Introduction
The common transmission route for HBV and HIV underscores the prevalence of co-infection. Viral hepatitis, with its tendency to induce inflammation and damage to liver tissue, further emphasizes the interconnected challenges posed by these concurrent infections [1]. Among the various types of hepatitis viruses (A, B, C, D, E, and G), Hepatitis B stands out as the most severe form, capable of progressing to chronic liver disease and, in severe cases, resulting in mortality [2].
Worldwide, approximately 240 million people are affected by HBV, with the highest prevalence observed in East Asia and sub-Saharan Africa (SSA) [3]. Sub-Saharan Africa (SSA) is also recognized for having the largest population of people living with HIV (PLWHIV) [4]. Additionally, it accounts for 12% of hospital admissions and 31% of mortality in medical wards, attributed to conditions such as viral hepatitis, chronic viral hepatitis, cirrhosis of the liver, and hepatocellular carcinoma [5].
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Several factors have been identified as potential risk factors for HBV and HIV co-infection, including socio-demographic factors such as age, sex, monthly income, educational level, marital status, place of residence, current occupational status, health-related factors such as history of blood transfusion, multiple sexual partner, CD4 count, surgical history, OIs, history of hospital admission, history of STDs/STIs, viral load status, cultural factors such as tattoo on the body, ear piercing, and tooth extraction, and behavioral factors such as smoking and alcohol drinking [6‐8].
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 and materials
Study area, period, and study design
A cross-sectional study was undertaken from April to May 2022in the South Wollo zone of northeast Ethiopia health centuries. South Wollo zone is situated 401 km from Addis Ababa, Ethiopia’s capital [9].
Population
The source population consisted of all HIV-positive patients attending ART clinics at the Health Center in the South Wollo zone, northeast Ethiopia. The study population comprised randomly selected HIV-positive patients attending ART clinics at the same health center during the study period. Specifically, the study included HIV-positive patients with follow-ups at the ART clinic in the South Wollo zone, northeast Ethiopia. Critically ill individuals who were unable to communicate during data collection were excluded from the study.
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Sample size, sampling procedures, and techniques
The Sample size based on the first specific objective was determined by using a formula for estimating a single population proportion and assuming a confidence interval of 95%, marginal error of 3%, and considering 8.4% proportion of HBV infection among HIV patients [10]. By adding a 10% non-response rate, the final sample size became 361. So, the final sample size was taken at 361 which is calculated for the prevalence.
The sample size was determined using Epi info version 7 by taking the assumptions of 95% confidence level, 3% margin of error, 80% power, taking the percent of outcome exposed from previous studies, and 10% non-response reveals result as presented below (Table 1).
Table 1
Sample size for factors HBsAg status of HIV-positive adults who are attending ART Clinic Northeast Ethiopia, 2022
Variables | Proportion of outcome among | OR | Sample size | Final sample size (10% for non-response) | Citation | |
|---|---|---|---|---|---|---|
Exposed | Unexposed | |||||
Multiple sexual partner | 19.2 | 5.2 | 4.3 | 198 | 218 | (39) |
Marital status (Single ) | 12.3 | 1.2 | 14.75 | 146 | 161 | (23) |
CD4 count ≤ 200/cells/ml | 18.1 | 3.2 | 6.7 | 158 | 174 | (30) |
Participants were chosen through a systematic sampling technique, with the initial respondents identified using a random method. The allocation of sample sizes to health facilities was proportional to the average number of patients per month at each respective health facility.
Data collection tools, procedure, and Data quality assurance
Structured questionnaires, developed through a review of previous literature, were employed for data collection. The questionnaire, translated into the local language, predominantly featured closed-ended questions. A team of 3 BSc nurses and 2 laboratory technicians conducted data collection. Both data collectors and supervisors underwent a one-day training session covering the study’s objectives, questionnaire content, data collection procedures, participant assistance, and ethical considerations. A pre-test was conducted with 5% of participants at Borumeda Hospital’s ART clinic, leading to necessary questionnaire modifications. Continuous close supervision was maintained by both supervisors and the principal investigator throughout the study.
Standardized procedures were rigorously adhered to during blood sample collection, storage, and the analytical process. Test results were interpreted and reported as positive or negative according to the manufacturer’s instructions. Confirmation of HBsAg positive serum samples was carried out using a 3rd generation ELISA assay at Amhara Regional Red Cross Laboratory, Dessie branch. Throughout the data collection period, the principal investigator and supervisors diligently checked the collected data daily to ensure completeness.
Data processing and analysis
The data were inputted into Epi Data version 4.4.2.1 Software and subsequently exported to SPSS version 25 for further analysis. Descriptive statistics, including frequency, proportion, and summary measures, were computed. For identifying statistically significant factors associated with HBV/HIV co-infection, a binary logistic regression model was employed.
Initially, a bi-variable binary logistic regression analysis was conducted for each independent variable against the outcome variable. Variables with a P-value less than 0.2 in this analysis were then included in the final model for multivariable binary logistic analysis regression. In the multivariable binary logistic regression analysis, variables with a P-value less than 0.05 and a 95% confidence interval that did not cross one were deemed statistically significant. To assess the model’s fitness, the Hosmer and Lemeshow goodness-of-fit test was employed.
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Results
Socio-demographic characteristics of the respondents
A total of 350 participants took part in the study, yielding a robust response rate of 97%. The demographic profile revealed that a majority of the study participants were male, accounting for 56.3%, and the majority 45.4% of the participants were felled in the ages of 28–37. In terms of marital status, over two-thirds of the participants, comprising 68% were married, while 66 individuals (18.9%) reported being divorced.
Educational backgrounds varied, with 31.7% of participants unable to read and write, 21.1% completing primary education, and 8% having a secondary school education. (Table 2).
Table 2
Socio-demographic characteristics of HIV-positive adults who are attending ART Clinic Northeast Ethiopia, 2022
Variables | Frequency | Percentage (%) |
|---|---|---|
Sex | ||
Male | 197 | 56.3 |
Female | 153 | 43.7 |
Age | ||
18–27 | 27 | 7.7 |
28–37 | 159 | 45.4 |
38–47 | 128 | 36.6 |
≥ 48 | 36 | 10.3 |
Marital status | ||
Married | 238 | 68 |
Single | 46 | 13.1 |
Divorced | 66 | 18.8 |
Widowed | 0 | 0% |
Education Status | ||
Unable to read and write | 116 | 33.1 |
Read and write | 111 | 31.7 |
Primary | 77 | 22 |
Secondary | 28 | 8 |
College and above | 18 | 5.1 |
Monthly income | ||
< 500 | 19 | 3.8 |
500–1000 | 33 | 9.4 |
1000–1500 | 162 | 46.2 |
1500–2000 | 84 | 24 |
2000–2500 | 19 | 5.4 |
> 2500 | 33 | 9.4 |
Place of residence | ||
Urban | 151 | 43.1 |
Rural | 199 | 46.9 |
Health-related, cultural characteristics of the study participants
The majority of participants in the study exhibited encouraging outcomes regarding viral load, with 42.6% with viral loads below 1000 copies/ml. However, 16.3% of participants had viral loads equal to or exceeding 1000 copies/ml, suggesting a significant portion of the cohort may require closer monitoring or intervention. Regarding risky behaviors, a notable 69.8% reported engaging in multiple sexual partners. Additionally, while the majority (77.4%) reported no history of blood transfusion.
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The majority of participants in the study reported a positive history of sharing sharp instruments, with 13.5% acknowledging this behavior. Furthermore, 27.3% of participants had a family history of HBV. Additionally, a substantial proportion (32.7%) reported undergoing dental extraction. Notably, a majority of participants (69.3%) had a history of opportunistic infections (OIs. Moreover, 41.7% reported a history of sexually transmitted infections (STIs)(Table 3).
