6.3% Prevalence of hepatitis B and C in pregnant women who are infected with HIV
American Journal of Obstetrics and Gynecology
Volume 193, Issue 3, Supplement 1 , September 2005, Pages 1270-1273
Transactions of the Twenty-Fifth Annual Meeting of the Society for Maternal-Fetal Medicine Feb 2005
Patricia Santiago-Munoz MDScott Roberts MD, MS, Jeanne Sheffield MD, Barbara McElwee BSN, RNC, WHCNP and George D. Wendel, Jr. MD
Department of Obstetrics and Gynecology, The University of Texas Southwestern Medical Center, Dallas, TX
".....Prevalence of HBV in the general US population is 0.4%. HCV is present in approximately 1.8% of the United States...... The prevalence of HBV in our HIV-infected pregnant patients is 1.5% and that of HCV is 4.9%....... The prevalence of HBV and HCV in the US female HIV-infected cohort is 4.6% and 7.7% to 9.7%, respectively.....routine testing for viral hepatitis during pregnancy provides the opportunity to assess the potential for vertical transmission, which allows the obstetrician and pediatrician to act jointly with interventions that decrease the incidence of HIV, HBV, and potentially HCV transmission to the newborn infant. Similarly, the patient herself may benefit from the knowledge of her co-infected status because therapy is available to modify disease status.."
The purpose of this study was to evaluate the prevalence of hepatitis B and hepatitis C virus co-infection among pregnant women who are infected by human immunodeficiency virus and who attend an obstetric complications prenatal clinic.
A de-identified research obstetric human immunodeficiency virus database was reviewed regarding patient demographic characteristics, risk factors for infection, history of sexually transmitted diseases, and initial CD4 count.
Four hundred fifty-five women who are infected with human immunodeficiency virus with 572 pregnancies were delivered over 11 years.
The overall prevalence of human immunodeficiency virus and hepatitis B or C virus co-infection in our population was 6.3%.
More specifically, 1.5% was co-infected with hepatitis B virus, and 4.9% was co-infected with hepatitis C virus.
Patients with hepatitis virus were more likely to use intravenous drugs (52% vs 18%; P < .01) and alcohol (38% vs 5%; P < .01).
Co-infected patients were older (28 vs 25.6 years; P = .04), but there were no racial differences.
Median baseline CD4 counts in hepatitis B virus co-infected patients were significantly lower (310 cells/mm3) than those in either hepatitis C virus co-infected patients (453 cells/mm3) or patients who were not co-infected with human immunodeficiency virus (414 cells/mm3).
One of 16 pregnant women who were infected with human immunodeficiency virus was co-infected with hepatitis B or hepatitis C virus. Hepatitis B co-infections appear to be associated with more compromised immune status in our cohort.
Estimates for the prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infections in the United States are 0.4% and 1.8%, respectively.1 and 2 Data are limited regarding the estimates of these prevalences in pregnancy: 0.5% to 1.5% for HBV and 1% for HCV.3 and 4 Absent from the obstetric literature is a description of HBV and HCV prevalence in pregnant women who are infected with human immunodeficiency virus (HIV) in the United States.
The HIV-infected pregnant cohort represents a unique population. Risk factors that are associated with HIV infection are also associated with HBV in sub-Saharan Africa and HCV infection. One study from sub-Saharan Malawi, Africa, described the prevalence of persistent HBV as 13% and HCV as 16.5% in HIV-infected pregnant women. In this region, HBV and HCV are highly endemic and are not associated with HIV co-infection.5 (ED NOTE from Jules Levin: I disagree, I think coinfection rates are high in Africa & the developing world. This I think will emerge as a problem in the future & affect outcomes of HIV therapy with HAART & health outcomes. A recently published article reported 50 million HBV+ individuals). These prevalences were in agreement with other reports from highly endemic areas.6, 7, 8 and 9
The aim of this study was to describe the seroprevalence of HBV and HCV co-infections in HIV-infected pregnant women who attended an inner city obstetric complications clinic in the United States. Liver disease that is caused by chronic HBV and HCV is currently an important cause of morbidity and death among HIV-infected patients.10
Prevalence of HBV in the general US population is 0.4%. HCV is present in approximately 1.8% of the United States. Because of shared routes of transmission, co-infection with either HBV or HCV is common among HIV-infected patients, and the prevalence of both is higher than in the general population. The prevalence of HBV and HCV in the US female HIV-infected cohort is 4.6% and 7.7% to 9.7%, respectively.12 and 13 Overall, co-infection with HBV or HCV appears to be lower in our cohort of pregnant patients than reported elsewhere in HIV-infected women in the United States.
The prevalence of HBV in our HIV-infected pregnant patients is 1.5% and that of HCV is 4.9%. This is most likely due to differences in risk factors between the groups, unlike in highly endemic areas, where the prevalence of HBV or HCV is unchanged in the presence of HIV co-infection. The lower prevalence of both HBV and HCV can be explained by the young age of our cohort. It can also be explained by differences in indications for medical care (prenatal care vs acute or ambulatory care). In this cohort in which local endemic rates of HBV and HCV are low, risk factors in the acquisition of HBV and HCV assume more importance than in highly endemic areas.5, 6, 7, 8 and 9 This effect is illustrated in the study by Choy et al14 in which increasing age and HIV infection are risk factors that are associated significantly with HCV infection. As expected, injection drug use is an efficient mode of HCV transmission. This is not apparent for HBV co-infection in this population. Alcohol abuse is a strong independent risk factor, but it is likely that heterosexual transmission is most efficient for HIV and HBV infection in this cohort.
