Seroprevalence of Blood-borne Viral Infections in Post HAART Era at a Tertiary Care Hospital in South India: A Five Year Trend Analysis (2008-2012) and a Comprehensive Review

Aim: Human Immunodeficiency Virus (HIV), Hepatitis B (HBV) and Hepatitis C (HCV) viruses are the major causes of chronic viral infections globally and their prevalence has been extensively reported in the literature in various study groups including general population, health care workers, sex workers, homosexuals, pregnant woman. There are only fewer reports of Seroprevalence in tertiary care centers. We aim to study the trends of such infections in a tertiary care teaching hospital located at South India. Study Design: This is a prospective study conducted over a 5 year period (2008-2012). Place and Duration of Study: Department of Microbiology, Prathima Institute of Medical Sciences, Karimnagar, Andhrapradesh, India from 2008-2012. Methodology: We performed a prospective study of patients presenting at the Prathima Results: Of the 16796 individuals tested a total of 570 (3.3%) showed seropositivity to one of the three viral infections tested. Among the population tested 258(1.5%) were seropositive for antibodies against HIV-1, and none showed HIV-2 seroprevalence (0%). Prevalence of Hepatitis B and Hepatitis C were found as 305(1.8%) and 7(0.04%) respectively. Co-infection of HIV-1 with Hepatitis B was observed only in 10(0.06%) cases. Conclusion: The present study revealed that there was a slight increasing trend for Seroprevalence of HIV- 1 antibodies among the tested population. Hepatitis B surface antigen Seroprevalence has shown a gradual increase during the last five years. Seroprevalence rates of Hepatitis C viral infection also showed an increasing trend through a five year period.


INTRODUCTION
Human Immunodeficiency Virus (HIV), Hepatitis B (HBV) and Hepatitis C (HCV) viruses are the major causes of chronic viral infections globally [1]. Transmitted from one person to the other through various modes including sexual, mucosal contact, needle stick injuries, blood and blood product transfusion and from mother to child through transplacental barrier (congenital), these viral infections have become a cause for major health concern both in the developing and developed nations [2]. The Anti viral therapy, though is available for most of these viral infections, the cause of concern is inability to completely clear the virus from blood, chronicity of infections, high transmissibility, the morbidity they cause and unavailability of an approved vaccine (except HBV vaccine). Since the introduction of Highly Active Antiretroviral Therapy (HAART) in 1995, there has been a gradual decrease in morbidity and mortality among HIV seropositive patients [3]. The availability and accessibility of HAART in developing and low socioeconomic countries paved the way for better life expectancy among the HIV infected individuals [3]. Screening for such viral pathogens becomes crucial since it helps us in understanding the burden of such infections. Seroprevalence of HIV, HBV and HCV have been extensively reported in the literature in various study groups including general population, health care workers, sex workers, homosexuals and pregnant women [4, 5, and 6]. Significant reduction in transmission of these blood borne viral infections has been achieved due to screening blood of voluntary blood donors. Risk groups who are predisposed to such viral infections include homosexuals, drug addicts, patients on haemodialysis and thalessemia patients who require frequent blood and blood product transfusions [7,8]. World Health Organization (WHO) estimates that about 5-7% of the world population is harboring HBV [9]. Based on the prevalence rates of HBV, countries or a region is categorized as high (>8%), intermediate (2-7%) and low (<2%) endemic areas. South-East Asia and South Asia fall in to regions with high and intermediate HBV endemicity respectively [10]. In India the overall HBV prevalence ranges from 2-4.7% [11,12]. WHO 1999 estimate, shows that 3% of the world population is infected with HCV [13]. Prevalence rates of HCV have been different in various parts of the world. African people are among those with high HCV prevalence (5.3%) and European population reveal lower rates of HCV positivity (1.03%) [14]. