Sero Prevalence of Hepatitis B Surface Antigen Among Individuals With

Vol. 19 No. 2 June, 2004

Contents Page

Sero – Prevalence of Hepatitis B Surface Antigen Among Individuals with

HIV – Related Cutaneous disorders at A Tertiary Referral Dermatology

Clinic in Dar es Salaam.

YM Mgonda 1

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

Zinc Supplementation in Children Recovering From Severe Protein Energy

Malnutrition Admitted at Muhimbili National Hospital, Dar es Salaam Tanzania

S Mushi, E Munubhi, JA Kitundu, AA Msengi+,MC Makwaya 4

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

Rationalising Human Resource Deployment in the Wake of Reforms:

The Need for Measuring Health Workers Workload

DO Simba, M Mwangu, G Msamanga 7

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

A Case of Beals – Hecht Syndrome in an African Neonate

KP Manji 11

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

Perinatal Risk Factors for Neonatal Bleeding at the Muhimbili National

Hospital Dar-es-Salaam, Tanzania

IZK Maduhu, KP.Manji, RL Mbise 13

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

Morphological Pattern and Frequency of Intracranial Meningioma in Tanzania

HA Mwakyoma, JF Kahamba 16

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

the influence of Human Immuno-Deficiency Virus (HIV) Infection on

Orphaned Neonates.

KP Manji, B Tamim, UW Massawe 19

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

The Current Management of Congestive Heart Failure

Eden E Maro 23

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

Morphological Pattern and Frequency of Intracranial Tumours in Adults and

Children in Tanzania

HA Mwakyoma, JF Kahamba 27

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

Nutrition status of the elderly in Peri-Urban Dar es Salaam, Tanzania

Liwayway Hussein, Asia K. Hussein 30

TANZANIA MEDICAL JOURNAL

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

EDITORIAL BOARD:

ADVISORY BOARD:

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

Y. Mgonda - Chief Editor

M. Njelekela - Deputy Editor

M. Aboud - Board Chairman

V. Mashinji - Treasurer

S. Yongolo - Member

N. Mbembati - Member

R. Kaushik - Member

V. Maro - Member

J. B.Kataraihya - Member

I. Maduhu - Member

A. Massele - MUCHS/ DSM

E. Lyamuya - MUCH/ DSM

S.G Chugulu - KCMC/Moshi

S. E. Kalluvya - BMC/Mwanza

E. Kakande - Makerere/ Kampala

K. Pallangyo - MUCH/ DSM

K. Manji. - MUCH/ DSM

E. Mwaikambo - HKM/ DSM

H. Mgaya - MUCHS/DSM

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

ISSN 0856-0719

Published by the Tanzania Medical Journal

(Organ of Medical Association of Tanzania)

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Vol. 19 No. 2, June 2004 Tanzania Medical Journal

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Vol. 19 No. 2, June 2004 Tanzania Medical Journal

SERO – PREVALENCE OF HEPATITIS B SURFACE ANTIGEN AMONG INDIVIDUALS WITH HIV – RELATED CUTANEOUS DISORDERS AT A TERTIARY REFERRAL DERMATOLOGY CLINIC IN DAR ES SALAAM.

YM Mgonda

Vol. 19 No. 2, June 2004 Tanzania Medical Journal

Summary

Background: HIV and hepatitis B virus (HBV) infections are common in sub Saharan Africa. HIV/AIDS is associated with a wide variety of cutaneous disorders which herald the onset of severe immunosuppression. In sub Saharan Africa, HBV is transmitted mainly horizontally through skin contact. Few studies if any have determined the prevalence of HBV infection among HIV sero-positive individuals with HIV – related cutaneous disorders.

Objective: To determine the sero – prevalence of hepatitis B surface antigen among HIV – seropositive individuals with HIV- related cutaneous disorders.

Setting: Tertiary referral Dermatology clinic, Muhimbili National Hospital, Dar es Salaam.

Design and methods: Hospital based controlled study whereby consecutive patients with HIV – related cutaneous disorders were enrolled. After filling in a questionnaire and undergoing dermatological examination blood was drawn for HBsAg and HIV antibody screening. Adult and secondary school student blood donors were used as controls.

Results: 384 patients with HIV-related skin lesions were enrolled into the study. 354 (92%) were HIV sero positive while 30 (8%) were sero- negative. The majority, 204/354 (58%) had PPE alone or co existing with other cutaneous lesions. Thirty of the 354 (8%) HIV - positive patients were co infected with hepatitis B virus. Of the adult voluntary blood donors, 28/333 (8%) were HIV sero positive, 32/333 (10%) were HBsAg positive while 4/333 (1.2%) had HIV and HBV co infection. For student blood donors, 2/120 (2%) were HIV positive while 10/120 (8%) were HBsAg positive and none of them had HIV and HBV co infection. The sero prevalence of HBsAg did not differ significantly between patients with HIV – related skin disorders, adult and secondary school student blood donors (p= 0.64)

Conclusion: Although the prevalence of HBsAg among HIV positive individuals with HIV related cutaneous disorders was apparently similar to that of adult and student blood donors, the HBV and HIV co infection rate of 8% among individuals with HIV related cutaneous disorders may pose a significant challenge in terms of the implicated liver - related mortality and rational choice of anti- retroviral drugs especially in this era of HAART.

Key words: HBsAg, HIV, HIV – related skin diseases.

