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 Table of Contents  
ORIGINAL ARTICLE
Year : 2013  |  Volume : 10  |  Issue : 2  |  Page : 76-81

Prevalence of hepatitis B and C virus infections among HIV-infected patients in a tertiary hospital in North-Western Nigeria


1 Department of Medicine, Bayero University; Department of Medicine, Infectious Diseases Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
2 Department of Medicine, Bayero University; Department of Medicine, Gastroenterology Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
3 Department of Medicine, Infectious Diseases Unit, Aminu Kano Teaching Hospital, Kano, Nigeria
4 Department of Medicine, Bayero University; Department of Medicine, Pulmonology Unit, Aminu Kano Teaching Hospital, Kano, Nigeria

Date of Web Publication7-Dec-2013

Correspondence Address:
Muhammad Hamza
Department of Medicine, Aminu Kano Teaching Hospital/Bayero University, PMB 3452, Kano
Nigeria
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0331-8540.122765

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  Abstract 

Introduction: Infections from HIV, Hepatitis B and to some extent Hepatitis C viruses constitute a major public health challenge in sub-Saharan Africa, and there are evidences to suggest that there is faster progression of HIV in those co-infected with either HBV or HCV. The aim of this study was to determine the prevalence of HBV and HCV infections among HIV-infected patients, and describe the socio-demographic features and correlates of HIV and HBV/HCV co-infected patients at Aminu Kano Teaching Hospital (AKTH), Kano, Nigeria. Materials and Methods: This was a cross-sectional study carried out among HIV-positive individuals seen at the adult HIV clinic of AKTH. Four Hundred and forty (440) consecutive HIV-positive adult patients who consented to the study were screened for markers of HBV and HCV using Enzyme-linked Immunosorbent Assay (ELISA) technique. CD 4 Count and serum ALT were also obtained from the recruited patients. Socio-demographic characteristics and Body Mass Index (BMI) were obtained. Differences and relationships between groups were determined using students t-test and Chi-square test where appropriate, and a P < 0.05 was regarded as significant. Results: Prevalence rates of Hepatitis B and C virus infections obtained were 12.3% and 1.6%, respectively. Individuals who were 40 years or younger were the most affected. HBV co-infection was more common among males than females (16.9% vs 9.2%, respectively, P = 0.0153). Mean serum ALT among participants with HIV alone was 31.6 International Units (IU), but was significantly higher (45.3 IU) for those with HIV/HBV co-infection, P = 0.048. Mean CD 4 count for HIV/HBV co-infected participants (259.7 c/mm 3 ) was significantly higher than that for participants with HIV alone (240.0 c/mm 3 ), P = 0.0170 whereas the mean BMI was not significantly different between participants with HIV alone (21.3 kg/m 2 ) versus HIV/HBV co-infected participants (22.2 kg/m 2 ), P = 0.1385. Conclusion: Co-infection with hepatitis B virus is common among HIV-infected patients in our setting and this further reaffirms the need for routine baseline screening for this marker, as it is a major consideration in the initiation and choice of highly active antiretroviral therapy. Furthermore, those found to be negative should be immunized with HBV vaccine to improve the prognosis of their HIV status.

Keywords: Hepatitis B, Hepatitis C, HIV, Nigeria, prevalence


How to cite this article:
Hamza M, Samaila AA, Yakasai AM, Babashani M, Borodo MM, Habib AG. Prevalence of hepatitis B and C virus infections among HIV-infected patients in a tertiary hospital in North-Western Nigeria. Niger J Basic Clin Sci 2013;10:76-81

How to cite this URL:
Hamza M, Samaila AA, Yakasai AM, Babashani M, Borodo MM, Habib AG. Prevalence of hepatitis B and C virus infections among HIV-infected patients in a tertiary hospital in North-Western Nigeria. Niger J Basic Clin Sci [serial online] 2013 [cited 2019 Mar 20];10:76-81. Available from: http://www.njbcs.net/text.asp?2013/10/2/76/122765


  Introduction Top


There are estimated 34.2 million people living with HIV/AIDS worldwide, and sub-Saharan Africa remains the region most affected by the global Acquired Immunodeficiency Syndrome (AIDS) pandemic. [1] On the other hand Hepatitis B virus (HBV) constitutes a major public health challenge in this same region of the world with prevalence of >8% of the population. Epidemiologically HIV, HBV and Hepatitis C virus (HCV) have common routes of transmission, hence the frequent occurrence of their co-infections.