Table 3
Health-related, cultural characteristics and their HBsAg status of HIV-positive adults who are attending ART Clinic Northeast Ethiopia, 2022
Variables | Frequency | Percentage |
|---|---|---|
Viral load | ||
No detectable | 144 | 41.1 |
< 1000 copies/ml | 149 | 42.6 |
≥ 1000 copies/ml | 57 | 16.3 |
Multiple sexual | ||
No | 106 | 30.2 |
Yes | 244 | 69.8 |
Blood transfusion | ||
NO | 271 | 77.4 |
YES | 79 | 22.6 |
Regular sexual partner | ||
NO | 141 | 40.3 |
YES | 209 | 59.7 |
Hospital admission | ||
NO | 289 | 82.6 |
YES | 61 | 17.4 |
Surgical history | ||
NO | 272 | 77.7 |
YES | 78 | 22.3 |
Awareness about HBV prevention | ||
NO | 289 | 82.6 |
YES | 61 | 17.4 |
Family history of HBV | ||
NO | 279 | 72.7 |
YES | 71 | 27.3 |
Sharing sharp Instrument | ||
NO | 303 | 86.5 |
YES | 47 | 13.5 |
Dental extraction | ||
NO | 237 | 67.7 |
YES | 113 | 32.3 |
Ear piercing | ||
NO | 212 | 60.6 |
YES | 138 | 39.4 |
History of OIs | ||
NO | 111 | 31.7 |
YES | 239 | 69.3 |
History of STI | ||
NO | 169 | 48.3 |
YES | 181 | 41.7 |
CD4 count | ||
< 200 | 125 | 35.7 |
200–350 | 94 | 26.8 |
351–500 | 94 | 26.8 |
> 500 | 37 | 10.7 |
Factor associated with HBV/HIV co-infection
In bivariate analysis namely sex, viral load, history of blood transfusion, educational level, regular sexual partner, multiple sexual practices, hospital admission, surgical history, Awareness about HBV prevention, family history of HBV, sharing of sharp instrument, place of residence, marital status and CD4 count were selected for the multiple logistic regression analysis based on a p-value of < 0.2. The fitness of the model was checked by the Hosmer and Lemeshow goodness of fit test. Accordingly, the model was considered fit if it was found to be insignificant (p > 0.05) based on the fit test. The Hosmer and Lemeshow goodness-of-fit test yielded a p-value of 0.08, indicating a good fit of the model to the observed data.
Start within the multiple logistic regressions namely sex, educational status, viral load, marital status surgical history, and CD4 count) were significantly associated with HIV-HBV co-infection, then The analysis revealed that females were 0.14 times less likely to be infected with HBV co-infection compared to males, with an 86% reduction in the odds of HBV infection [AOR = 0.14; 95% CI: 0.041, 0.478]. Participants with the educational status of only reading and writing were 8.7 times more likely to be infected with HBV than college and above [AOR = 8.7; 95% CI: 1.143, 66.5]. Participants having marital status of single were 2 times more likely to be infected with HBV than married [AOR = 2.04; 95% CI: 1.346, 28.6].
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Participants having a surgical history of 0.206 were less likely to have HBV/HIV Co-infection as compared to those who did not [AOR = 0.206; 95% CI: 0.057,0.746]. Participants with educational status categorized as unable to read and write or only able to read and write were respectively 7.8 and 8.7 times more likely to be infected with HBV compared to those with a college education or higher [AOR = 7.8; 95% CI: 1.3, 62.3] and [AOR = 8.7; 95% CI: 1.14, 66.4] respectively. Participants having CD4 count 351–500 cells/ ml were 10.4 times more likely to be infected with HBV than CD4 count > = 500 cells/ [AOR = 10.4; 95% CI: 1.28,85]. Participants having viral load < = 1000 copies/ml were 16.2 times more likely to be infected with HBV than viral load not detectable [AOR = 16.53; 95% CI: 3.6, 72.59]. Participants who had viral load > 1000 copies/ml were 6.53 times more likely to be infected with HBV than viral load not detectable [AOR = 6.53; 95% CI: 1.87, 22.72]. Moreover, participants with a history of surgical procedures exhibited significantly lower odds of HBV infection [AOR = 0.15; 95% CI: 0.43–0.49] (Table 4).
