Chronic hepatitis B infection in sub-Saharan Africa: a grave challenge and a great hope

Prevalence of HIV and hepatitis B virus among pregnant women in Luanda (Angola): geospatial distribution and its association with socio-demographic and clinical-obstetric determinants

Background

HIV and HBV infections remain responsible for high rate of morbidity and mortality in many African Countries, affecting women and newborns. This study aims to analyze the spatial pattern of HIV and HBV infections in pregnant women in Luanda, Angola, and the statistical association between HIV and HBV and socio-economic characteristics, hygiene, and health status.

Methods

Detection of anti-HIV antibodies (total anti-HIV-1, anti-HIV-2 and HIV-1 p24 antigen) and Hepatitis B antigens (HBsAg, HBeAg) and antibodies (anti-HBc Total II, HBc IgM, Anti-HBsT II) was performed by Enzyme Linked Fluorescent Assay (ELFA) in serum samples of 878 pregnant women attended at the Lucrecia Paim Maternity Hospital (LPMH). Data were collected by questionnaire after written consent, and spatial distribution was assessed through a Kernel Density Function. The potential risk factors associated with HIV HBV infection were evaluated using bivariate and multivariate binomial logistic regression analysis.

Results

Anti-HIV antibodies were positive in 118 samples (13.4%) and HBV infection were positive in 226 (25.7%). The seroprevalence of HIV/HBV coinfection was of 6.3%. The results showed that the seroprevalence of HBV was similar in most municipalities: 25.8% in Belas; 26.6% in Viana; 27.6% in Luanda; 19.2% in Cacuaco; and 15.6% Cazenga. For HIV, the seroprevalence was also close ranges among the municipalities: 10.0% in Belas; 14.5% in Viana 14.9% in Luanda and 12.5% in Cazenga. However, the seroprevalence in municipality of in Cacuaco was lower (5.8%) and bivariate and multivariate analysis showed a lower risk for HIV in this area (OR 0.348, CI 0.083–0.986; OR 0.359, CI 0.085–1.021). The multivariate analysis had also showed a significant increased risk for HIV in women with 2 or 3 births (OR 1.860, CI 1.054–3.372).

Conclusions

Our results underlined the need to improve the screening and clinical follow-up of HIV and HBV in Angola, as well the educational campaigns to prevent not only the morbidity and mortality associated with these diseases, but also their transmission, mainly in women in reproductive age and pregnant, encouraging the pre-natal consultations in order to avoid mother-to-child transmission.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12985-021-01698-7.

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.

Diagnostic performance evaluation of hepatitis B e antigen rapid diagnostic tests in Malawi

Background

The World Health Organization (WHO) has targeted a reduction in viral hepatitis-related mortality by 65% and incidence by 90% by 2030, necessitating enhanced hepatitis B treatment and prevention programmes in low- and middle-income countries. Hepatitis B e antigen (HBeAg) status is used in the assessment of eligibility for antiviral treatment and for prevention of mother-to-child transmission (PMTCT). Accordingly, the WHO has classified HBeAg rapid diagnostic tests (RDTs) as essential medical devices.

Methods

We assessed the performance characteristics of three commercially available HBeAg RDTs (SD Bioline, Alere, South Africa; Creative Diagnostics, USA; and Biopanda Reagents, UK) in two hepatitis B surface antigen-positive cohorts in Blantyre, Malawi: participants of a community study (n = 100) and hospitalised patients with cirrhosis or hepatocellular carcinoma (n = 94). Two investigators, blinded to the reference test result, independently assessed each assay. We used an enzyme-linked immunoassay (Monolisa HBeAg, Bio-Rad, France) as a reference test and quantified HBeAg concentration using dilutions of the WHO HBeAg standard. We related the findings to HBV DNA levels, and evaluated treatment eligibility using the TREAT-B score.