For HIV and HBV co-infection (HIV/HBV), the seroprevalence rate ranges from 6.3% to as high as 39% [2],[3] while for HIV and HCV co-infection (HIV/HCV), the seroprevalence ranges from 8 to 30%. [4],[5],[6]

Whether HBV or HVC affects HIV progression has been a matter of much debate. However, there are evidences to suggest that there is faster progression of HIV, even to AIDS-defining illness, in those co-infected with either HBV or HCV. [7],[8] With the advent of highly active antiretroviral therapy (HAART) and the possibility for HIV patients living longer, clinicians are more likely to be confronted with issues relating to co-infection with these viruses and the management challenges they present, especially in resource-limited settings like ours. Several antiretroviral drugs (ARVs) have dual activity against HIV and HBV as such reliable epidemiological data are needed in order to make estimations on the logistical and economical impact of HIV/HBV co-infection.

The objectives of this study were to

  1. Determine the prevalence of HBV and HCV infection among HIV-infected patients in Aminu Kano Teaching Hospital; Kano (AKTH).
  2. Describe the socio-demographic features and correlates of HIV and HVB/HCV co-infected patients at AKTH.



  Materials and Methods Top


This was a cross-sectional study carried out among HIV-positive adult individuals seen at the adult HIV clinic in AKTH Kano, North-western Nigeria. AKTH serves as a referral Centre for Kano and neighboring states of Jigawa, Katsina, Gombe, Bauchi, Kaduna and Yobe. The adult HIV clinic in AKTH is supported by the President Emergency Plan for AIDS Relief (PEPFAR) through the Institute of Human Virology in Nigeria (IHVN).

Four-hundred and forty consecutive HIV-positive individuals who consented were recruited for the study. Ethical clearance was obtained from the Ethical Committee of AKTH, Kano. Information was obtained with the aid of an interviewer-administered questionnaire. Socio-demographic characteristics, weight, height and body mass index (BMI) were obtained. Status of serological markers for HIV, HBV (HBsAg) and HCV (anti-HCV) were determined using Enzyme-linked Immunosorbent Assay (ELISA).

HIV screening was done using the national algorithm; i.e., using DETERMINE TM (manufactured by ABBOTT CO LTD, MINATO-KU, JAPAN) and STAT PAK TM (manufactured by CHEMBIO DIAGNOSTIC SYSTEMS INC, USA) techniques and a third test GENIE II test served as a tie breaker if there were discordant results with the first two tests. HBsAg test was done using First Response HBsAg Card Test, manufactured by PMC Medical (India) Pvt. Ltd. Kachigam Daman (UT) 396215, India. Anti-HCV test was done using Clinotech Diagnostic Kit manufactured by Clinotech Diagnostics Inc. Canada. CD 4 Count Estimations were done using Cyflow SL-Green, manufactured by Patex, Germany.

All investigations were carried out in the Central Laboratory of AKTH with the assistance of a Chemical pathologist and a Microbiologist.

Statistical analysis

Data obtained were entered into and analysed using the Statistical package for Social Sciences (SPSS) programme version 16 (Chicago, IL, USA). Analyses were carried out using descriptive statistics with mean and standard deviations (SD) or proportions, for continuous or categorical variables, respectively. Differences and relationships were determined using Students t-test and Chi-square test where applicable and a P < 0.05 was regarded as significant.


  Results Top


A total of 440 patients comprising 178 (40.5%) males and 262 (59.5%) female with a male to female ratio of 1:1.5 were studied. Majority of the participants were in the 25-30 age group, representing 31.9% and 27.9% of participants with HIV alone and those with co-infection, respectively [Table 1]. The mean age for co-infected participants (34.42 ± 10.12 years) was not significantly different from that of participants with HIV alone (33.4 ± 10.39 years), P = 0.8157.
Table 1: Socio-demographic characteristics of study subjects

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Married men and women constituted the largest proportion of the participants in all categories [Table 1]. Higher proportion of participants who were HIV/HBV co-infected consumed alcohol as compared to participants with HIV alone.