Table 4
Risk factors associated with Hepatitis B surface antigen from bivariable and multivariable logistic regression analysis, among HIV Positive adults attending ART clinic Northeast Ethiopia, 2022
Variables | HBV | COR(95% CI) | AOR(95%CI) | |
|---|---|---|---|---|
Yes | No | |||
Sex | ||||
Female | 5 | 148 | 0.29(0.11–0.82) | 0.14 (0.41–0.48) * |
Male | 20 | 177 | 1 | 1 |
Educational status | ||||
Unable to read and write | 3 | 113 | 6.28(1.175–33.54) | 7.8(1.1–62.3)* |
Only read and write | 6 | 105 | 2.92(0.66,-12.7) | 8.7(1.14–66.4)* |
Primary school | 10 | 64 | 1.07(0.26–4.29) | 1.14(0.199–6.23) |
Secondary school | 3 | 25 | 1.38(0.251–7.68) | 1.08(0.13–8.5) |
College and above | 3 | 18 | 1 | 1 |
Viral load | ||||
No detectable | 5 | 139 | 1 | 1 |
≤ 1000 copies/ml | 9 | 140 | 6.65(2.19–20.1) | 16.12(3.6–72.5)* |
> 1000 copies/ml | 11 | 46 | 3.75(1.45–9.54) | 6.53(1.87–22.72)* |
Marital status | ||||
Married | 9 | 229 | 1 | 1 |
Single | 7 | 39 | 4.02(1.53–10.58) | 2.04(1.346–28.6)* |
Divorced | 9 | 57 | 0.88(0.32–2.56) | 2.59(0.56–11.95) |
Surgical history | ||||
NO | 11 | 261 | 1 | 1 |
YES | 14 | 64 | 0.19(0.08–0.44 | 0.15(0.43–0.49)* |
CD4 count | ||||
< 200 | 12 | 113 | 1.823(0.633–5.247) | 0.942(0.176-5.1) |
200–350 | 5 | 89 | 1.02(0.363–2.86) | 1.58(0.28–8.89) |
351–500 | 2 | 92 | 1.21(0.421–3.45) | 10.4(1.28-85)* |
> 500 | 6 | 31 | 1 | 1 |
Discussion
The study revealed an overall HBV/HIV co-infection rate of 7.14%, indicating a moderate public health concern among adults living with HIV on antiretroviral therapy in the study area. Significant associations with co-infection were found for females, viral load exceeding 1000 copies/ml, single marital status, educational level unable to read and write or read and write, CD4 count between 351 and 500 cells/ml and surgical history. This prevalence closely aligns with other studies, such as the one conducted in Addis Ababa Public Hospital, which reported a comparable 7.3% co-infection rate [10]. Goba general hospital 7.4% [11]and Gondar 7.3% [12]. On the other hand, this study’s finding is higher than the study conducted in Hawassa referral hospital 6.9% [13].HBsAg prevalence from this study is also in agreement with previous studies conducted among HIV-positive adults in India 8.35 [14] and Ghana 8.8 [15]. This difference might be due to the accessibility of information about the mode of transmission and prevention as can be seen from the proportion of participants with poor knowledge scores in this study.
In the present study significant association has been found between HBsAg positivity and gender other studies done in the country from ART centers [16], females were found to have less HBsAg positivity and the study revealed that females were 0.14 times Less likely to have HBV/HIV co-infection than male. The possible explanation could be, that in developing countries, like Ethiopia because of their job nature, males travel more frequently than females. Those who have viral load < 1000 copies/ml were about more likely to have HBV/HIV Co-infection as compared to viral load not detectable, followed by Those who have viral load > 1000 copies/ml were about more likely to have HBV/HIV Co-infection. The association might be because HIV patients who have HBV/HIV co-infection have weaker immunity than those who have not HBV/HIV co-infected HIV patients which will make them more prone to increased viral load [17]. This study revealed that a significantly high prevalence of HBV/HIV co-infection was observed among individuals with a marital status of single who are more likely to have HBV/HIV co-infection than those married. This is because patients having marital status, and single most of the time have a history of multiple sexual practices which can lead to increased HBV/HIV co-infection [13]. Regarding HBV infection, even though, studies from Debretabor Hospital [18] and Mekelle Hospital [16], showed no significant association between marital status and history of surgery with HBV infection.
Conclusion
In this study area, the prevalence of HBV infection was found to be moderate in HIV-infected patients. Furthermore, this study it was also observed a greater HBV Prevalence among males, individuals having viral load > 1000 copies/ml, individuals who were single and divorced, a history of surgery, and educational status who were only read and written were found statistically associated factors for HBV infection.
Acknowledgements
We are grateful to thank the Institutional Review Board of the college of Zemen Postgraduate, Dessie, Ethiopia. Also, we want to gratify study participants and data collectors.
Declarations
Competing interests
The authors declare no competing interests.
Ethical approval and consent to Participate
Ethical approval was obtained from the Institutional Review Board of the college of Zemen Postgraduate, Dessie, Ethiopia. After explaining the purpose of the study, written informed consent was obtained from participants before data collection. They were informed that participating in the study was voluntary and their right to withdraw from the study at any time during the interview was assured. For this purpose, a one-page consent letter was attached as a cover page of each questionnaire stating the general objective of the study and issues of confidentiality. All methods and materials were performed according to the guidelines.
Consent to Publish
Not applicable.
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