virus prevalence in children and adults in Mbeya Region, Tanzania: results from a cohort study 2002 - 2009

INTRODUCTION

sub-Saharan Africa bears a high prevalence for hepatitis B virus (HBV) infection. This analysis aims at elucidating the exposure to HBV across different age groups in Mbeya Region in Tanzania and determines prevalences of hepatitis C (HCV) and hepatitis delta antigen (HDV) infections.

METHODS

plasma samples from children and adults with defined HIV status were analysed for HBV, HCV and HDV markers.\.

RESULTS

hepatitis B (HBs)-antigen positivity was 8.3% (3/36) in the 0 to 5 years age group, 13.3% (8/60) in the 6 to 7 years, 17.2% (10/58) in the 8 to 14 years and 13.3% (8/60) in the 15 to 18 years age groups. In adults 5.0% of samples were HBs-antigen positive. Overall, 17.1% were HIV-1 positive. Adults infected with HIV-1 were significantly more often HBs-antigen positive (7.5%) than HIV-1 negative adults (4.5%; p<0.05). A serological sub-study including 174 adults showed that both total anti-HBs and total anti-HBc positivity increased with age in HBs-antigen negative participants. Across all age groups, HCV antibodies were found in 9 individuals, HDV antibodies in 3 individuals.

CONCLUSION

children presented a high prevalence of HBs-antigen carriers, with lower levels in the younger children. Among adults, the overall prevalence of HBs-antigen was lower than in children, either corresponding to clearance of HBV over time or due to a die-off effect. HBs-antigen positive adults had higher frequencies of anti-HBc- and anti-HBe-antibodies, indicating better immunological control of HBV infection than children. This supports claims that HBV infections in Africa are mostly acquired in childhood and to a large extent cleared again by adulthood. One in 20 adults remains chronically infected, emphasising the importance of HBV vaccination strategies.

Non-cirrhotic hepatocellular carcinoma in chronic viral hepatitis: Current insights and advancements

Primary liver cancers carry significant morbidity and mortality. Hepatocellular carcinoma (HCC) develops within the hepatic parenchyma and is the most common malignancy originating from the liver. Although 80% of HCCs develop within background cirrhosis, 20% may arise in a non-cirrhotic milieu and are referred to non-cirrhotic-HCC (NCHCC). NCHCC is often diagnosed late due to lack of surveillance. In addition, the rising prevalence of non-alcoholic fatty liver disease and diabetes mellitus have increased the risk of developing HCC on non-cirrhotic patients. Viral infections such as chronic Hepatitis B and less often chronic hepatitis C with advance fibrosis are associated with NCHCC. NCHCC individuals may have Hepatitis B core antibodies and occult HBV infection, signifying the role of Hepatitis B infection in NCHCC. Given the effectiveness of current antiviral therapies, surgical techniques and locoregional treatment options, nowadays such patients have more options and potential for cure. However, these lesions need early identification with diagnostic models and multiple surveillance strategies to improve overall outcomes. Better understanding of the NCHCC risk factors, tumorigenesis, diagnostic tools and treatment options are critical to improving prognosis and overall outcomes on these patients. In this review, we aim to discuss NCHCC epidemiology, risk factors, and pathogenesis, and elaborate on NCHCC diagnosis and treatment strategies.

Prevalence of hepatitis B virus infection in pregnant women with and without HIV in Jos, Nigeria

OBJECTIVE

To compare the prevalence of hepatitis B virus (HBV) in pregnant women with and without human immunodeficiency virus (HIV) in Jos, Nigeria.

METHODS

This comparative cross-sectional study of pregnant women was undertaken between 1 November 2017 and 30 April 2018. Informed consent was obtained, demographic data and predictors for HBV were collected, and all women were screened for HIV and HBV. Descriptive statistics and multivariate analyses using STATA Version 15 were performed.

RESULTS

Of 3238 women enrolled, 12.6% and 7.2% of those with and without HIV had HBV, respectively (P = 0.01). Women with HIV, higher parity [adjusted odds ratio (aOR) 0.68, P < 0.01], lower gestational age (aOR 1.04, P < 0.01) and without prior HBV vaccination (aOR 0.40, P < 0.01) were significantly more likely to have HBV infection.

CONCLUSIONS

Among pregnant women, the prevalence of HBV was higher among those with HIV. Predictors of HBV included being multigravida or grand-multigravida, registration for antenatal care before 20 weeks of gestation, and no prior HBV vaccination. In settings with endemic HBV and HIV, integration of effective HBV and HIV prevention services could greatly decrease the transmission and prevalence of HBV.

Hepatitis B and HIV coinfection in Northern Uganda: Is a decline in HBV prevalence on the horizon?

Background

The available data concerning hepatitis B virus (HBV) infection in Uganda are limited, particularly in the case of people living with HIV/AIDS (PLWH). HBV is not routinely tested when starting antiretroviral therapy (ART). We aimed to determine the prevalence, the correlates of the risk of HBV infection, and the association with outcomes of ART among PLWH attending a busy HIV clinic in a referral hospital in Northern Uganda.

Patients and methods

From April to June 2016, a random sample of 1000 PLWH attending the outpatients’ clinic of St. Mary’s Hospital, Gulu, Uganda were systematically selected to undergo a rapid hepatitis B surface antigen (HBsAg) test after administering a questionnaire in this cross-sectional study. HIV care parameters were obtained from client files. Multivariate logistic regression and general linear model were used for the analysis.

Results

950 of the 985 evaluable patients (77% females; mean age 42.8 years) were receiving ART. The overall prevalence of HBsAg was 7.9% (95% confidence interval [CI] 6.2–9.6%), and was significantly lower among the females (6.8% vs 11.7%; p = 0.020). The factors independently associated with higher HBV infection were having lived in an internally displaced persons’ camp (adjusted odds ratio [aOR] 1.76, 95% CI 1.03–2.98; p = 0.036) and having shared housing with HBV-infected people during childhood (aOR 3.30, 95% CI 1.49–7.32; p = 0.003). CD4+ T cell counts were significantly lower in HBV patients (p = 0.025), and co-infection was associated with a poorer CD4+ T cell response to ART (AOR 0.88; 95% CI 0.79–0.98; p = 0.030).

Conclusions

The observed prevalence of HBV among the PLWH may be underestimated or a signal of HBV decline in the region. The factors favouring horizontal HBV transmission identified suggest extending HBV screening and vaccine prophylaxis among PLWH.