Results

Among 194 HBsAg positive patients, median age was 37 years, 42% were femaleand 26% were HIV co-infected. HBeAg prevalence was 47/194 (24%). The three RDTs showed diagnostic sensitivity of 28% (95% CI 16–43), 53% (38–68) and 72% (57–84) and specificity of 96–100% for detection of HBeAg. Overall inter-rater agreement κ statistic was high at 0.9–1.0. Sensitivity for identifying patients at the threshold where antiviral treatment is recommended for PMTCT, with HBV DNA > 200,000 IU/ml (39/194; 20%), was 22, 49 and 54% respectively. Using the RDTs in place of the reference HBeAg assay resulted in 3/43 (9%), 5/43 (12%) and 8/43 (19%) of patients meeting the TREAT-B treatment criteria being misclassified as ineligible for treatment. A relationship between HBeAg concentration and HBeAg detection by RDT was observed. A minimum HBeAg concentration of 2.2–3.1 log₁₀IU/ml was required to yield a reactive RDT.

Conclusions

Commercially available HBeAg RDTs lack sufficient sensitivity to accurately classify hepatitis B patients in Malawi. This has implications for hepatitis B public health programs in sub-Saharan Africa. Alternative diagnostic assays are recommended.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12879-021-06134-3.

Hepatitis B Awareness and Vaccination Patterns among Healthcare Workers in Africa

Hepatitis B virus (HBV) vaccination patterns and the understanding of its risks among healthcare workers (HCWs) is a critical step to decrease transmission. However, the depth of this understanding is understudied. We distributed surveys to HCWs in 12 countries in Africa. Surveys had nine multiple-choice questions that assessed HCWs' awareness and understanding of HBV. Participants included consultants, medical trainees, nurses, students, laboratory personnel, and other hospital workers. Surveys were completed anonymously. Fisher's exact test was used for analysis, with a P-value of < 0.05 considered significant; 1,044 surveys were collected from Kenya, Egypt, Sudan, Tanzania, Ethiopia, Uganda, Malawi, Madagascar, Nigeria, Cameroon, Ghana, and Sierra Leone. Hepatitis B virus serostatus awareness, vaccination rate, and vaccination of HCWs' children were 65%, 61%, and 48%, respectively. Medical trainees had higher serostatus awareness, vaccination rate, and vaccination of their children than HCWs in other occupations (79% versus 62%, P < 0.001; 74% versus 58%, P < 0.001; and 62% versus 45%, P = 0.006, respectively). Cost was cited as the most frequent reason for non-vaccination. West African countries were more aware of their serostatus but less often vaccinated than East African countries (79% versus 59%, P < 0.0001 and 52% versus 60%, P = 0.03, respectively). West African countries cited cost as the reason for non-vaccination more than East African countries (59% versus 40%, P = 0.0003). Our study shows low HBV serostatus awareness and vaccination rate among HCWs in Africa, and reveals gaps in the perception and understanding of HBV prevention that should be addressed to protect HCWs and improve their capacity to control HBV infection.

Epidemiology of HBV in Pregnant Women, South West Nigeria

Hepatitis B virus (HBV) remains a leading cause of chronic hepatitis, maternal complications, and neonatal deaths in sub-Saharan Africa. Pregnant women serve as a major reservoir for the persistence and ongoing transmission of hepatitis B virus and HIV in a generalized heterosexual epidemic. The aim of this study is to assess the epidemiology of Hepatitis B infection among pregnant women in South West-Nigeria. This is a cross-sectional study of 353 pregnant women across 10 health facilities in the region. Results showed that of the 353 pregnant women tested, 37 were positive for the HBV antigen giving a prevalence estimate of 10.5% (95% CI: 7.5%–14.2%). We found significant negative association between odds of HBV infection and knowledge of HBV transmission through sex (OR: 0.30: 95%CI–0.11–0.82) and a positive association with blood transfusion in the past three months (OR: 9.5: 95% CI-1.58–57.14). Findings strongly suggest high endemicity of HBV and the possible implication of blood transfusion as a major route of ongoing HBV transmission among pregnant women in south-western Nigeria. We recommend further study of a prospective design to investigate the possible causal link between blood transfusion and the risk of HBV infection among pregnant women in Nigeria.