We found a lower median CD4 count in patients who were carriers of HBV infection as compared with those patients with serologic evidence of resolution of past HBV infection. This difference in CD4 count suggests immune-mediated differences between HBV carriers and those patients who were able to recover successfully from HBV infection. This attenuation of T-cell response in chronic HBV carriers has been described.15 and 16
All of the aforementioned factors underline the importance of the routine identification of hepatitis co-infection in HIV-infected patients. It is unclear whether chronic HBV or HCV infection increases HIV disease progression, but they may increase the risk of hepatotoxicity of anti-retroviral therapy.17 Appropriate counseling, therapy, and lifestyle changes may have an opportunity to decrease the occurrence and morbidity of co-infection at an earlier age. Likewise, routine testing for viral hepatitis during pregnancy provides the opportunity to assess the potential for vertical transmission, which allows the obstetrician and pediatrician to act jointly with interventions that decrease the incidence of HIV, HBV, and potentially HCV transmission to the newborn infant. Similarly, the patient herself may benefit from the knowledge of her co-infected status because therapy is available to modify disease status.
Patients who were eligible for this study were drawn from an obstetric complications clinic that specializes in infectious diseases. Participation in this clinic includes all patients in the Parkland Health and Hospital System who were known to be HIV-infected before or during pregnancy. The prevalence of HIV infection in our general obstetric population is approximately 0.4% to 0.5%. Parkland Hospital, which is a county-supported tertiary care center in Dallas County, Tex, delivers approximately 15,000 to 16,000 women annually, and serves a predominantly young, indigent Hispanic population. Institutional Review Board approval was obtained before this study was performed.
Our study cohort consisted of all HIV-infected pregnant women who were followed in this prenatal clinic over the course of 11 years. The study involved 455 individual patients consecutively who were seen from January 1, 1993, to December 31, 2003, some of whom had >1 delivery during this time period. Patients with HIV infection who were cared for in the infectious disease clinic followed an evidence-based treatment protocol. In addition to routine prenatal laboratory evaluations, pregnant HIV-infected patients were tested for HBV and HCV infection at the initial visit. At intake, CD4 cell count, HBV surface antigen (HBsAg), HBV anti-core antibodies (anti-HBc immunoglobulin G and M), and HCV antibodies were obtained. If hepatitis serologic test results returned positive, the appropriate confirmatory tests were ordered. HIV viral loads were not collected consistently until the latter part of this longitudinal study and were not included in our final analysis. Demographic information and details concerning risk factors for infection such as alcohol abuse, intravenous drug use, and history of sexually transmitted diseases were collected. All pregnant women who were found to be infected with HBV or HCV underwent appropriate counseling and treatment, if warranted.
Between January 1, 1993, and December 31, 2003, a total of 455 women with HIV infection were followed and were delivered of 572 pregnancies through the infectious disease complications clinic. All of these women were included in our study cohort. The overall prevalence of HIV and HBV or HCV co-infection among pregnant women tested in this population was 6.3% (29/455 women). More specifically, 1.5% (7/455 women) were co-infected with HBV, and 4.9% (22/455 women) were co-infected with HCV. No women were co-infected with both HBV and HCV; however, 73% of HCV co-infected women (16/22 women) had evidence of past HBV infection.
The Table summarizes the demographic characteristics of our co-infected population compared with our patients who were not co-infected. There were no differences in racial background or history of sexually transmitted diseases between the groups. However, patients who were co-infected with either of the hepatitis viruses and HIV were older (P = .04), and were more likely to abuse alcohol and intravenous drugs (P < .01 for both).
Table. HBV or HCV co-infected cohort versus no hepatitis co-infected HIV
The HBV co-infected pregnant women were compared with the HCV co-infected patients. There was a significant difference in immune status between the groups, as shown by a lower median CD4 cell count in those patients with HBV (310 cells/mm3 vs 453 cells/mm3; P = .02). Drug use was also significantly more common in the HCV co-infected cohort (63.6% vs 14.3%; P = .03). There were no differences, however, in age, rates of alcohol abuse or history of sexually transmitted diseases.
Women who were asymptomatic HBV carriers and those who had serologic evidence of previous infection and natural immunity were also compared with each other. The women who were chronic carriers of HBV had lower median CD4 counts than those who had cleared previous HBV infection (310 cells/mm3 vs 466 cells/mm3; P = .03).
Injection drug use was identified as a risk factor for HCV co-infection (odds ratio, 3.8; 95% CI, 1.3-10.9). Alcohol abuse was identified as a risk factor for HCV co-infection (odds ratio, 7.4; 95% CI, 2.5-22.1) and any HBV co-infection (odds ratio, 5.8; 95% CI, 2.2-15.4)
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17 Department of Health and Human Services (DHHS). Guidelines for the use of antiretroviral agents in HIV-1-infected adults and adolescents, April 7, 2005. Last accessed: June 5, 2005. Available at: http://aidsinfo.nih.gov/guidelines/adult/AA_040705.pdf.
Presented at the Twenty-Fifth Annual Meeting of the Society for Maternal Fetal Medicine, Reno, Nevada, February 7-12, 2005.