[Table 2] Shows the prevalence of hepatitis B and C virus among the study participants based on age and sex. Of the 440 participants who were studied 54 were seropositive for HBsAg, seven were positive for anti-HCV and none were positive for both viruses. This gives a prevalence of 54/440 (12.3%) for HIV/HBV co-infected participants and 7/440 (1.6%) for HIV/HCV co-infected participants.
Table 2: Prevalence of hepatitis B and C co - infection with HIV

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However, with sex stratification 30/178 (16.9%) of males were HIV/HBV co-infected versus 24/262 (9.2%) of females, P = 0.0154. For HIV/HCV co-infected participants 3/178 (1.7%) of males were anti-HCV positive compared to 4/262 (1.5%) of females, P = 0.8042.

The mean BMI was not significantly different between participants with HIV alone (21.3 kg/m 2 ) versus HIV/HBV co-infected participants (22.2 kg/m 2 ), P = 0.1385.

Mean serum ALT level among participants with HIV alone was 31.6 International Units (IU), and this was significantly higher (45.3 IU) for those with HIV/HBV co-infection, P = 0.048, and not significantly different (31.7 IU) for those with HIV/HCV co-infection, P = 0.7792 [Table 3].
Table 3: Clinical and laboratory characteristics of HIV infection in co - infected patients

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The mean CD 4 count for HIV/HBV co-infected participants (259.7 c/mm 3 ) was significantly higher than that for participants with HIV alone (240.0 c/mm 3 ), P = 0.0170. However, those with HIV/HCV co-infection had a mean CD 4 count of (213.4 c/mm 3 ) which was not significantly different when compared with the corresponding value for participants with HIV alone P = 0.7232 [Table 3].

There was an inverse relationship between the serum level of ALT and CD 4 count among patients with HIV alone (P = 0.029); however, no statistically significant correlation between the serum level of ALT and CD 4 count among HIV/HBV co-infected patients (P = 0.119) or HIV/HCV co-infected patients (0.2532).

[Table 4] compares the findings in this study with those from similar studies in sub-Saharan Africa [9],[10],[11],[12],[13],[14],[15],[16] .
Table 4: Comparison of results from this study with those from similar studies in sub - Saharan Africa

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  Discussion Top


We studied 440 HIV-positive patients receiving care in a tertiary centre in North-western Nigeria. The mean age of the participants with HIV alone versus those with co-infection was not significantly different and the age distribution of participants in this study is consistent with what obtains in HIV epidemics where the sero-prevalence of HIV infection peaks at 25-30 years for females and 30-40 years for males. Moreover the sex distribution of participants, 59.5% for females and 40.5% males, is similar to the findings in Jos where 40% were male [17] but contrast sharply with studies in Italy [18] and Spain [19] where 72% and 84%, respectively, were males. The patients in Italy and Spain had their predominant modes of transmission (over 70%) of HIV as intravenous drug use and homosexual contacts as distinct from the predominant heterosexual mode in the environment of this study.

The prevalence HIV/HBV co-infection in this study was 12.5% and 1.6% for HIV/HCV co-infection. Individuals aged 40 years and younger and males were most affected. The prevalence of HIV/HBV co-infection in this study is similar to the findings of 11.9% in Ibadan [9] and 11.5% in Abuja [10] , both in Nigeria. However, our finding is lower than the prevalence of 25.9% for HIV/HBV co-infection reported from Jos [2] , Nigeria. Reason(s) for this disparity is not very clear.

The prevalence of HIV was highest in participants aged 40 years and younger, 79.4%. Similarly among those co-infected the age group 40 years and younger accounted for the highest prevalence of HIV/HBV (74.1%) and HIV/HCV (85.7%). Gender stratification showed that males had a higher prevalence of HIV/HBV co-infection (16.9% versus 9.2%). This finding could be linked with the earlier observation that a high proportion of HBV infection in sub-Saharan Africa is acquired vertically or horizontally from family members or other children before the age of 5 years. [20] Since boys tend to participate more in aggressive sports which may result in injury and bleeding when compared to girls. Societal acceptance of multiple sexual partners for men may contribute to higher HBV prevalence among HIV-infected men. Male preponderance in HBV sero-positivity has also been reported in HIV sero-negative individuals. [21]

