Hepatitis B testing, treatment, and virologic suppression in HIV-infected patients in Cameroon (ANRS 12288 EVOLCAM)

Abstract

Background: Hepatitis B is a major concern in Africa, especially in HIV-infected patients. Unfortunately, access to hepatitis B virus (HBV) testing and adequate treatment remains a challenge in the continent. We investigated HBV testing, treatment, and virologic suppression in HIV-infected patients followed up as part of Cameroon's national antiretroviral programme. Methods: A cross-sectional survey was performed in adult patients receiving antiretroviral therapy (ART) in 19 hospitals in the Centre and Littoral regions in Cameroon. The proportions of patients tested for hepatitis B surface antigen (HBsAg) prior to the study were compared among all study hospitals using the Chi-square test. The association of individual and hospital-related characteristics with HBV testing and virologic suppression was assessed using multilevel logistic regression models. Results: Of 1706 patients (women 74%, median age 42 years, median time on ART 3.9 years), 302 (17.7%) had been tested for HBsAg prior to the study. The proportion of HBV-tested patients ranged from 0.8 to 72.5% according to the individual hospital (p < 0.001). HBV testing was lower in women (adjusted odds ratio [aOR] 0.64, 95% confidence interval [CI] 0.46-0.89, p = 0.010) and higher in patients who initiated ART in 2010 or later (aOR 1.66, 95% CI 1.23-2.27, p < 0.001). Of 159 HBsAg-positive patients at the time of the study (9.3%), only 97 (61.0%) received Tenofovir + Lamivudine (or Emtricitabine). Of 157 coinfected patients, 114 (72.6%) had a HBV viral load < 10 IU/mL. HBV suppression was higher in patients with a HIV viral load < 300 copies/mL (aOR 3.46, 95% CI 1.48-8.09, p = 0.004) and lower in patients with increased ALT level (aOR 0.86 per 10 IU/mL increase, 95% CI 0.75-0.97, p = 0.019). Conclusions: A substantial proportion of HIV/HBV coinfected patients were at higher risk of liver disease progression. Improving the management of HBV infection in the routine healthcare setting in Africa is urgently required in order to achieve the 2030 elimination targets. Micro-elimination of HBV infection in people living with HIV could be an easier and cost-effective component than more widely scaling up HBV policies.

Hepatitis B screening practices and viral control among persons living with HIV in urban Senegal

“…Despite the importance of HBV testing for the clinical management of individuals on ART, our study shows that even in tertiary care settings, HBV testing is not a priority in routine clinical care: only one third of PLWH on ART had been tested prior to our intervention and that proportion was lower in women and patients aged 40 and above. The observed gender disparity in access to HBV testing was consistent with previous findings from Zambia and Cameroun, where men were more likely to be HBsAg screened than women in primary and secondary care HIV clinics 16,17 . Given the risk of vertical transmission in women with poorly controlled HBV infection, HBV testing should especially be reinforced in women of childbearing age 18 .…”

“…Over 90% of newly diagnosed co‐infected individuals in our study were on a TDF‐based regimen for at least 3 years. These estimates are higher than those from similar studies in Cameroon and the Gambia, where only 60.5% and 11.5% of co‐infected individuals were on TDF, most likely due to differences in the timing of roll‐out of TDF in first‐line ART across the region 16,21 . Despite the use of ART including TDF, 9% of co‐infected individuals had an HBV VL >20 IU/ml at the time of assessment, the majority being HIV‐suppressed.…”

“…The observed gender disparity in access to HBV testing was consistent with previous findings from Zambia and Cameroun, where men were more likely to be HBsAg screened than women in primary and secondary care HIV clinics. 16 , 17 Given the risk of vertical transmission in women with poorly controlled HBV infection, HBV testing should especially be reinforced in women of childbearing age. 18 PLWH were more likely to be tested for HBV infection if enrolled into care after 2014, when Senegalese national guidelines adopted the WHO recommendations on HBV screening before ART initiation and the use of TDF as one of the recommended first‐line regimens.…”

“…These estimates are higher than those from similar studies in Cameroon and the Gambia, where only 60.5% and 11.5% of co‐infected individuals were on TDF, most likely due to differences in the timing of roll‐out of TDF in first‐line ART across the region. 16 , 21 Despite the use of ART including TDF, 9% of co‐infected individuals had an HBV VL >20 IU/ml at the time of assessment, the majority being HIV‐suppressed. Our results are in line with those from a small prospective study in Ivory Coast: among 86 HIV/HBV‐co‐infected patients on TDF‐containing ART, 94.2% had a suppressed HBV VL after a median of 35 months.…”

British HIV Association guidelines for the management of HIV‐2 2021

“…Observational evidence from populations with HIV‐1 and HBV indicates that co‐infection is associated with higher levels of HBV replication and an increased risk of cirrhosis, end‐stage liver disease and liver‐related mortality [86‐90]. Higher HBV DNA levels at baseline appear to be associated with increased mortality [91].…”