Serological evidence of HIV, Hepatitis B, C, and E viruses among liver disease patients attending tertiary hospitals in Osun State, Nigeria

Hepatitis infection in HIV positive individuals with liver diseases causes high mortality worldwide. HIV worsens the pathological effect of hepatitis viruses and potentiates reactivation of latent hepatitis infections due to reduced immunity. This research therefore aimed to study the occurrence of HIV and hepatitis viruses among liver diseases patients (LVDP) attending tertiary hospitals in Osun State, southwestern Nigeria. A total of 121 LVDP blood samples collected were tested for HIV and Hepatitis B, C, and E using and enzyme linked Immunossorbent assay (ELISA). Data were analyzed using packages within SPSS and P ≤ 0.05 was considered significant. Prevalence of 32.2%, 0.8%, 10.7%, and 18.2% for HBsAg, Anti-HCV, HEV-IgM, and HIV were found respectively. Marital status showed a significant association with HEV-IgM infection (χ² = 9.869, P = .020). The prevalence of HBsAg, HEV, and HIV among LVDP in Osun State is alarming and health education among the patients and general populace is hereby advocated. High HEV-IgM seroprevalence implies that HEV routine screening should be incorporated into blood screening. Since HEV is associated with unhygienic practice, people should be enlightened on how to improve their living conditions.

Sero-prevalence and determinants of Hepatitis B among a cohort of HIV-infected women of reproductive age in Nigeria

INTRODUCTION

Sub-Saharan Africa houses over two-thirds of the 37 million people living with human immunodeficiency virus (HIV) globally and of this, 5-20% are co-infected with Hepatitis B virus (HBV). This is double jeopardy, especially for women of reproductive age in these settings, who can transmit both viruses vertically as well as horizontally to their children. The objectives of this study were to investigate the prevalence and determinants of HBV among women of reproductive age living with HIV.

METHODS

This was a cross-sectional study of HIV-infected women of reproductive age in Benue State, Nigeria. Participants were eligible for the study if they were HIV-infected women (ages 18-45 years) receiving care from any of the selected study sites. A global rapid hepatitis B surface antigen (HBsAg) antibody test strip was used to test for HBsAg in plasma. A pretested questionnaire was used to collect data on sociodemographic, clinical and lifestyle characteristics of participants. We estimated prevalence of HBV infection and used multivariable logistic regression to determine factors associated with the infection at a significance level of <0.05.

RESULTS

A total of 6577 women were screened for HBsAg. The prevalence of HBV was 10.3% (95% CI: 9.5-10.9%). Age, parity and male partner's HIV status were found to be associated with having HBV infection. Compared to women older than 40 years, the odds of HBV infection increased significantly with increasing age until age 35 years and decreased significantly with increasing parity (versus no parity). Women with HIV-infected partners and those without a partner had higher odds of HBV infection compared to women with HIV-negative partners.

CONCLUSION

HBV is hyperendemic among HIV-infected women of reproductive age in North Central Nigeria. Specific programs targeting HBV testing, vaccination and treatment of all women of reproductive age need to be developed in this resource-limited, high-need setting.

Hepatitis B virus drug resistance mutations in HIV/HBV co-infected children in Windhoek, Namibia

In patients who are HIV infected, hepatitis B virus (HBV) infection is an important co-morbidity. However, antiretroviral options for HIV/HBV co-infected children are limited and, at the time of this study, only included lamivudine. These children may remain on this regimen for many years until late adolescence. They are at high risk of developing HBV drug resistance and uncontrolled HBV disease. The aim of this study was to characterize HBV infection in HIV/HBV co-infected children. Known HIV-infected/HBsAg-positive children, previously exposed to lamivudine monotherapy against HBV, and their mothers were recruited at the Katutura Hospital paediatric HIV clinic in Windhoek, Namibia. Dried blood spot and serum samples were collected for HBV characterization and serological testing, respectively. Fifteen children and six mothers participated in the study. Eight of the 15 children (53.3%) tested HBV DNA positive; all eight children were on lamivudine-based ART. Lamivudine-associated resistance variants, together with immune escape mutants in the surface gene, were identified in all eight children. Resistance mutations included rtL80I, rtV173L, rtL180M, rtM204I/V and the overlapping sE164D, sW182*, sI195M and sW196LS variants. HBV strains belonged to genotypes E (6/8, 75%) and D3 (2/8, 25%). Further analysis of the HBV core promoter region revealed mutations associated with reduced expression of HBeAg protein and hepatocarcinogenesis. All six mothers, on HBV-active ART containing tenofovir and lamivudine, tested HBV DNA negative. This study confirms the importance of screening HIV-infected children for HBV and ensuring equity of drug access to effective HBV treatment if co-infected.

Hepatitis B, hepatitis C and HIV prevalence and related sexual and substance use risk practices among key populations who access HIV prevention, treatment and related services in South Africa: findings from a seven-city cross-sectional survey (2017)

Background

People who use drugs including people who inject drugs (PWUD/ID), sex workers (SWs) and men who have sex with men (MSM) are at increased risk of HIV and viral hepatitis infection. Limited epidemiological data on the infections exists in key populations (KPs) in South Africa. We investigated the prevalence of hepatitis B (HBV), hepatitis C (HCV) and HIV and selected risk factors among these KPs to inform effective responses.

Methods

We used convenience sampling to recruit a targeted 3500 KPs accessing HIV-related health services across Cape Town (SWs, MSM, PWUD/ID), Durban (SWs, PWUD/ID), Pietermaritzburg (SWs), Mthatha (SWs), Port Elizabeth (SWs), Johannesburg (MSM) and Pretoria (MSM and PWUD/ID) into a cross-sectional survey. An interviewer questionnaire to assess socio-demographic characteristics, drug use and sexual risk practices, was administered. HBV surface antigen (HBsAg); HCV antibody, viral load and genotype, and HIV antibody, was tested.

Results

Among the 3439 people included in the study (1528 SWs, 746 MSM, 1165 PWUD/ID) the median age was 29 years, most participants were black African (60%), and 24% reported homelessness. 82% reported substance use in the last month, including alcohol (46%) and heroin (33%). 75% were sexually active in the previous month, with condom use at last sex at 74%. HIV prevalence was 37% (highest among SWs at 47%), HBsAg prevalence 4% (similar across KPs) and HCV prevalence was 16% (highest among PWUD/ID at 46%).

Conclusions

HBV, HCV and HIV pose a health burden for KPs in South Africa. While HIV is key for all included KPs, HCV is of particular importance to PWUD/ID. For KPs, HBV vaccination and behavioural change interventions that support consistent condom and lubricant access and use are needed. Coverage of opioid substitution therapy and needle and syringe services, and access to HCV treatment for PWUD/ID need to be expanded.

Hepatitis B virus activity in untreated hepatitis B e antigen-negative human immunodeficiency virus-hepatitis B virus co-infected patients from sub-Saharan Africa

BACKGROUND

In human immunodeficiency virus (HIV) and hepatitis B virus (HBV) co-infected patients from sub-Saharan Africa with hepatitis B e antigen (HBeAg)-negative status, data are limited on the evolution of HBV activity when antiretroviral treatment (ART) is absent.

