Phylogenetic and drug- and vaccine-resistance profiles of Hepatitis B Virus among children with HIV co-infection in Pakistan

INTRODUCTION

HIV-1 and hepatitis B virus (HBV) share common routes of transmission and therefore co-infection is common. In 2019, an HIV-1 outbreak that resulted in >1000 children being infected, predominantly through nosocomial transmission, occurred in Sindh, Pakistan. We conducted a phylogenetic and drug resistance analysis of the HBV Reverse Transcriptase (RT) gene in children with HIV-1 and HBV co-infection.

METHODOLOGY

Blood samples were collected from 321 children with HIV who were recruited as part of a study to investigate the HIV-1 outbreak. All samples were tested for HBV surface antigen (HBsAg) using an ELISA assay, and positive samples were used to amplify and sequence the HBV RT gene. The phylogenetic relationship between sequences was analyzed, and drug- and vaccine- resistance mutations in the RT gene were explored.

RESULTS

Of 321 samples, 23% (n = 75) were positive for HBsAg on ELISA. Phylogenetic analysis of the sequences revealed that 63.5% of HBV sequences were sub-genotype D1, while the rest were sub-genotype D2. Cluster analysis revealed grouping of sub-genotype D1 sequences exclusively with Pakistani sequences, while clustering of sub-genotypes D2 predominantly with global sequences. The 236Y mutation associated with resistance to tenofovir was observed in 2.8% of HBV sequences. Additionally, seven vaccine escape mutations were observed, the most common being 128 V.

CONCLUSION

Our study suggests ongoing transmission of HBV D1 and D2 sub-genotypes in the HIV-1 co-infected population, likely nosocomially, given common routes of HVB and HIV-1 transmission. The prevalence of major HBV drug- and vaccine-resistant mutations remains low. Surveillance for further transmissions and the possible emergence of major drug- or vaccine-resistant variants is required.

Is hepatitis delta underestimated?

Hepatitis D virus may be underestimated because it is a significant problem in HBsAg-positive patients, especially those who inject drugs, have HIV or HCV co-infections and/or live in certain endemic regions. In the past few decades, the prevalence of HDV was expected to have decreased as a result of improvements in public healthcare policies and universal HBV vaccination programs. However, HDV has continued to spread in low-income countries, with local outbreaks and migration to less endemic areas, so that its prevalence has remained stable or even increased in certain regions. As a result, research has been focused on the epidemiology of HDV. Contradicting data from three large recent meta-analyses have reported that the prevalence of HDV may be between 0.16% and 1.00% in the global general population, and 4.5% and 14.6% in HBsAg-positive patients, with an estimated 12 to 70 million HDV patients worldwide. The exact prevalence and estimated number of HDV patients is still a subject of debate for several reasons, including the unreliable assessment of the infection and a lack of real-world screening. HDV infection is associated with an increased risk of progression to cirrhosis and the development of HCC compared to patients with HBV mono-infection, a risk which is even higher in patients with HIV co-infection. Morbidity and mortality from HDV-related cirrhosis should not be overlooked. In conclusion, hepatitis D virus is probably underestimated and certainly underdiagnosed, and screening for HDV should be performed in all HBsAg-positive patients in clinical practice.

Hepatitis B infection in people living with HIV who initiate antiretroviral therapy in Zimbabwe

Setting

There is little information about the diagnosis and treatment of hepatitis B virus (HBV) infection in people living with HIV (PLHIV) in Zimbabwe despite recommendations that tenofovir (TDF) + lamivudine (3TC) is the most effective nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) backbone of antiretroviral therapy (ART) in those with dual infection.

Objective

To determine 1) numbers screened for hepatitis B surface antigen (HBsAg); 2) numbers diagnosed HBsAg-positive along with baseline characteristics; and 3) NRTI backbones used among PLHIV initiating first-line ART at Mpilo Opportunistic Infections Clinic, Bulawayo, Zimbabwe, between October 2017 and April 2019.

Design

This was a cross-sectional study using routinely collected data.