HIV/HCV co-infection was detected in 1.6% of participants in our study this is lower than the prevalence of 4.8% and 3% reported from Ibadan [9] and Abuja [10] both in Nigeria, respectively. Reason for this regional disparity is not very clear. A study from Lagos which compares prevalence of Anti-HCV between HIV/AIDS patients and HIV-negative controls found prevalence of HIV/HCV co-infection to be 5.8%, and the HIV-positive participants were 7 times more likely to have HCV infection than the HIV-negative controls. [22]

Baseline ALT was significantly higher among HIV/HBV co-infected participants compared to those with HIV alone and this is in agreement with the findings of other investigators. [23] There was an elevation of liver enzymes among all the patient groups. The mean level was highest for those co-infected with hepatitis B. This finding is corroborated by a study in Lagos. [24] In that study, liver enzymes were significantly higher in HIV patients than in controls, as well as higher in HIV patients who were also positive for hepatitis B surface antigen compared to those not co-infected. This finding highlighted some challenges being encountered in treating patients who were co-infected, especially regarding the choice of HAART regimen, how to prevent further hepatic damage, and when to initiate HAART, especially in resource-limited settings with limited ARV options. [8],[24],[25] Additionally, HIV worsens HCV infection, leading to severe fibrosis, cirrhosis and, ultimately, death from liver disease. [25],[26]

A statistically significant relationship was found between the mean CD 4 count and HBsAg serological status of the participants. Individuals with HIV/HBV co-infection had the highest mean value of CD 4 count (P = 0.0170) when compared with participants with HIV alone. Previous investigators reported variable findings, with some corroborating findings similar to this study. However, the implication of this finding may relate to HAART-associated hepatotoxicity which is commonly seen in patients with relatively higher baseline CD 4 count, for instance HAART-naïve women with baseline CD 4 count > 250/mm 3 and HAART-naïve men with CD 4 count > 400/mm 3 are at increased risk of hepatotoxicity when started on Nevirapine-based HAART. The mechanism of HAART-related hepatotoxicity in patients with HIV/HBV co-infection is mainly by immune reconstitution and some authors have identified an increase in CD 4 count of >50/mm 3 after initiating HAART as an independent risk factor for hepatotoxicity. [19],[27]

Mean BMI was not significantly different between different study groups.

Anti-HCV was detected in patients with lower CD 4 ; however, HCV has not been shown to be an independent risk factor for rapid CD 4 decline.

Knowledge of a patient's HBV or HCV status can help clinicians interpret clinical problems and laboratory results. More importantly, such information can guide decisions on which ARVs can best be prescribed in co-infected patients.

Patients who are HIV/HBV or HCV co-infected should be informed about routes of transmission and methods to prevent further spread of the viruses. Furthermore, HIV patients who test HBV-negative and have not yet been vaccinated should receive HBV vaccine in order to prevent future infection, thereby, improving the prognosis of their HIV status.

Limitations

Being a cross-sectional study we cannot establish cause and effect relationship on the viral markers detected in the HIV patients. Risk factors for viral hepatitis acquisition were not explored as such we cannot comment on this important aspect of the epidemiology. Since plasma HIV, HBV and HCV viral load were not quantified we could not make a distinction of active HBV and HCV infections.


  Conclusion and Recommendations Top


Our findings confirm that HBV is a major co-morbid infection and a threat to HIV/AIDS patients in Nigeria. The high frequency of HBsAg and modest frequency of anti-HCV in HIV patients confirms the need for routine baseline screening for these markers in HIV-infected patients, as this could affect the choice of HAART regimen for the patients. ALT level and CD 4 count were significantly higher among participants with HIV/HBV co-infection while BMI appears to be similar in all categories of patients. Therefore, serum ALT should be monitored more closely in HBV and/or HCV co-infected HIV patients in our setting.


  Acknowledgment Top


We would like to acknowledge the effort of the staff in Chemical Pathology and Microbiology departments, AKTH, who helped in analysing the samples. We also acknowledge the support of the Institute of Human Virology-Nigeria (IHVN), who facilitated our work and equipped our Laboratory with flow cytometry. We are greatly indebted to the participants in the study.

 
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    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]


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