METHODS

A total of 43 HBeAg-negative co-infected patients not indicated for ART (per concomitant World Health Organization recommendations) were followed during participation in a randomized controlled trial in Côte d'Ivoire. Chronic HBeAg-negative phases were classified at yearly visits and defined as 'infection' (HBV DNA ≤10 000 copies/mL and normal alanine aminotransferase [ALT]) or 'hepatitis' (HBV DNA >10 000 copies/mL and/or above normal ALT). Dispersion in HBV DNA and ALT levels during follow-up was assessed using interquartile range (IQR) regression.

RESULTS

During a median 25 months (IQR 19-31), 17 (40%) patients consistently had 'infection', 5 (12%) consistently had 'hepatitis' and 21 (48%) fluctuated between phases. Wider dispersion in HBV DNA over time was associated with higher baseline HIV RNA (p=0.02) and higher baseline HBV DNA levels (p=0.008), while wider dispersion in ALT was associated with higher baseline HIV RNA (p<0.001), higher baseline ALT levels (p=0.02) and baseline hepatitis surface antigen >4.0 log10 IU/mL (p=0.02).

CONCLUSIONS

HBV activity is common with HBeAg-negative status, whose variation is partly linked to HIV replication. Fluctuations in disease phase make it difficult to assess the risk of morbidity and mortality after ART initiation.

Hepatitis B Virus Infection and Associated Factors Among Adults in Southwest Ethiopia: Community-Based Cross-Sectional Study

Purpose

Ethiopia is grouped with countries with no national strategy for surveillance of viral hepatitis. Hence, data on hepatitis B virus (HBV) infection in the general population are limited. The aim of this study was to estimate the prevalence and associated factors of HBV infection among adults in Southwest Ethiopia.

Materials and Methods

A community-based cross-sectional study was conducted in Southwest Ethiopia, from November 1, 2017–January 30, 2018. A total of 612 individuals were included in the study using a multistage sampling technique. A structured questionnaire was used to collect data and a whole blood sample was aseptically collected and tested for HBsAg using a commercially available rapid serological test kit. Bivariate and multivariate logistic regression were employed and odds ratio with 95% confidence interval was retrieved. P-value <0.05 was considered as statistically significant.

Results

Among 612 participants, half of them, 310 (50.7%), were in the age range of 25–34 years. The mean age of the respondents was 32.5 [SD ±7.5] years. Seroprevalence of HBsAg among adults was 55/612 (9.0%). Tattooing on gums (AOR=23.9, 95% CI (2.2–26.3)), tattooing on the body (AOR=6.8, 95% CI (1.1–43.1)), and contact with a jaundiced person (AOR=20.7, 95% CI (6.7–63.8)) were significantly associated with seroprevalence of HBsAg.

Conclusion

Hepatitis B virus infection in adults at the community level is highly endemic. Modifiable risk factors such as tattooing on gums, tattooing on body, and contact with a jaundiced person account for the high HBV infection. Hence, behavioral education and communication programs designed to reduce HBV infection need to address these modifiable factors.

Treatment advantage in HBV/HIV coinfection compared to HBV monoinfection in a South African cohort

OBJECTIVES

Prompted by international targets for elimination of hepatitis B virus (HBV), we set out to characterise individuals with HBV monoinfection vs. those coinfected with HBV/HIV, to evaluate the impact of therapy and to guide improvements in clinical care.

METHODS

We report observational data from a real world cross-sectional cohort of 115 adults with chronic hepatitis B infection (CHB), at a university hospital in Cape Town, South Africa. HIV coinfection was present in 39 (34%) subjects. We recorded cross-sectional demographic, clinical and laboratory data.

RESULTS

Compared to those with HIV coinfection, HBV monoinfected adults were less likely to be HBeAg-positive (p=0.01), less likely to have had assessment with elastography (p<0.0001), and less likely to be on antiviral treatment (p<0.0001); they were more likely to have detectable HBV viraemia (p=0.04), and more likely to have features of liver disease including moderate/severe thrombocytopaenia (p=0.007), elevated bilirubin (p=0.004), and elevated APRI score (p=0.02). Three cases of hepatocellular carcinoma all arose in HBV monoinfection.

CONCLUSIONS

Our data demonstrate that individuals with HBV monoinfection may be disadvantaged compared to those with HIV coinfection, highlighting potential systematic inequities in referral, monitoring and treatment.

Impact of Lamivudine-Based Antiretroviral Treatment on Hepatitis B Viremia in HIV-Coinfected South Africans

This prospective study investigated the impact of lamivudine-containing antiretroviral therapy (ART) on HIV-positive patients in South Africa with baseline hepatitis B virus (HBV) infection. Follow-up samples from 56 HBV/HIV co-infected patients, 25 with occult HBV infection (OBI) and 31 with chronic HBV infection (CHB), were available for analysis. HBV viral loads were quantified at 6, 12, 18, and 24 months post-ART initiation by the COBAS TaqMan HBV Test 48 assay, and the HBV polymerase gene was amplified with an in-house nested polymerase chain reaction assay. During 24 months of lamivudine-based ART, 6 of 8 (75%) OBI and 4 of 6 (67%) CHB patients achieved undetectable levels of HBV DNA, while 2 patients had persistent HBV DNA levels ≥ 2 × 10⁵ despite lamivudine-based ART for 24 months. HIV viremia was undetectable in all patients at 12 months, suggesting high adherence to ART. Several lamivudine-associated HBV resistance mutations, including L180M, A181T, M204I, and M204V, were observed. Sequence analysis also revealed a rare genotype G infection. While resource-limited settings may use lamivudine-based ART because of availability and low cost, antivirals with dual therapy against HBV and HIV (e.g., lamivudine and tenofovir) should always be recommended with the regular monitoring of HBV viremia levels.

Nanopore sequencing from extraction-free direct PCR of dried serum spots for portable hepatitis B virus drug-resistance typing

BACKGROUND

Effective drug regimens for the treatment of hepatitis B virus (HBV) infections are essential to achieve the World Health Organisation commitment to eliminate viral hepatitis by 2030. Lamivudine (3TC) is widely used in countries with high levels of chronic HBV, however resistance has been shown to occur in up to 50 % of individuals receiving continuous monotherapy for 4 years. Telbivudine (LdT) is now more commonly used in place of lamivudine but is ineffective against 3TC-resistant HBV. Genotyping and identification of resistanceassociated substitutions (RAS) is not practical in many locations.

OBJECTIVES

A novel assay was designed to enable HBV genotyping and characterisation of resistance mutations directly from serum samples stored on filter paper, using Sanger and MinION sequencing.

STUDY DESIGN

The assay was applied to a cohort of 30 samples stored on filter paper for several years with HBV viral loads ranging from 8.2 × 10⁸ to 635 IU/mL. A set of 6 high-titre samples were used in a proof-of-principle study using the MinION sequencer.

RESULTS

The assay allowed determination of HBV genotype and elucidation of RAS down to 600 IU/mL using a 550bp amplicon. Sequencing of a 1.2 kb amplicon using a MinION sequencer gave results consistent with Sanger sequencing and allowed the identification of minor populations of variants.

