key: cord-0265636-6aezty3a
authors: Bejiga, B.; Ebo, G. G.; Yimam, J. A.; Tur, J. B.; Wariso, F. B.; Lulseged, S.; Eticha, G. T.; Wolde, T. K.; Abrahim, S. A.
title: Prevalence and factors associated with hepatitis B and C virus infections among female Sex workers in Ethiopia: Results of the national biobehavioral Survey, 2020
date: 2022-05-26
journal: nan
DOI: 10.1101/2022.05.24.22275494
sha: aa2dc1733590b642378d409c2eeeb7e2b02087d0
doc_id: 265636
cord_uid: 6aezty3a

Background: Hepatitis B and C virus infections are endemic diseases in sub-Saharan Africa, the region with the highest prevalence of these infections in the world. Female sex workers are exposed to sexually transmitted infections, including hepatitis B and C, because of their high-risk sexual behavior and limited access to health services. There is no data on national prevalence estimate on hepatitis B and C virus infections among female sex workers in Ethiopia, a critical gap in information this study aimed to fill. Methods: This was a cross-sectional, biobehavioral, national study conducted from December 2019 - April 2020 among 6085 commercial female sex workers aged >=15 years and residing in sixteen (n=16) regional capital cities and selected towns of Ethiopia. Blood samples were collected for hepatitis B and C virus serological testing from the participants. The data were collected using an open data kits (ODK) software and imported into STATA version16 for analysis. Descriptive statistics (frequencies and proportions) were used to summarize data on the study variables. Bivariate and multivariate logistic regression analyses were conducted to determine the strength of association between independent variables (risk factors) and the outcome (hepatitis B and C virus infection). Adjusted Odd ratio (AOR) was used to determine independent associations, 95% confidence interval to assess precision of the estimates, and a P value <= 0.05 was considered statistically significant. Results: The prevalence of hepatitis B and C infections among the 6085 female sex workers was 2.6% [(95% CI (2.2,2.8)] and 0.5% [(95% CI (0.4,0.7)], respectively. Female sex workers who had 61-90 and >=91 paying clients in the past six months [(AOR=1.66; 95% CI, (0.99, 2.79); P =0.054] and [(AOR=1.66 95% CI, (1.11, 2.49); P=0.013], respectively, age at first sex selling of 20-24 and >25 years [(AOR=1.67; 95% CI, (1.14, 2.44); P =0.009)] and [(AOR=1.56; 95% CI (1.004, 2.43); P =0.048)], respectively, known HIV positive status [(AOR=1.64; 95% CI (1.03, 2.62); P =0.036] were significantly associated with the prevalence of hepatitis B virus infection. Similarly, hepatitis C was significantly associated with, age at first sex <=15 years and age 16-20 years [(AOR=0.21; 95%CI (0.07,0.61); P =0.005)] and [(AOR=0.18; 95% CI (0.061, 0.53); P =0.002)], respectively, known HIV positive status [(AOR=2.85; 95%CI (1.10,7.37); P =0.031)] and testing positive for syphilis [(AOR=4.38; 95% CI (1.73,11.11); P =0.002)], respectively. Conclusion: This analysis reveals an intermediate prevalence of hepatitis B and a low prevalence of hepatitis C infection among female sex workers in Ethiopia. It also suggests that population groups like female sex workers are highly vulnerable to hepatitis B, hepatitis C, and other sexually transmitted infections. There is a need for strengthening treatment and prevention interventions, including immunization services.