Hepatitis B and C infections in HIV-1 and non-HIV infected pregnant women in the Brong-Ahafo Region, Ghana

Background

Hepatitis B (HBV) or hepatitis C (HCV) virus co-infections in HIV are alarming during pregnancy due to the risk of vertical transmission and the eventual adverse effects on neonates. This study was conducted to ascertain the sero-prevalence of HIV/HBV and HIV/HCV co-infections, evaluate the effect of the co-infections on the immunological and virological characteristics and assess the association between some demographic and lifestyle characteristics and risk of HBV, HCV, HIV/HBV and HIV/HCV co-infections among pregnant women living in the Brong-Ahafo Region of Ghana.

Methods

This comparative cross-sectional study was conducted at the anti-retroviral therapy (ART) clinics of the St. Elizabeth Hospital and the Holy Family Hospital, Brong-Ahafo Region, Ghana. A total of 248 consecutive consenting pregnant Ghanaian women, 148 diagnosed with HIV [HIV (+)] and 100 who were HIV negative [HIV (-)], were recruited. Validated questionnaire was used to obtain demographic and lifestyle data. Venous blood samples were obtained and HCV status, HBV profile, CD4+ T cell count, and HIV-1 RNA load were determined.

Results

The sero-prevalence of HIV (+) /HBV, HIV (+) /HCV, HIV (-)/HBV, and HIV (-)/HCV infections were 22 (14.9%), 6 (4.1%), 10 (10.0%), and 12 (12.0%) respectively. HIV-1 viral load was not significantly different between HIV/HBV, HIV/HCV co-infection and HIV mono-infection. However, CD4+ T lymphocyte count (364 vs 512 vs 514 cells/μl; p = 0.0009) was significantly lower in HIV/HBV co-infection compared to HIV/HCV and HIV mono-infection respectively. There was no significant association between demographic and lifestyle characteristics and risk of HBV and HCV infections in HIV positive and negative subjects except for late diagnosis of HIV and history of sharing razors blades and pins, where increased odds of HIV (+) /HBV and HIV (-)/HBV infection were observed.

Conclusions

The prevalence of HIV (+)/HBV (14.9%), HIV (+)/HCV (4.1%), HIV (-)/HBV (10.0%), and HIV (-)/HCV (12.0%) are high among pregnant women in the Brong Ahafo Region of Ghana. HIV/HBV is associated with reduced CD4+ T lymphocyte count but not HIV-1 viral load. Early diagnosis of HIV and intensification of routine antenatal HBV and HCV are essential to abate the risk of maternal to child transmission.

Hepatitis B Virus (HBV) Infection and Re-activation During Nucleos(t)ide Reverse Transcriptase Inhibitor-Sparing Antiretroviral Therapy in a High-HBV Endemicity Setting

Background

We monitored the evolution of markers of hepatitis B virus (HBV) infection in virologically suppressed HIV-positive patients switching to nucleoside reverse transcriptase inhibitor (NRTI)–sparing antiretroviral therapy within a randomized trial in Cameroon.

Methods

 HBV surface antigen (HBsAg), HBV DNA, and antibodies against surface (anti-HBs), core (total anti-HBc), and e-antigen (anti-HBe) were measured retrospectively in samples collected at study entry and over 48 weeks after NRTI discontinuation.