CONCLUSIONS

We present two approaches for reliable HBV sequencing and RAS identification using methods suitable for resource-limited environments. This is the first demonstration of extraction-free DNA sequencing direct from DSS using MinION and these workflows are adaptable to the investigation of other DNA viruses.

Hepatitis B in sub-Saharan Africa-How many patients need therapy?

Hepatitis B is endemic in sub-Saharan Africa with ~60 million people chronically infected. While prevention, through vaccination, is central to elimination strategies, only 11 countries have birth dose vaccination and full vaccine coverage remains at suboptimal levels. Furthermore, to fully realize elimination, those chronically infected need to be identified, assessed for therapy and then linked to care. Given current treatment criteria, the precise quantum of people warranting therapy, according to criteria, is essentially unknown. The issue is further complicated by data to suggest differences in the numbers of people requiring treatment when applying WHO as compared to European Association for the Study of the Liver, EASL, criteria. Optimal determination of treatment eligibility is further hindered by the lack of available tools to adequately assess individual patients. It is conceivable that accurately determining the number of those requiring treatment, given the heterogeneity of hepatitis B in Africa, is difficult. Better studies and data are required. More signifcantly, improved access and availability to the diagnostic tools needed to assess patients in additon to access to drugs are as, if not more important, to achieve elimination.

Prevalence of hepatitis B and C virus co-infection in HIV positive patients attending a health institution in southeast Nigeria

BACKGROUND

The health of people living with HIV/AIDS becomes progressively worse when co-infected with hepatitis B virus (HBV) and hepatitis C virus (HCV), resulting in shortened life span. The modes of transmission of HIV, HBV and HCV are similar.

OBJECTIVE

To determine the prevalence of HBV and HCV co-infection in HIV patients.

METHOD

This was a retrospective study of serology test results for hepatitis B surface antigen (HBsAg) and antibodies to HCV (anti-HCV) of HIV positive patients registered from 2008-2013 (6years) at the University of Nigeria Teaching Hospital. Adult patients with confirmed HIV seropositivity were included. Ethical approval was obtained and confidentiality of the patient information was maintained. Laboratory records were reviewed to obtain HBsAg, anti-HCV, and CD4 T-lymphocyte results. Prevalence was determined by the number of positive results over total number of patients tested. Chi-square test was used to determine relationships and p<0.05 was considered to be statistically significant.

RESULTS

4663 HIV patient records were included comprising 3024 (65%) females and 1639 (35%) males. Serology results showed 365/4663 (7.8%) tested HBsAg-positive only; 219/4663 (4.7%) tested anti-HCV-positive only; and 27/4663 (0.58%) tested both HBsAg and anti-HCV-positive. Correlation of age and sex were statistically significant with HBV and HCV (p<0.05) but not CD4 count (p>0.05).

CONCLUSION

HBV co-infection was more prevalent than HCV, and triple infection was also observed. Screening for these viral infections in the HIV population is necessary for early identification to enable appropriate, holistic management of these patients.

Molecular Identification of HIV-1 in the Presence of Hepatitis B Virus and Hepatitis C Virus Co-infections

Background

Because of their similar modes of transmission, the simultaneous infection of viral hepatitis and human immunodeficiency virus are increasingly seen as a big problem related to human health.

Aims

To determine the drug mutations in hepatitis B virus and/or hepatitis C virus co-infected human immunodeficiency virus-1 patients in Turkey.

Study Design

Retrospective cross-sectional study.

Methods

The present study was conducted between 2010 and 2017. HBsAg, anti-hepatitis C virus, and anti-human immunodeficiency virus were tested with ELISA. All anti-human immunodeficiency virus positive results by ELISA were verified for anti-human immunodeficiency virus positivity by a Western blot test, and Anti-human immunodeficiency virus positive patients with HBsAg and/or anti-hepatitis C virus positivity were included in the study. Subtyping and genotypic resistance analyses were performed by population sequencing of the viral protease and reverse transcriptase regions of the human immunodeficiency virus-1 pol gene.

Results

We detected 3896 human immunodeficiency virus-1 positive patients whose sera were sent from numerous hospitals across the country to our polymerase chain reaction unit for detection of drug resistance mutations and whose molecular laboratory tests were completed. Viral hepatitis co-infections were detected in 4.3% (n=170) of patients. Hepatitis B virus and hepatitis C virus co-infection were observed in 3.2% and 0.5% of all human immunodeficiency virus-1 infected patients, respectively. The major human immunodeficiency virus-1 subtype detected was group M, subtype B (62.9%). However, 13.5% of drug resistance mutation motifs were found in human immunodeficiency virus-1 genomes of patients included in the study.

Conclusion

Due to similar transmission routes, HIV1 patients are at risk of hepatitis B and C virus co-infection. However, antiretroviral drug resistance mutation model is similar to patients with hepatitis negative.

Hepatitis B virus seroepidemiology data for Africa: Modelling intervention strategies based on a systematic review and meta-analysis

BACKGROUND

International Sustainable Development Goals (SDGs) for elimination of hepatitis B virus (HBV) infection set ambitious targets for 2030. In African populations, infant immunisation has been fundamental to reducing incident infections in children, but overall population prevalence of chronic hepatitis B (CHB) infection remains high. In high-prevalence populations, adult catch-up vaccination has sometimes been deployed, but an alternative Test and Treat (T&T) approach could be used as an intervention to interrupt transmission. Universal T&T has not been previously evaluated as a population intervention for HBV infection, despite high-profile data supporting its success with human immunodeficiency virus (HIV).

METHODS AND FINDINGS

We set out to investigate the relationship between prevalence of HBV infection and exposure in Africa, undertaking a systematic literature review in November 2019. We identified published seroepidemiology data representing the period 1995-2019 from PubMed and Web of Science, including studies of adults that reported prevalence of both hepatitis B surface antigen (HBsAg; prevalence of HBV infection) and antibody to hepatitis B core antigen (anti-HBc; prevalence of HBV exposure). We identified 96 studies representing 39 African countries, with a median cohort size of 370 participants and a median participant age of 34 years. Using weighted linear regression analysis, we found a strong relationship between the prevalence of infection (HBsAg) and exposure (anti-HBc) (R2 = 0.45, p < 0.001). Region-specific differences were present, with estimated CHB prevalence in Northern Africa typically 30% to 40% lower (p = 0.007) than in Southern Africa for statistically similar exposure rates, demonstrating the need for intervention strategies to be tailored to individual settings. We applied a previously published mathematical model to investigate the effect of interventions in a high-prevalence setting. The most marked and sustained impact was projected with a T&T strategy, with a predicted reduction of 33% prevalence by 20 years (95% CI 30%-37%) and 62% at 50 years (95% CI 57%-68%), followed by routine neonatal vaccination and prevention of mother to child transmission (PMTCT; at 100% coverage). In contrast, the impact of catch-up vaccination in adults had a negligible and transient effect on population prevalence. The study is constrained by gaps in the published data, such that we could not model the impact of antiviral therapy based on stratification by specific clinical criteria and our model framework does not include explicit age-specific or risk-group assumptions regarding force of transmission.