Introduction

Hepatitis B virus (HBV) infection is endemic throughout sub Saharan Africa where it is associated with significant morbidity and mortality.(1) On average, 10 - 11% of the general population has chronic HBV infection (HBsAg carriers).(2) Horizontal transmission by skin contact is the most important transmission route in sub Saharan Africa.(3) The prevalence of HIV infection is highest in the same areas where hepatitis B virus infection is very common.(4) HIV and HBV are transmitted by similar mechanisms but differ in their infectivity and the predominance of the modes of transmission. HBV, whose transmission in sub Saharan Africa is mostly horizontal, is about 100 times more infective than HIV which on the

Correspondence to: Mgonda YM, Box 65001, Muhimbili University College of Health Sciences

Department of Internal Medicine

contrary, is mainly transmitted heterosexually.(3) Studies have shown that the onset of some of the HIV – related skin diseases predicts the occurrence of an advanced stage of immunosuppression with an increased risk of acquiring opportunistic infections.(5) Hepatitis B virus is a well-documented opportunistic pathogen among HIV infected individuals. The presence of HIV – related skin lesions, may make horizontal transmission of HBV more likely.(3) Furthermore, HIV disease causes multidimensional immunosuppression, which could compromise one’s ability to recover spontaneously from an acute HBV infection thus leading to a chronic disease.(6)

The prevalence of HBV infection among individuals with HIV related cutaneous disorders is largely unknown, particularly in sub Saharan Africa although the prevalence of both infections in the general population is alarmingly high. The effect of HIV infection on those infected with HBV is not clearly understood. Some studies suggest that the progression of liver disease is diminished, which might be expected since the pathogenesis of hepatitis B is immunologically mediated and the immunity is compromised in the presence of HIV infection.(7) However, other studies suggest that the progression of liver destruction is increased leading to early chronic active hepatitis, liver cirrhosis and finally hepatocellular carcinoma the mechanism of which is not very clear.(6, 12) The effect of HIV infection on the natural course of hepatitis B could also be modified by the highly active antiretroviral therapy (HAART).(7) The HAART associated liver toxicity and immune restoration could both accelerate liver damage leading to increased of early liver related death.(7)

There is therefore a need to determine the disease burden of HBV co infection among different categories of HIV positive individuals, like those with HIV- related cutaneous lesions many of which are potentially ulcerative and markers of severe immunosuppression. This knowledge would challenge clinicians to take appropriate preventive and therapeutic interventions including rational choice of anti retro viral drugs. It was on this background that this study was conducted with the main objective of determining the prevalence of HBV co infection among HIV – seropositive individuals with HIV- related cutaneous disorders.

Materials and methods

The study was conducted at the tertiary referral dermatology unit of Muhimbili National Hospital in Dar es Salaam, between June 2002 and July 2003. During this period, consecutive patients with HIV - related cutaneous disorders were recruited into the study after obtaining their fully informed verbal consent. Each patient underwent a full physical and dermatological examination. Diagnoses of HIV related - skin diseases were made clinically in most cases except for doubtful dermatoses as well as cases of cutaneous Kaposi’s sarcoma where skin biopsies were performed for histological confirmation. A structured questionnaire was used for data recording.

After a pre – test counseling, whole blood for HIV and HBsAg screening was collected in empty sterile vacutainer tubes from which plasma was separated. A qualitative immunoassay for the detection of antibodies to HIV 1&2 was done using Determine TM kit (Abbot Japan Co Ltd. Minato – Ku Tokyo, Japan). Screening for HBsAg was performed with Virotect – HBsAg kit (Omega diagnostics Ltd, Omega House, Scotland, UK). Post – test counseling was offered to all subjects.

Samples of blood from all adult and student voluntary blood donors who came to the hospital over a randomly selected period of three months within the study period were anonymously collected and screened for HIV and HBV using the same techniques as for the study subjects. These were used as controls.

Data were entered into a computer and validated to ensure that all entries were accurate. Analysis was done using Epi info version 6 software and p – value was considered to be significant if it was less than 0.05.

Results

A total of 384 patients with skin disorders suggestive of HIV infection were enrolled into the study. Of these, 354 (92%) tested HIV sero positive while 30 (8%) were sero negative. Out of 354 - sero positive individuals, 171(48%) were males while183 (52%) females. The age (table 1) ranged from 2 to 57 years with a mean of 35 years. The 25th and 75th centiles were 30 and 42 years of age respectively. Overall, the age group that was mostly affected was 31 – 40 years (43%) followed by 41 – 50 (22%) and 21 – 30 years (17%).

Table 1: Age and sex distribution of patients with HIV

related skin disorders (n=354)

Age / Sex
Male (%) / Female (%) / Total (%)
0 - 10 / 12 (3) / 3 (1) / 15 (4)
11 – 20 / 12 (3) / 12 (3) / 24 (7)
21 – 30 / 18 (5) / 42(12) / 60 (17)
31 – 40 / 63 (18) / 87 (25) / 150 (43)
41 – 50 / 54 (15) / 24 (7) / 78 (22)
51 – 60+ / 12 (3) / 15 (4) / 27 (7)
Total / 171 (48) / 183 (52) / 54 3 (100)

Table 2 shows the different HIV – related skin diseases among the 354 HIV – positive patients. The majority, 204/354 (58%) had PPE either alone or co existing with other cutaneous lesions. PPE presented alone in 168 (47%) patients. Cutaneous epidemic Kaposi’s sarcoma (CEKS) was seen in 60/354 (17%) of whom, 48 (80%) had this lesion alone. All patients with CEKS alone or in combination with other skin diseases were HIV sero - positive. Psoriasis alone or in combination with seborrhoeic eczema (sebo – psoriasis) was seen in 36/354 (10%). Herpes zoster with or without other skin conditions was seen in 27 (8%) patients. Eighteen patients (5%) had genital herpes simplex in addition to other cutaneous lesions. The other skin conditions encountered with numbers in brackets included; superficial mycosis including onychomycosis (18), plane warts (12), molluscum contagiosum (9), genital warts (9) and lichen planus subtropicus (3).