Results

Participants (n = 80, 75% females) had a plasma HIV-1 RNA <60 copies/mL, a median CD4 count of 466 cells/mm³, and undetectable HBsAg and HBV DNA at study entry. After NRTI discontinuation, 3/20 (15.0%) anti-HBc-negative patients showed evidence indicative or suggestive of incident HBV infection (163 cases/1000 person-years); 6/60 (10.0%) anti-HBc-positive patients showed evidence indicative or suggestive of HBV reactivation (109 cases/1000 person-years). In one case of reactivation, anti-HBs increased from 14 to >1000 IU/L; sequencing showed HBV genotype A3 and 3 escape mutations in surface (Y100C, K122R, Y161FY). Alongside new-onset detection of HBsAg or HBV DNA, 1 patient experienced acute hepatitis and 6 patients experienced mild or marginal increases in serum transaminase levels.

Conclusions

Evolving treatment strategies for sub-Saharan Africa must be accompanied by the formulation and implementation of policy to guide appropriate assessment and management of HBV status.

Uptake of hepatitis B-HIV co-infection screening and management in a resource limited setting

Background

WHO hepatitis B guidelines recommend testing all new HIV patients, treating them accordingly or providing immunization. At the Infectious Diseases Institute (IDI) following an audit done in 2012, only 46% patients had been screened for hepatitis B with variable management plans therefore new internal guidelines were implemented. This study describes the uptake of hepatitis B screening and management of patients with hepatitis B and HIV con-infection after the implementation.

Methods

Data included for all HIV positive patients in care at IDI by October 2015. Data are expressed as median with interquartile range (IQR) and percentages were compared using the chi square test. Statistical analysis was performed using STATA version 13. The IDI laboratory upper limit of normal for alanine aminotransferase (ALT) and aspartate aminotransferase (ASTs) was 40 IU/ml.

Results

Number of hepatitis B screening tests increased from 800 by 2012 to 1400 in 2015. By 2015 8042/8604(93.5%) patients had been screened for hepatitis B. Overall hepatitis B positive were 359 (4.6%). 166 (81.4%) hepatitis B positives were switched to a tenofovir (TDF) containing regimen.

Conclusion

Our study confirms the importance of screening for hepatitis B and of using ART regimens containing tenofovir in hepatitis B co-infected patients. Whilst our program has made improvements in care still 18.6% of patients with hepatitis B were not on tenofovir regimens, 98.1% had no hepatitis B viral loads done. Clinicians should recognize the potential for hepatitis B in HIV positive patients and the importance of early diagnosis and treatment to ensure optimal management of cases and follow up.

Is laboratory screening prior to antiretroviral treatment useful in Johannesburg, South Africa? Baseline findings of a clinical trial

BACKGROUND

Screening for renal, hepatic and haematological disorders complicates the initiation of current first-line antiretroviral therapy (ART). Each additional test done adds substantial costs, both through direct laboratory expenses, but also by increasing the burden on health workers and patients. Evaluating the prevalence of clinically relevant abnormalities in different population groups could guide decisions about what tests to recommend in national guidelines, or in local adaptations of these.

METHODS

As part of enrolment procedures in a clinical trial, 771 HIV-positive adults, predominantly from inner-city primary health care clinics, underwent laboratory screening prior to ART. Participants had to be eligible for ART, based on the then CD4 eligibility threshold of 350 cells/μL, antiretroviral naïve and have no symptoms of peripheral neuropathy.

RESULTS

Participants were mostly female (57%) and a mean 34 years old. Creatinine clearance rates were almost all above 50 mL/min (99%), although 5% had microalbuminuria. Hepatitis B antigenaemia was common (8% of participants), of whom 40% had a raised AST/ALT, though only 2 had transaminase levels above 200 IU/L. Only 2% of participants had severe anaemia (haemoglobin <8 g/dl) and 1% neutropaenia (neutrophils <0.75 × 10^9/L). Costs per case detected of hepatitis B infection was USD135, but more than USD800 for a raised creatinine.

CONCLUSIONS

Hepatitis B continues to be a common co-infection in HIV-infected adults, and adds complexity to management of ART switches involving tenofovir. Routine renal and haematological screening prior to ART detected few abnormalities. The use of these screening tests should be assessed among patients with higher CD4 counts, who may even have fewer abnormalities. Formal evaluation of cost-effectiveness of laboratory screening prior to ART is warranted.