CONCLUSIONS

The unique data set collected in this study highlights how regional epidemiology data for HBV can provide insights into patterns of transmission, and it provides an evidence base for future quantitative research into the most effective local interventions. In combination with robust neonatal immunisation programmes, ongoing PMTCT efforts, and the vaccination of high-risk groups, diagnosing and treating HBV infection is likely to be of most impact in driving advances towards elimination targets at a population level.

Hepatitis B infection and risk factors among children living with HIV in Yaounde, Cameroon: an integrated management

Background

The endemicity of hepatitis B virus (HBV) prompted the systematic immunization of newborns in Cameroon since 2005. In the frame of a considerable burden of HIV/HBV co-infection (17.5%), monitoring HBV among children living with HIV (CLHIV) would guide toward HIV/HBV integrated paediatric care. We sought to ascertain the prevalence and determinants of HBV infection in the population of CLHIV and performance of commonly used rapid diagnosis tests (RDTs).

Methods

Cross-sectional study conducted from February through June 2017 in a subset of CLHIV ≤15 years old at the Essos Hospital Centre, Yaounde, Cameroon. HBV was tested by HBsAg ELISA sandwich in duplicates for each sample, and the mean optical density was calculated. The Determinants of HBV-prevalencewere evaluated, and p < 0.05 was the significance threshold. The performance of two HBV RDTs (Diaspot vs. HBV-5) was evaluated in comparison to ELISA (used as gold standard).

Results

Of the 83 CLHIV enrolled (54.2% female, mean age 8.7 [±3.8] years, 60% vaccinated against HBV, all breastfed), HBV-prevalence was 2.41% (2/83). HBV-positivity was significantly associated with unknown maternal HBV status (2.9% [2/69] vs. 0.0% [0/14], p = 0.0097) and vaginal delivery (2.4% [2/82] vs. 0.0% [0/1], p = 0.0018). Moreover, the most likely to be positive were aged 11 and 15 years, and had experienced neither anti-HBV vaccination nor anti-HBV serum administration, and both had not been treated with any antiseptic solution at birth. Regarding the performance of Diaspot vs. HBV-5 respectively, sensitivity was 100% (2/2) vs. 50% (1/2), while specificity was 100% (45/45) vs. 97.8% (44/45); positive and negative predictive values of Diaspot versus HBV-5 were respectively 100% (2/2) and 100% (45/45) versus 50% (1/2) and 97.8% (44/45).

Conclusion

HBV-infection in the population of CLHIV appears at a moderate prevalence, suggesting a decreased burden likely due to preventive measures including the wide vaccine coverage. Focusing on mothers with unknown HBV status and promoting safer delivery mode (caesarean section) for HBV-positive motherswould contribute toward pediatric HBV elimination. In context of limited resources, Diaspot test appears more reliable to rollout HBV-infection in the population of CLHIV. As findings are limited to a small sample size, studies on a wider population would be relevant.

Drug resistance outcomes of long-term ART with tenofovir disoproxil fumarate in the absence of virological monitoring

Objectives

The resistance profiles of patients receiving long-term ART in sub-Saharan Africa have been poorly described. This study obtained a sensitive assessment of the resistance patterns associated with long-term tenofovir-based ART in a programmatic setting where virological monitoring is yet to become part of routine care.

Methods

We studied subjects who, after a median of 4.2 years of ART, replaced zidovudine or stavudine with tenofovir disoproxil fumarate while continuing lamivudine and an NNRTI. Using deep sequencing, resistance-associated mutations (RAMs) were detected in stored samples collected at tenofovir introduction (T0) and after a median of 4.0 years (T1).

Results

At T0, 19/87 (21.8%) subjects showed a detectable viral load and 8/87 (9.2%) had one or more major NNRTI RAMs, whereas 82/87 (94.3%) retained full tenofovir susceptibility. At T1, 79/87 (90.8%) subjects remained on NNRTI-based ART, 5/87 (5.7%) had introduced lopinavir/ritonavir due to immunological failure, and 3/87 (3.4%) had interrupted ART. Whilst 68/87 (78.2%) subjects maintained or achieved virological suppression between T0 and T1, a detectable viral load with NNRTI RAMs at T0 predicted lack of virological suppression at T1. Each treatment interruption, usually reflecting unavailability of the dispensary, doubled the risk of T1 viraemia. Tenofovir, lamivudine and efavirenz selected for K65R, K70E/T, L74I/V and Y115F, alongside M184V and multiple NNRTI RAMs; this resistance profile was accompanied by high viral loads and low CD4 cell counts.

Conclusions

Viraemia on tenofovir, lamivudine and efavirenz led to complex resistance patterns with implications for continued drug activity and risk of onward transmission.

Evaluation of hepatic and kidney dysfunction among newly diagnosed HIV patients with viral hepatitis infection in Cape Coast, Ghana

OBJECTIVE

HIV positive individuals infected with viral hepatitis B (HBV) or C (HCV) are at an increased risk of progression to kidney and liver failures. Therefore, prior to initiation of antiretroviral therapy, early diagnosis and initiation of appropriate treatment protocols are imperative for co-infected individuals. This study evaluated the prevalence of HBV and HCV, and extent of liver and renal dysfunction among 90 newly diagnosed HIV patients attending the Cape Coast Teaching Hospital HIV clinic.

RESULTS

Levels of alanine aminotransferase, aspartate-platelet ratio index and estimated glomerular filtration rate were used respectively to diagnose hepatotoxicity, liver fibrosis and chronic kidney disease (CKD). Association analyses were evaluated by Pearson's Chi-square test or Fisher's exact test and considered significant at p < 0.05. Using rapid diagnostic tests, 75.6% (n = 68) had HIV1 mono-infection, 24.4% (n = 22) had HIV1/HBV co-infection while 0.0% (n = 0) had HIV1/HCV co-infection. The prevalence of hepatotoxicity, liver fibrosis, and CKD were 7.8% (n = 7), 2.2% (n = 2), and 15.5% (n = 14) respectively. Similar proportions of HIV1/HBV and HIV1 were diagnosed with liver fibrosis (p = 0.431). In relation to hepatotoxicity Grade, a high proportion of HIV1/HBV were diagnosed with Grade 2 (p = 0.042). Also, severely reduced kidney function (CKD stage 4) was observed in only HIV1/HBV (n = 2, 9.1%, p = 0.053).

