Abstract
Globally, in 2017 35 million people were living with HIV (PLHIV) and 257 million had chronic HBV infection (HBsAg positive). The extent of HIV‐HBsAg co‐infection is unknown. We undertook a systematic review to estimate the global burden of HBsAg co‐infection in PLHIV. We searched MEDLINE, Embase and other databases for published studies (2002‐2018) measuring prevalence of HBsAg among PLHIV. The review was registered with PROSPERO (#CRD42019123388). Populations were categorized by HIV‐exposure category. The global burden of co‐infection was estimated by applying regional co‐infection prevalence estimates to UNAIDS estimates of PLHIV. We conducted a meta‐analysis to estimate the odds of HBsAg among PLHIV compared to HIV‐negative individuals. We identified 506 estimates (475 studies) of HIV‐HBsAg co‐infection prevalence from 80/195 (41.0%) countries. Globally, the prevalence of HIV‐HBsAg co‐infection is 7.6% (IQR 5.6%‐12.1%) in PLHIV, or 2.7 million HIV‐HBsAg co‐infections (IQR 2.0‐4.2). The greatest burden (69% of cases; 1.9 million) is in sub‐Saharan Africa. Globally, there was little difference in prevalence of HIV‐HBsAg co‐infection by population group (approximately 6%‐7%), but it was slightly higher among people who inject drugs (11.8% IQR 6.0%‐16.9%). Odds of HBsAg infection were 1.4 times higher among PLHIV compared to HIV‐negative individuals. There is therefore, a high global burden of HIV‐HBsAg co‐infection, especially in sub‐Saharan Africa. Key prevention strategies include infant HBV vaccination, including a timely birth‐dose. Findings also highlight the importance of targeting PLHIV, especially high‐risk groups for testing, catch‐up HBV vaccination and other preventative interventions. The global scale‐up of antiretroviral therapy (ART) for PLHIV using a tenofovir‐based ART regimen provides an opportunity to simultaneously treat those with HBV co‐infection, and in pregnant women to also reduce mother‐to‐child transmission of HBV alongside HIV.
Highlights
Chronic hepatitis B (CHB) infection, defined as persistence of hepatitis B surface antigen (HBsAg), is a major public health problem resulting in an estimated 900 000 deaths in 2015.1-4 HBV can be prevented with vaccination, in 2015, there were an estimated 257 million persons chronically infected
Overall, when we compared HBsAg estimates from 25 598 HIVpositive with 286 121 HIV-negative individuals, we found increased odds for HBsAg positivity among all HIV-positive population groups compared to HIV-negative populations (OR = 1.42; 95% confidence interval (CI) = 1.10-1.83) there was a high degree of heterogeneity (I squared = 95.3%, P < .001)
We estimate a global prevalence of 7.6% (IQR 5.6%-12.1%) or 2.7 million (IQR 2.0-4.2 million) cases of HIV-HBsAg co-infection
Summary
Chronic hepatitis B (CHB) infection, defined as persistence of hepatitis B surface antigen (HBsAg), is a major public health problem resulting in an estimated 900 000 deaths in 2015.1-4 HBV can be prevented with vaccination, in 2015, there were an estimated 257 million persons chronically infected. Between 20 and 30% of those with chronic infection develop complications, mainly cirrhosis and hepatocellular carcinoma (HCC). CHB accounts for 43% of cases of HCC and 40% of cirrhosis, with much higher proportions in lower middle-income countries, and 5%-10% of liver transplants in high-income countries. Age is a key determinant of the risk of chronic infection: chronicity is common following acute infection in neonates (around 90%) and young children under the age of 5 years (20–60%), but occurs rarely (5%) is in sub-Saharan Africa, East Asia, parts of Balkans, the Pacific Islands and the Amazon Basin. Regional variation exists in the epidemiology of HBV: perinatal or horizontal transmission predominates in sub-Saharan Africa and Asia, whereas in high-income countries transmission is predominantly via injection drug use and high-risk sexual behaviours.. We included papers with country-level estimates of HBsAg co-infection among an HIV population sample greater than 50, recruited based on their HIV-positive status or other behavioural characteristics, such as injecting drug use. We report HIV-HBsAg co-infection prevalence among six population groups (general population, heterosexual and pregnant women, PWID, MSM, children and young people, and other high-risk populations) by country and region, reporting the best estimate and range for each country from all studies. Data were entered into R (R Foundation for Statistical Computing, Vienna, Austria) to generate maps presenting country-level HIV-HBV co-infection prevalence estimates Across these six populations, we synthesized estimates of HBsAg prevalence in PLHIV and HIV-negative populations where samples were recruited based on population characteristic rather than known HIV status and undertook a meta-analysis of the odds of being HBsAg positive among HIV-positive populations compared to HIV-negative populations stratified by population group. TA B L E 1 Summary of global HIV-HBsAg co-infection prevalence estimate in general population sample, heterosexual and pregnant PLHIV, PWID and MSM
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