Results

Of the 422 PLHIV initiating first-line ART (median age 34 years, IQR 25-43), 361 (85%) were screened for HBV, with 10% being HBsAg-positive. HBsAg positivity was significantly associated with anaemia (adjusted prevalence ratio [aPR] 2.3, 95%CI 1.1-4.7) and elevated ala-nine transaminase levels (aPR 2.9, 95%CI 1.5-5.8). Of 38 PLHIV who were diagnosed HBsAg-positive, 30 (79%) were started on ART based on tenofovir (TDF) and lamivudine (3TC), seven were given abacavir (ABC) + 3TC-based ART and one was given zido vudine (ZDV) + 3TC-based ART.

Conclusion

In PLHIV, HBV screening worked well, the prevalence of HIV-HBV co-infection was high and most patients received appropriate treatment for both conditions. Recommendations to improve screening, diagnosis and treatment of HIV-HBV co-infection are discussed.

Profile and prevalence of HBV among HIV affected individuals attending the largest public HIV care center in India

A large number of people living with HIV/AIDS residing in HBV endemic regions such as in India are highly susceptible to acquire co-infections like HBV but also transmit them to other due to their high risk behaviours. The present study aimed to estimate HBV prevalence and distribution of various HBV serological markers among HIV infected individuals. This cross sectional survey covered HIV infected individuals attending the largest HIV care center in India. Socio-demographic details and blood samples to screen for HBV seromarkers using commercial ELISA kits were collected. Among 1160 HIV infected patients, prevalence of HBcAb, HBsAb, HBsAg and HBeAg was 66, 29.4, 16.6 and 5.8 % respectively. Overall, 28.9 % individuals had no evidence of any of the four markers, indicating lack of previous exposure and future risk of acquiring HBV infection. Presence of anti-HBsAg in a mere 0.9 % of individuals reflected low levels HBV vaccine conferred immunity which could be due to poor HBV vaccine coverage in this high risk population. With high prevalence and evidence of exposure to HBV as well as considering the growing literature on increase in hepatic complications in HIV-HBV co-infected individuals, the need for mandatory HBV screening of all HIV infected individuals cannot be over-emphasised. The policy makers and HIV programme managers must consider HBV vaccination for newly detected HBV naive HIV infected individuals and also focus on creating public awareness on HBV and HIV prevention.

THE PREVALENCE LIVER FUNCTION AND IMMUNOLOGIC STATUS OF CHILDREN WITH HIV AND HEPATITIS B VIRUS COINFECTION IN ENUGU, NIGERIA

BACKGROUND

Hepatitis B Virus (HBV) co-infection is prevalent among HIV infected individuals because of shared routes and mechanisms of transmission. The multidimensional immunosuppression from HIV infection causes impaired spontaneous recovery from an acute HBV infection, predisposing to chronic infection which is worsened by younger age at infection. Co-infection increases the risk of HBV replication, hepatotoxicity and liver related deaths from Highly Active Antiretroviral Therapy (HAART). The study was undertaken to highlight the burden of co-infection among HIV positive children in Enugu, determine the associated risk factors and compare the effect of co-infection between co-infected and non-co-infected children using liver enzyme and CD4 counts.

MATERIALS AND METHODS

A cross sectional study was carried out among HIV positive children attending the Paediatric ARV clinic of the University of Nigeria Teaching Hospital, Ituku-Ozalla. A total of 140 HIV infected children aged 18 months to 15 years were recruited. An interviewer questionnaire was administered. Hepatitis B surface antigen (HBsAg) was determined using Determine test Kit. Baseline and recent CD4 counts/CD4% were retrieved from the patients' folders.

RESULTS

Fourteen (10%) were positive for HBsAg. The highest prevalence of HBsAg was observed among children aged 11- 15 years. The higher the socioeconomic class the less likely the HBsAg positivity. Seven (50%) of the co-infected children had elevated baseline ALT compared with 57 (45.2%) of non-co-infected children though the difference was not statistically significant (t = 0.6, P = 0.56). After the initiation of HAART, 10 (76.9%) of the co-infected and 18 (15.1%) of the non-co-infected children had elevated ALT. The baseline median CD4 count among children ≥ 6 years was 230 cells/mm³ and 360 cells/mm³ respectively among the co-infected and non- co-infected, (P = 0.67). However, in children ≤ 5 years, it was 25% and 15 % respectively (P = 0.06).

CONCLUSION

HBV co-infection among HIV infected children is common in our environment, and co-infection is associated with impaired immunity and probably liver enzyme derangement.