TB preventive therapy for people living with HIV: key considerations for scale-up in resource-limited settings

Tuberculosis (TB) is the leading cause of death for persons living with the human immunodeficiency virus (PLHIV). TB preventive therapy (TPT) works synergistically with, and independently of, antiretroviral therapy to reduce TB morbidity, mortality and incidence among PLHIV. However, although TPT is a crucial and cost-effective component of HIV care for adults and children and has been recommended as an international standard of care for over a decade, it remains highly underutilized. If we are to end the global TB epidemic, we must address the significant reservoir of tuberculous infection, especially in those, such as PLHIV, who are most likely to progress to TB disease. To do so, we must confront the pervasive perception that barriers to TPT scale-up are insurmountable in resource-limited settings. Here we review available evidence to address several commonly stated obstacles to TPT scale-up, including the need for the tuberculin skin test, limited diagnostic capacity to reliably exclude TB disease, concerns about creating drug resistance, suboptimal patient adherence to therapy, inability to monitor for and prevent adverse events, a 'one size fits all' option for TPT regimen and duration, and uncertainty about TPT use in children, adolescents, and pregnant women. We also discuss TPT delivery in the era of differentiated care for PLHIV, how best to tackle advanced planning for drug procurement and supply chain management, and how to create an enabling environment for TPT scale-up success.

Prevalence of HIV, Hepatitis B and C Virus Co-infections among Iranian High-Risk Groups: A Systematic Review and Meta-Analysis

Co-infection with hepatitis B and C among HIV infected patients are prevalent among high-risk populations. This meta-analysis aimed to estimate the prevalence of HIV, HCV and HBV co-infections among high-risk populations in Iran.

We systematically searched the national and international electronic databases until 2016. The primary outcome was the prevalence of HIV, HBV, HCV and HIV co-infections in different high-risk populations in Iran. All English and Persian studies conducted on Iranian high-risk groups were included in the study. The review was reported based on PRISMA guidelines and data were analysed at 95% confidence level using random effect models.

Overall, 916 relevant papers were recognised and 14 articles were included in the meta-analysis. The pooled estimates of HBV/HCV, HCV/HIV, HBV/HIV and HBV/HCV/HIV were 1.3% (95%CI: 0.5–2.1), 16.3% (95%CI: 1.1–31.6), 0.5% (95%CI: 0–1.4) and 0.5% (95%CI: 0.2–0.8), respectively. Based on subgroup analysis, there was a higher proportion of all co-infections from the years 2010–2016 as compared to that of the years 2003–2009.

Our results highlighted that HCV/HIV co-infection in Iranian high-risk groups including injection drug users (IDUs) and prisoners is common. In addition, the increasing trend of coinfections should be considered alarming for policymakers.

Modelling cost-effectiveness of tenofovir for prevention of mother to child transmission of hepatitis B virus (HBV) infection in South Africa

BACKGROUND

International sustainable development goals for the elimination of viral hepatitis as a public health problem by 2030 highlight the need to optimize strategies for prevention, diagnosis and treatment of hepatitis B virus (HBV) infection. An important priority for Africa is to have affordable, accessible and sustainable prevention of mother to child transmission (PMTCT) programmes, delivering screening and treatment for antenatal women and implementing timely administration of HBV vaccine for their babies.

METHODS

We developed a decision-analytic model simulating 10,000 singleton pregnancies to assess the cost-effectiveness of three possible strategies for deployment of tenofovir in pregnancy, in combination with routine infant vaccination: S1: no screening nor antiviral therapy; S2: screening and antiviral prophylaxis for all women who test HBsAg-positive; S3: screening for HBsAg, followed by HBeAg testing and antiviral prophylaxis for women who are HBsAg-positive and HBeAg-positive. Our outcome was cost per infant HBV infection avoided and the analysis followed a healthcare perspective.

RESULTS

Based on 10,000 pregnancies, S1 predicts 45 infants would be HBV-infected at six months of age, compared to 21 and 28 infants in S2 and S3, respectively. Relative to S1, S2 had an incremental cost of $3940 per infection avoided. S3 led to more infections and higher costs.

CONCLUSION

Given the long-term health burden for individuals and economic burden for society associated with chronic HBV infection, screening pregnant women and providing tenofovir for all who test HBsAg+ may be a cost-effective strategy for South Africa and other low/middle income settings.

Screening for retroviruses and hepatitis viruses using dried blood spots reveals a high prevalence of occult hepatitis B in Ghana

Background:

Recent advances in antiviral therapy show potential for a cure and/or control of most human infections caused by hepatitis viruses and retroviruses. However, medical success is largely dependent on the identification of the large number of people unaware of these infections, especially in developing countries. Dried blood spots (DBS) have been demonstrated to be a good tool for collecting, storing and transporting clinical specimens from rural areas and limited-resource settings to laboratory facilities, where viral infections can be more reliably diagnosed.

Methods:

The seroprevalence and virological characterization of hepatitis B virus (HBV) and hepatitis C virus (HCV), as well as human retroviruses (HIV-1, HIV-2, human T-cell leukaemia virus type 1 [HTLV-1] and human T-cell leukaemia virus type 2 [HTLV-2]), were investigated in clinical specimens collected from DBS in Ghana.

Results:

A total of 305 consecutive DBS were collected. A high prevalence of chronic HBV (8.5%) and occult hepatitis B (14.2%) was found, whereas rates were lower for HIV-1, HTLV-1 and HCV (3.2%, 1.3% and 0.6%, respectively). HIV-2 and HTLV-2 were absent. CRF02_AG was the predominant HIV-1 subtype, whereas genotype E was the most frequent HBV variant.

Conclusions:

DBS are helpful in the diagnosis and virological characterization of hepatitis and retrovirus infections in resource-limited settings. The high rate of hepatitis B in Ghana, either overt or occult, is noteworthy and confirms recent findings from other sub-Saharan countries. This should encourage close clinical follow up and antiviral treatment assessment in this population, as well as universal HBV vaccine campaigns.

Hepatitis B infection among pregnant and post-partum women living with HIV and on antiretroviral therapy in Kinshasa, DR Congo: A cross-sectional study

BACKGROUND

Hepatitis B virus (HBV) co-infection in HIV-infected individuals increases the risk of hepatic complications and mortality. Further, the risk of perinatal HBV transmission increases among HBV/HIV co-infected pregnant women. Although HBV is endemic in the Democratic Republic of Congo, there is little data on HBV/HIV co-infection. We aimed to assess the burden and risk factors of HBV surface antigen (HBsAg) positivity among HIV-infected pregnant and post-partum women.

METHODS

This cross-sectional study was conducted as part of an ongoing trial to assess the effect of data-driven continuous quality improvement interventions (CQI) for optimal prevention of mother-to-child transmission (PMTCT) of HIV (CQI-PMTCT study, NCT03048669). In each of the 35 health zones of Kinshasa province, all HIV-infected pregnant or breastfeeding women (≤1 year post-delivery) presenting for care in one of the three busiest maternal and child health clinics of the health zone were tested for HBsAg using Alere Determine, Japan. We used logistic regression with general estimating equation accounting for within-clinic clustering to assess risk factors of HBsAg positivity.