Commercial sex work (CSW) is a high-risk activity associated with HBV, HCV, and several other 82 STI (6, 9). The higher risk of getting infected with HIV and other STI, such as syphilis and hepatitis 83 among FSW is primarily associated with the high number of sexual partners and increased 84 frequency of unprotected sex. Several studies have shown that low adherence to condom use, 85 multiple sexual partners, unsafe sexual practices, illicit drug use, and co-infection with other STI 86 increase the risk of HBV and HCV transmission. FSW also have a higher risk of contracting STI 87 from their non-paying partners than from their paying clients (10,11). 88 In Ethiopia, FSW carry a disproportionate burden of HBV, HCV, and HIV infection. According 89 to the Ethiopian Demographic and Health Survey (EDHS) 2016 report, the marked regional 90 variation that was driven by most at-risk populations (MARPS) indicates that urban areas and 91 females are more affected than rural areas and males, respectively (12). Small towns are also . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 26, 2022. ; https://doi.org/10.1101/2022.05.24.22275494 doi: medRxiv preprint 92 becoming hotspots and can potentially bridge further the spread of the HIV and HBV infections to 93 rural settings, where the female are twice more affected than males (12). 94 Ethiopia is in the region where HBV prevalence is considered hyper-endemic with a prevalence of 95 between 8%-12%, and that of HCV prevalence is estimated at not less than 2.5% (13). An earlier 96 study conducted in Ethiopia reported that 12% of hospital admissions and 31% of the mortality on 97 the medical wards in Ethiopian hospitals were due to chronic liver disease (CLD) (13). However, 98 there isn't much done and the available data on associated chronic liver disease or hepatocellular 99 carcinoma are not sufficient. 100 There are limited data from isolated studies showing the prevalence of HBV in Ethiopia -Hawassa 101 9.2% (14), Gonder 28.9% (15) , Mekelle 6% (16), Dessie 13.1% (11), and northwest Ethiopia 102 (11.9%) (17). FSW have been identified as a population group with the highest risk for STI, 103 including HBV and HCV, and should perceive priority in the national HIV/AIDS program (18). 104 Although there is an ongoing HBV, HCV, and other STI program in the country, there is no 105 national data among FSW to determined HBV and HCV prevalence and driving factors. Therefore, 106 the current study was conducted to explore the prevalence of HBV and HCV infections and 107 identify the factors associated with these infections among FSW in Ethiopia.

Study setting and population: 110 The study was done in Ethiopia, a country divided into eleven regions and two city administrations, 6 115 4.6, infant mortality rate (IMR) 41per 1,000 live births, and adult literacy rate of 49% in 2016 in 116 2016, when the country started a national viral hepatitis prevention and control program (21). This was a crass-sectional, nation-wide, biobehavioral study conducted among FSW aged 123 ≥15 years during the period from December 2019 -April 2020.

Target population: 125 The target population of the study is all FSW living in cities and towns in Ethiopia, and the 126 sampling frame is the list of FSW residing in the regional capitals and selected towns with FSW-127 hotspots in Ethiopia.

Study population: 129 FSW aged ≥15 years residing in regional capitals and selected towns with FSW-hotspot or who 130 worked in these cities and towns in the last one month preceding the survey. The survey included 131 both fixed (venue-based) and floating (street-based) FSW.

Inclusion and exclusion criteria: 133 We included women aged ≥15 years, who received money/other benefits in exchange for sex with 134 four or more people within the last 30 days, agree to participate in the survey including 135 interviewing and biological testing, able to provide informed consent and communicate in one of 136 the survey languages, had a valid coupon provided by the study team , and residing or working in 137 the survey city or town for the last one month.

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Sample size and sampling procedure: 139 The sample size was determined by single population proportion formula 140 141 using 95% confidence interval, α = 0.05, margin of error of 35% (d), and proportion (p) (22) of 142 2%, and DEFF = design effect with a replacement for non-responders. With these assumptions, 143 the minimum desired sample size of FSW in sixteen (n=16) major regional capitals and selected 144 towns with FSW hotspots was 6085 after adding 10% contingency. This was divided and assigned 145 to 16 sites proportionate to population size.

Specific hotspot areas for FSW were identified during tools and procedures pretesting with support 147 from HIV/AIDS Prevention and Control office (HAPCO), woreda (district) health offices, and 148 drop-in-clinics (DICs), local organizations working with FSW. We used a respondent-driven 149 consecutive sampling using a standardized questionnaire for recruitment of study participants. The 150 local organizations assisted in identifying the initial respondents of the survey, referred to as 151 "seeds". The number of seeds for each site was determined based on the result of a formative 152 assessment. Five "seeds" for each site with allocated sample of <450, six-eight seeds for each site 153 with sample 450-900, and 12 seeds for each site with sample of 1101 were recruited. The "seeds" 154 were selected based on the type of sex worker, age category, and geographic location of the site.

These include those FSW who were bar-and/or hotel-based, red lighthouses, local drinking 156 houses, street-based and hidden (cell phone-based).

FSW with a known social network were given each three coupons for use to invite her friends or 158 other FSW contacts who were in her network. This approach helped in reaching as many eligible 159 FSW as possible. The coupon remained active from the day it was given to the potential participant

. CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Data collection procedure and data quality management: 172 Data were collected using a pre-tested structured questionnaire initially developed in English and 173 then translated into the local language (Amharic) was entered onto open data kits (ODK) software.

Training was provided to the study team, coordinators, interviewers, blood sample collectors, hepatitis-B and syphilis testing. After collecting whole blood of 5 ml using EDTA tube; HIV 182 testing, Hepatitis B surface antigen (HBsAg), hepatitis C antibody (HCVAb) and syphilis testing . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) were performed right after sample collection. Then after centrifuging the whole blood, the plasma 184 was separated and a liquated in two a 1.8 ml preprinted labeled nunc tube for viral load 185 quantification and quality control testing.

