Research Article: Low sero-prevalence of hepatitis delta antibodies in HIV/ hepatitis B co-infected patients attending an urban HIV clinic in Uganda

Date Published: December , 2017

Publisher: Makerere Medical School

Author(s): Elizabeth Katwesigye, Emmanuel Seremba, Fred Semitala, Ponsiano Ocama.


Co-infection with hepatitis B (HBV) and hepatitis D (HDV) is common among human immunodeficiency virus (HIV) infected individuals in developing countries and it aggressively accelerates progression of liver disease to cirrhosis and other complications. There is scarcity of data on HDV in sub-Saharan Africa .We investigated the sero-prevalence and factors associated with HDV antibody among HIV/HBV co-infected patients attending a large urban HIV clinic in Uganda.

We screened 189 HIV/HBV co-infected individuals for anti-HDV immunoglobulin G (IgG) and performed logistic regression to determine the associated factors. Socio-demographic, clinical data, immunological status, and liver fibrosis (as determined by the Aspartate transaminase to platelet ratio index and transient elastography) were included.

Participants were predominately young and of sound immunologic status (median age 40 years, median CD4 440 cells/µl). 98% were on ART regimens containing anti-HBV active medications (95.2% were on TDF/3TC while 4.8% on 3TC containing regimen). Median duration on ART was 36 months (IQR 22–72). Anti-HDV was detected in 6/198, 3.2% (95% CI 1.14–6.92%), associated with male gender and a duration of more than 5 years since HIV diagnosis.

The sero-prevalence of HDV antibodies among the HIV/HBV co-infected patients is low in a Ugandan urban cohort.

Partial Text

Hepatitis delta virus (HDV) is a defective virus and depends on the hepatitis B surface antigen (HBsAg) for its existence1–3. Worldwide approximately 15–20 million people have been exposed to HDV infection, which approximately represents 5% of the population of chronic hepatitis B.. Hepatitis D virus infection results in the most aggressive form of chronic viral hepatitis especially in HIV infected persons4,5. Triple infection with HDV/HBV and human immune deficiency virus (HIV) is common due to shared modes of transmission; mainly through unprotected sexual intercourse and exposure to contaminated blood products6,7. Current treatment options for HIV/HBV have a limited effect on HDV infection therefore not be adequate if there is HDV coinfection as response to HDV will not be achieved and liver disease progression continues to occur8–12. There is scarcity of data on HDV in Uganda. To the best of our knowledge there has only been one study which reported HDV antibody prevalence of 30.6 % in the HBsAg positive population and 3.1 % in the general population in the Northern part of Uganda13. The aim of this study was to measure the prevalence and to ascertain the factors associated with hepatitis D antibodies among HIV/HBV co-infected adults individuals in Uganda.

This cross sectional study was performed at the Infectious Diseases Institute clinic (IDI), Makerere University, Uganda located within Mulago Hospital complex. Ever since it was opened in 2002, this clinic has registered over 10,000 individuals of whom 8,300 are active and are receiving ART. Over the last two years, routine screening of HIV-infected clients for hepatitis B virus has been ongoing and there 250 HIV/HBV co-infected patients attending the IDI clinic.

Data collected was analyzed using STATA software package version 11. Logistic regression was performed to determine the factors associated with anti-HDV. A P-value of < 0.05 was considered to be significant. A convenient sample of 189 HIV/HBV co-infected patients was recruited. The study population was composed mainly of young individuals; median age of 40 (IQR 33–46) years and of sound immunological status (median CD4 440 (IQR 155–590 cells/yl). Ninety-eight percent were on ART regimens that contained anti-HBV active medication (95.2% were on TDF/3TC while 4.8% on 3TC containing regimen, 2% were not on ART). Median duration on ART was 36 months (IQR 22–72). The majority (56%) had documented HIV infection for more than 5 years and over two-thirds had been diagnosed with HBV co-infection at least two years prior to this study (table 1). Our study demonstrated a prevalence of hepatitis delta antibodies in HIV/HBV co infected patients in an urban HIV clinic in Uganda of 3.2%. These results are comparable to some other studies in sub-Saharan Africa (SSA) done in similar settings14–16 but quite different in other selected sub-populations including those with chronic liver disease in West Africa where a high anti-HDV prevalence ranging from 12.2 to 81.7% was documented17. Also other studies in Africa have showed varying prevalence rates of HDV ranging from 0–50% in different countries18–20. Similarly in the developed countries, high anti-HDV prevalence's of 10–15% have been documented in recent studies1,21,22. Reasons for the variations in the prevalence of HDV exposure or infection are not clear. This could be a result of modes of transmission whereby in some of these countries there could be higher rates of IVD use21,22. Our study has some limitations. We used a convenient sample of HIV/HBV co-infected individuals that we could access. The few numbers of anti HDV antibody positive individuals identified in this study limited our ability to ascertain the factors associated with triple infection. However, given that similar findings had been recorded elsewhere in East Africa, our findings are likely to be valid. Furthermore, we were unable to perform HDV RNA to confirm current hepatitis delta infection and hence this study was based on HDV exposure and not necessarily current infection. The sero prevalence of HDV antibodies among the HIV/HBV co-infected patients is very low in a Ugandan urban cohort as compared with developed countries where intravenous drug use is common. Routine screening for anti-HDV among individuals with HIV/HBV co-infection in this setting may not be cost effective, however in absence of a known etiology, targeted testing can be done for patients with liver disease if not improving or developing liver disease while on a tenofovir based-ART regimen.   Source:


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