RESULTS

Between November 2016 and June 2018, a total of 1377 women, all on antiretroviral therapy, were tested for HBsAg. Overall, 4.7% [95% binomial confidence interval (CI): 3.7%-5.7%] tested positive for HBsAg. HBsAg prevalence was 3.3% (95% CI: 2.1%-4.8%) for women tested during pregnancy, 4.5% (2.5%-7.4%) for those tested at delivery, and 8.5% (5.6%-12.2%) for those tested post-partum (Ptrend = 0.001). In multivariate models including socio-economic status (SES), type of care facility, duration of antiretroviral therapy, HIV viral load, and self-reported intimate partner violence (IPV), lowest tertile of SES, ≤ 6 months of ART, and IPV were all consistently and positively associated with higher prevalence of HBsAg across pregnancy, delivery, and postpartum period while been tested in a health centre or having a viral load ≥ 1000 copies/mL were consistently associated with lower prevalence. However, only the association with IPV (OR = 2.74, 95% CI: 1.10-6.84) and viral load between 40-1000 copies/ml (OR = 4.28, 95% CI: 1.22-15.01) achieved statistical significance among pregnant women.

CONCLUSION

This study revealed an overall high prevalence of HBsAg among HIV-infected pregnant and post-partum women in Kinshasa with the latter showing the highest HBsAg prevalence. Among pregnant women, intimate partner violence was independently and statistically associated with HBsAg positivity, requiring further investigation.

Comparison of Demographic, Epidemiological, Immunological, and Clinical Characteristics of Patients with HIV Mono-infection Versus Patients Co-infected with HCV or/and HBV: A Serbian Cohort Study

OBJECTIVE

The study aimed to correlate the status of hepatitis C (HCV) and hepatitis B virus (HBV) co-infection in patients with human immunodeficiency virus (HIV) infection with clinical and demographic data prior to starting highly active antiretroviral therapy (HAART) and assess the impact of HCV and HBV co-infection on the natural history of HIV infection.

PATIENTS AND METHODS

The study involved a total of 836 treatment-naive patients with available serological status for HBV and HCV at the point of therapy initiation. Patients were stratified into four groups: HIV mono-infection, HIV/HCV, HIV/HBV, and HIV/HCV/HBV co-infection. Demographic, epidemiological, immunological and clinical characteristics were analyzed in order to assess the possible impact of HCV and HBV co-infection on HIV - related immunodeficiency and progression to AIDS.

RESULTS

The prevalence of HCV and HBV co-infection in our cohort was 25.7% and 6.3%, respectively. Triple HIV/HCV/HBV infection was recorded in 1.7% of the patients. In comparison with those co-infected with HCV, patients with HIV mono-infection had lower levels of serum liver enzymes activity and higher CD4 cell counts, and were less likely to have CD4 cell counts below100 cells/µL and clinical AIDS, with OR 0.556 and 0.561, respectively. No difference in the development of advanced immunodeficiency and/or AIDS was recorded between patients with HIV monoinfection and those co-infected with HBV, or both HCV/HBV.

CONCLUSION

HIV/HCV co-infection was found to be more prevalent than HIV/HBV co-infection in a Serbian cohort. Co-infection with HCV was related to more profound immunodeficiency prior to therapy initiation, reflecting a possible unfavorable impact of HCV on the natural history of HIV infection.

Understanding hepatitis B, hepatitis C and HIV among people who inject drugs in South Africa: findings from a three-city cross-sectional survey

BACKGROUND

People who inject drugs (PWID) are at high risk for hepatitis C (HCV), hepatitis B (HBV) and HIV without accessible harm reduction programmes. Coverage of needle and syringe and opioid substitution therapy (OST) services in South Africa is below global recommendations and no hepatitis services exist for PWID. We assessed HCV, HBV and HIV prevalence and risk factors among PWID accessing harm reduction services in Cape Town, Durban and Pretoria to inform policy and programming.

METHODS

We conducted a cross-sectional survey among PWID in these cities between August 2016 and October 2017. Participants were opportunistically sampled while accessing services. Study team members administered a questionnaire that assessed sociodemographic characteristics, drug use and sexual risk practices. We tested for HCV (antibody, viral load and genotype), HBV surface antigen (HBsAg) and HIV. Bivariate and multivariate analyses assessed associations with HCV serostatus.

RESULTS

Nine hundred and forty-three PWID were included in the per protocol analysis. The majority (87%, 819/943) were male, the overall median age was 29 and most lived on the street (66%, 626/943). At last injection, 77% (722/943) reported using a new needle and syringe and 17% (163/943) shared equipment. HIV prevalence was 21% (196/926), HBsAg positivity 5% (47/936), HCV seroprevalence 55% (513/937), HCV viraemic prevalence (proportion tested with detectable HCV) 43% (404/937) and HCV viraemic rate (proportion HCV antibody positive with detectable HCV) 79% (404/513). HCV genotype 1a (73%, 270/368) was the most prevalent. In multivariate analysis, HCV infection was positively associated with residing in Pretoria (adjusted odds ratio (aOR) 1.27, 95% CI 1.21-1.34), living on the street (aOR 1.90, 95% CI 1.38-2.60), frequent injecting (aOR 1.58, 95% CI 1.15-2.16) and HIV infection (aOR 1.69, 95% CI 1.15-2.47), and negatively associated with black race (aOR 0.52, 95% CI 0.36-0.74) and sexual activity in the previous month (aOR 0.61, 95% CI 0.42-0.88).

CONCLUSIONS

HCV and HIV are major health threats affecting PWID in these cities. Access to OST and needle and syringe services needs to be increased and integrated with HCV services. Social and structural factors affecting PWID who live on the street need to be addressed.

HBV vaccination and PMTCT as elimination tools in the presence of HIV: insights from a clinical cohort and dynamic model

BACKGROUND

Sustainable Development Goals set a challenge for the elimination of hepatitis B virus (HBV) infection as a public health concern by the year 2030. Deployment of a robust prophylactic vaccine and enhanced interventions for prevention of mother to child transmission (PMTCT) are cornerstones of elimination strategy. However, in light of the estimated global burden of 290 million cases, enhanced efforts are required to underpin optimisation of public health strategy. Robust analysis of population epidemiology is particularly crucial for populations in Africa made vulnerable by HIV co-infection, poverty, stigma and poor access to prevention, diagnosis and treatment.

METHODS

We here set out to evaluate the current and future role of HBV vaccination and PMTCT as tools for elimination. We first investigated the current impact of paediatric vaccination in a cohort of children with and without HIV infection in Kimberley, South Africa. Second, we used these data to inform a new parsimonious model to simulate the ongoing impact of preventive interventions. By applying these two approaches in parallel, we are able to determine both the current impact of interventions, and the future projected outcome of ongoing preventive strategies over time.