Biological analysis: 187 HBsAg and HCVAb were screened by using a rapid test kit according to manufacturer principles Data Analysis: 196 The data was collected using the ODK software on tablet computers, and was exported to MS- is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) Odd Ratios (AOR), precision of estimates determined using 95% confidence intervals, and a P 209 value ≤ 0.05 was used as cut-off to determine statistical significance. (Table 1) Sexual and behavioral characteristics: 235 The median (IQR) age at first sex was 16 (3) years. The majority, 3384 (55.6%), of respondents 236 had the first sex between the age of 16 and 20 years (Table 3) forced. In the last six months preceding the study, 1645 (27%) of the FSW reported they had more . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. Ethiopian setting is lower than the prevalence reported from the rest of Africa and South-East Asia 312 (5%), but higher than the prevalence in the Americas and Eastern Mediterranean (1%). This Ethiopia at various times reported varying prevalence by site and year of study -Dessie 13.1% 332 (11), Hawassa 9.2% (14), Gonder 28.9% (15) , and Mekelle 6% (16). This variation could largely 333 be explained by the differences in sociodemographic characteristics of study populations, study 334 settings, sample size, and sampling methods focusing on high-risk population groups.

Our study showed that HBV prevalence was significantly associated with the age groups 25-29 336 years and 30-34 years compared to the age group 15-19 years in the bivariate analysis, but these 337 did not achieve significant independent association in the multivariate analysis (P > 0.05). This is is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

The copyright holder for this preprint this version posted May 26, 2022. ; https://doi.org/10.1101/2022.05.24.22275494 doi: medRxiv preprint 374 1.64 times more likely to be infected by HBV than FSW who were HIV negative. The presence of 375 HBV infection among FSW might be due to a higher risk of developing hepatotoxicity following 376 the initiation of antiretroviral therapy or a lower CD4 T-cell count. 377 We found that the overall prevalence of HCV among FSW was 0.5%, a finding similar to that 378 reported form Nairobi, Kenya (0.76%) (43), and a previous study in Ethiopia (0.7%) (50). Our 379 finding is also concurs with the prevalence ranging between 0-1.4% reported from the united States The odds of being positive for syphilis compared with being negative was significantly and 418 independently associated with being HCV positive among FSW. In agreement with our finding, a . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity.

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previous study also indicated that HCV sero-reactivity or positivity was significantly predicted 420 and associated with syphilis sero-reactivity or positivity (63). Moreover, a study conducted by 421 Tessema B, et al (50) suggested that the highest rate of co-infection and the statistically significant 422 relationship between HCV and syphilis infections might be due to the fact that these pathogens 423 share common modes of transmission and risk groups. These findings are in line with our finding 424 showing that FSW with HCV infection were 4.4 times more likely to be syphilis sero-reactive or 425 positive than those who were syphilis non-reactive or negative. As HCV positive FSW were at a 426 higher risk for having syphilis, prevention mechanisms and intervention need to be instituted 427 among FSW to decrease further transmission of HCV and syphilis to the general population.

Of 6085 participants included in our study,184 (3%) had results for both HBsAg and HCVAb. The 

The previous prevalence estimates of HBV among general population in Ethiopia ranged from 435 8%-12%, and HCV prevalence estimated at greater than 2.5% (13). These findings were higher 436 than our finding among FSW, a group at a much high risk of getting HBV/HCV and STI. It appears 437 that the national estimates of these infections among the general population could have been The main strength of our study was the inclusion of participants from high-risk groups and being 447 the first report on the prevalence of viral hepatitis B and C among FSW in Ethiopia at national and Nevertheless, this study also had limitations. First, as part of the national surveillance, the survey 454 done in this round had targeted only provincial (regional) capitals, and major towns. Even in the 455 selected cities, the presence of harder-to-reach sex worker groups like home-based sex workers 456 might not be fully accounted for lack of detailed city maps for all regional capitals, and street 457 names were challenges in the mapping and presentation of the results from the size estimation 458 study. Second, as most studies were set in urban areas and as FSW were predominated included in 459 the study, the generalizability of the results need to be considered with some caution. influenced by difference in methodologies, our finding may also suggest that the coverage of . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review) . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. . CC-BY 4.0 International license It is made available under a is the author/funder, who has granted medRxiv a license to display the preprint in perpetuity. (which was not certified by peer review)

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