Hepatitis B vaccination coverage, knowledge and sociodemographic determinants of uptake in high risk public safety workers in Kaduna State, Nigeria: a cross sectional survey

OBJECTIVES

To estimate hepatitis B vaccination (HBVc) coverage, and knowledge and sociodemographic determinants of full dose uptake in Federal Road Safety Corps (FRSC) members, Kaduna State, Nigeria, to inform relevant targeted vaccination policies.

DESIGN

A cross sectional survey of FRSC members, Kaduna Sector Command.

SETTINGS

Six randomly selected unit commands under Kaduna Sector Command, Kaduna State, Nigeria.

PARTICIPANTS

A pilot tested, structured, self-administered questionnaire was administered to 341 participants aged ≥18 years with ≥6 months of service between 17 June and 22 July 2015. Excluded were FRSC members in road safety 1 zonal command headquarters as the zonal command includes other states beyond the study scope.

PRIMARY OUTCOME

HBVc status of participants categorised as 'not vaccinated' for uptake of <3 doses and 'vaccinated' for uptake of ≥3 doses.

ANALYSIS

Descriptive analysis estimated HBVc coverage while logistic regression ascertained associations.

RESULTS

Most participants were men, aged 30-39 years, with 3-10 years of service and of marshal cadre. HBVc coverage was 60.9% for ≥1 dose and 30.5% for ≥3 doses. Less than 47% of participants scored above the mean knowledge score for hepatitis B virus (HBV) and HBVc. Female sex (AOR 2.28, 95% CI 1.15 to 4.52, p<0.05), perceiving there to be an occupational risk of exposure to HBV (AOR 2.86, 95% CI 1.06 to 7.70, p<0.001) and increasing HBVc knowledge (AOR 2.68, 95% CI 1.83 to 3.92, p<0.001) were independent predictors of full dose HBVc in FRSC members, Kaduna Sector Command.

CONCLUSIONS

HBVc coverage and knowledge were poor among FRSC members, Kaduna Sector Command. Educational intervention, geared towards improving FRSC members' knowledge of HBVc and perception of risk of occupational exposure to HBV, is recommended for these vulnerable public safety workers. Such enlightenment could be a cheap and easy way of improving HBVc coverage in the study population.

Barriers to Linkage to Care for Hepatitis B Virus Infection: A Qualitative Analysis in Burkina Faso, West Africa

Hepatitis B virus (HBV) infection is a critical global health problem. The World Health Organization (WHO) has recently developed a global elimination strategy for HBV infection. Increasing access to screening, liver assessment, and antiviral treatment are crucial steps in achieving this goal. Little is known, however, about obstacles to linkage to care in low- and middle-income countries. Using a grounded theory approach, this qualitative study sought to characterize the diagnostic itineraries of people with chronic HBV infection in Burkina Faso, a west African country with high HBV prevalence, to identify barriers to linkage from screening to specialist care with hepatic assessment (alanine transaminase and hepatitis B e antigen or HBV DNA). We conducted 80 semistructured interviews with chronically infected people, their families, medical personnel, and traditional practitioners, and participant observation of HBV diagnostic announcements and consultations. Of 30 individuals diagnosed with chronic viral hepatitis, 18 inadvertently discovered their status through blood screening and 12 actively sought diagnosis for their symptoms. Only a quarter (8/30) were linked to care. Barriers included: 1) patients' ability to pay for testing and treatment; 2) a formal health system lacking trained personnel, diagnostic infrastructures, and other resources; 3) patients' familial and social networks that discouraged access to testing and HBV knowledge; 4) a well-developed demand for and provisioning of traditional medicine for hepatitis; and 5) a weak global politics around HBV. More training for medical personnel would improve linkage to care in sub-Saharan Africa. Developing effective communications between medical workers and patients should be a major priority in this elimination strategy.