RESULTS

Existing efforts have been successful in reducing paediatric prevalence of HBV infection in this setting to < 1%, demonstrating the success of the existing vaccine campaign. Our model predicts that, if consistently deployed, combination efforts of vaccination and PMTCT can significantly reduce population prevalence (HBsAg) by 2030, such that a major public health impact is possible even without achieving elimination. However, the prevalence of HBV e-antigen (HBeAg)-positive carriers will decline more slowly, representing a persistent population reservoir. We show that HIV co-infection significantly reduces titres of vaccine-mediated antibody, but has a relatively minor role in influencing the projected time to elimination. Our model can also be applied to other settings in order to predict impact and time to elimination based on specific interventions.

CONCLUSIONS

Through extensive deployment of preventive strategies for HBV, significant positive public health impact is possible, although time to HBV elimination as a public health concern is likely to be substantially longer than that proposed by current goals.

Effect of hepatitis B virus (HBV) surface-gene variability on markers of replication during treated human immunodeficiency virus-HBV infection in Western Africa

BACKGROUND & AIMS

Replication markers exhibit substantial variation during chronic hepatitis B virus (HBV) infection, part of which can be explained by mutations on the surface (S) gene. We aimed to identify S-gene mutations possibly influencing the quantification of HBV replication markers (MUPIQH) in HBV genotype E infection, common to Western Africa.

METHODS

Seventy-three antiretroviral treatment (ART)-naïve human immunodeficiency virus (HIV)-HBV co-infected patients from Côte d'Ivoire, initiating anti-HBV-containing ART, had available HBV S-gene sequences. S-gene MUPIQHs were screened at ART initiation based on lower HBV-DNA or HBsAg quantification (qHBsAg) compared to wildtype. Their association with HBV virological response and qHBsAg slope during treatment was evaluated.

RESULTS

Genotype E was predominant (95.9%). At ART initiation, median HBV-DNA was 7.27 log₁₀ copies/mL (IQR = 5.26-8.33) and qHBsAg 4.08 log₁₀ IU/mL (IQR = 3.49-4.61). Twelve S-gene MUPIQHs were identified among 21 patients (28.8%): sS140L (n = 4), sD144A (n = 1), sS167L (n = 2), sS174N (n = 6), sP178Q (n = 2), sG185L (n = 2), sW191L (n = 2), sP203Q/R (n = 2), sS204N/I/R/K/T/G (n = 7), sN207T (n = 2), sF212C (n = 1) and sV224A/Y (n = 7). MUPIQHs at positions s185+s191+s224 and s178+s204 were within highly covarying networks of S-gene mutations. Older age (P = 0.02), elevated transaminases (P = 0.03) and anti-hepatitis B "e" antibody-positive serology (P = 0.009) were significantly associated with prevalent MUPIQHs at ART initiation. During treatment, baseline MUPIQHs were not associated with time-to-undetectable HBV-DNA (P = 0.7) and qHBsAg levels decreased at similar rates between those with vs without MUPIQHs (P = 0.5).

CONCLUSION

Several novel S-gene mutations were associated with reductions in replication markers among West African co-infected patients. These mutations, however, do not affect response during antiviral treatment. Their diagnostic and clinical consequences need clarification.

Insights From Deep Sequencing of the HBV Genome-Unique, Tiny, and Misunderstood

Hepatitis B virus (HBV) is a unique, tiny, partially double-stranded, reverse-transcribing DNA virus with proteins encoded by multiple overlapping reading frames. The substitution rate is surprisingly high for a DNA virus, but lower than that of other reverse transcribing organisms. More than 260 million people worldwide have chronic HBV infection, which causes 0.8 million deaths a year. Because of the high burden of disease, international health agencies have set the goal of eliminating HBV infection by 2030. Nonetheless, the intriguing HBV genome has not been well characterized. We summarize data on the HBV genome structure and replication cycle, explain and quantify diversity within and among infected individuals, and discuss advances that can be offered by application of next-generation sequencing technology. In-depth HBV genome analyses could increase our understanding of disease pathogenesis and allow us to better predict patient outcomes, optimize treatment, and develop new therapeutics.

Impact of Highly Active Antiretroviral Therapy on Chronic Hepatitis B Serological Markers among Senegalese HIV Co-infected Children

BACKGROUND

Coinfection with human immunodeficiency virus (HIV) and hepatitis B virus (HBV) causes complex interactions. The aim of this study was to evaluate the seroprevalence and HBV evolution among HIV coinfected children receiving highly active antiretroviral therapy (HAART).

METHODS

A descriptive cross-sectional study was carried out among 252 HIV infected children enrolled in the Hôpital d'enfants Albert Royer, Dakar, Senegal, from April 2013 to March 2015. Clinical characteristics, immuno-virological status, alanine aminotransferase (ALT) levels, and HBV serological marker were taken from the patients' medical records.

RESULTS

Overall, 7 children were HBsAg positive with a determinate prevalence rate of 2.8%. Median age at HIV diagnosis was 3.5 years (1.3-14.4 years). According to World Health Organization (WHO) staging, 40.1% of children were stage 4 and 25.8% were stage 3. Of the 7 HIV/HBV-co-infected children, 6 (86%) received lamivudine alone at initiation of treatment, and only one child received tenofovir associated with emtricitabine. Overall median HAART duration treatment including lamivudine alone or tenofovir+lamivudine (or emtricitabine) was 7.7 years (3.3-11.3). Only the two children (29%) receiving lamivudine during follow-up had high HBV DNA load despite having good immuno-virological status. Suppression of HBV DNA replication was achieved in 5 (71.4%) of 7 children.

CONCLUSION AND GLOBAL HEALTH IMPLICATION

HIV/HBV coinfection prevalence was low in our study. HBsAg and HBeAg loss were low while suppression of HBV DNA replication was still higher on tenofovir. Screening and monitoring HBV infection among all HIV infected children are required to direct treatment in order to improve children HBV/HIV coinfected outcome.

Response of hepatitis B virus to antiretroviral treatment containing lamivudine in HBsAg-positive and HBsAg-negative HIV-positive South African adults

Both hepatitis B virus (HBV) and human immunodeficiency virus (HIV) infection are highly endemic in sub-Saharan Africa. This study examined serological and clinical follow-up data from 39 HBV DNA-positive, HIV-positive black South African adults, who returned for follow-up at 3, 6, 12, and 18 months post-initiation of antiretroviral therapy (ART). Of the 39 participants, 10 experienced full suppression of HBV and 29 experienced no suppression, with 10 of these showing a virological breakthrough. All 10 patients who fully suppressed were HBsAg-negative, with 16 of the 29 who did not suppress being HBsAg-positive and 13 HBsAg-negative (P < 0.05). Participants fully suppressing the virus had significantly lower aminotransferase levels and were all HBsAg-negative compared to those who did not suppress (P < 0.05). HBV viral loads between HBsAg-positive and HBsAg-negative samples were similar at baseline and at the final time-point. In these South African patients with HBV/HIV coinfection, HBsAg-negative status at baseline was a predictor of the outcome of HBV suppression in response to ART containing lamivudine.