Worldwide, human immunudeficiency virus (HIV), hepatitis B virus (HBV), and hepatitis C virus (HCV) are major public health problems. Liver disease is currently the major concern in HIV-infected patients coinfected with hepatitis B virus (HBV) or hepatitis C virus (HCV)[1,2]. HBV-HIV or HCV-HIV patients have more rapid progression of liver disease than those with HBV or HCV mono-infection. End-stage liver disease, such as liver cirrhosis or hepatocellular carcinoma, is commonly observed in patients with HBV-HIV or HCV-HIV coinfection[3-6]. Thus, national guidelines recommend that all HIV-infected patients should be tested for hepatitis viruses.
Due to common transmission routes, HBV and HCV infections are frequently seen together with HIV/AIDS . The prevalences of coinfection with HBV and HCV in HIV-infected patients have been variable, depending on the geographic regions and risk groups[8,9].
There is unsufficient data from Turkey on HIV/HBV coinfections. We aimed to determine the serological profiles of HBV among HIV-infected patients in Istanbul, Turkey which is classified as an intermediate HBV, low HIV endemic region.
A multicentre observational retrospective study has been conducted by ACTHIV-IST study group, including 4 centres following-up HIV patients in Istanbul. Patients followed-up between January 2006-November 2012 were enrolled in this study.
Three of these centers are located in university hospitals and two are in public training hospitals. All newly diagnosed HIV/AIDS patients with confirmed diagnosis through Western Blot verification test (HIV BLOT 2.2, MP Biomedicals Asia Pacific, Singapore) who attended the abovementioned clinics between January 2006 and November 2013 were includedThe patients were screened for HBsAg, anti-HBc IgG, anti-HBS and anti-HCV by ELISA method (Inno-test HCV Ab IV, Innogenetics, Belgium) and HBV DNA levels of seropositive patients were detected by polymerase chain reaction (PCR) (COBAS Ampliprep/COBAS TaqMan 96, Roche Molecular Systems, USA). The CD4+ cell counts were obtained by standard flow cytometry (FACScalibur, Becton Dickinson, New Jersey, USA) and HIV viral load was measured by PCR (COBAS Ampliprep/COBAS TaqMan HIV-1 Test, Roche Molecular Systems, USA). Demographic data including age, sex, transmission routes, and history of imprisonment, CD4+ counts, HIV RNA, HBsAg, anti-HBc IgG, anti-HBS and anti-HCV, HBV DNA, HCV RNA were collected retrospectively from medical records and were transferred to a HIV database system. Serological profiles of HBV were classified into four groups; current HBV infection, isolated anti-HBc, past infection and vaccinated.
All analysis were performed by using GraphPad Prism 5.0 (GraphPad Software, Inc., San Diego, CA, USA) and SPSS 15 (SPSS Inc, Chicago, IL, USA). Data were described using mean ± standard deviation (SD) (or median and range) and as an absolute number and percentage when indicated. The student t test was used to analyze quantitative data. A P value < 0.05 was considered as statistically significant.
A total of 567 HIV/AIDS patients were included in this study. Mean age was 38.5 years ± 11.2 (range: 18-79) and 81.5% were male. Four hundred twenty nine patients were tested for all HBV markers such as HBsAg, anti-HBc IgG, and anti-HBs. Serological profiles of these patients were shown in table 1: 8.4% had current HBV infection, 9.3% had been vaccinated and 16.8 % had past infection. Of 58 (13.5%) patients with isolated anti-HBc , 29 were tested for serum HBV DNA and 3 of them were positive. The relationship between serological profiles of HBV and patient baseline characteristics were shown in table 2.
Table 1:Serological profiles of HBV infection in patients infected with HIV
Table 2: The relationship between serological profiles of HBV and patient baseline characteristics
Worldwide, about 90% of HIV-infected patients have biologycal signs of prior HBV infection, and 5%-15% suffer from chronic infection 1) Turkey is classified as an intermediate HBV, low HIV endemic region. The estimated overall HBV infection prevalence is 4.57 . Although, many studies have been published about the prevalances of HBV infection among different populations in Turkey, there is insufficient data in HIV-infected patients. In this first study, we investigated the prevalence and epidemiological features of HBV coinfection in HIV-infected Turkish individuals. A total of HIV-infected patients, 8.4 % had chronic hepatitis B and 16.8% had resolved HBV infection. In our study, current HBV infection in HIV-infected patients is more common than in the general population . This may be caused by similarities in routes of transmission and risk factors between HBV and HIV.
We observed a significant association between having a lower CD4 cell count and current HBV infection. This result supports the fact that most immunocompromised patients are unable to control their HBV infection , and/or these patients may experience HBV reactivation . The alternative explanation to our observation could be that HBV co-infections may have cause further damage to the patients’ immune system which can subsequently boost HIV replication and lower CD4 counts.
Isolated anti-HBc is another common serologic pattern in HIV-infected patients. In published studies from different regions, the prevalance of isolated anti-HBc in HIV-infected populations ranged from 10.6-45 % [13,19]. The significiance of this serological pattern is unclear. It may represent either 1) resolved HBV infection with loss of anti-HBs, 2) a false positive test result, or 3) occult chronic HBV infection .
In our country, the prevaleance of isolated anti-HBc in general population ranges between 3%-5% in the previous studies [21,22]. In this study, isolated anti-HBc was determined in 58 (13.5 %) HIV-infected patients and this serologic profile was significantly more frequent thangeneral population. The prevaleance of occult infection in HIV-infected patients with isolated anti-HBc ranged from 0% to 89.5% [13,14,17,23,24].
In our study, of patients with isolated anti-HBc , 29 were tested for serum HBV DNA and 3 (10.3%) of them had occult infection. The difference of prevalance may be related with the regions, risk factors, use of ART and the sensitivity of the biology tecniques.
Current HBV infection and isolated anti-HBc prevalences are high among our HIV-infected patients. Parameters associated with current HBV infection were lower CD4 counts and increased ALT levels. Occult HBV infection was identified in 10.3% of patients with isolated anti-HBc tested for HBV DNA.
Serological profiles of HBV must be assesed among HIV-infected patients and HBV vaccination must be offered in those without HBV markers. Determination of HBV DNA should be performed in patients with isolated anti-HBc to rule out the presence of occult infection.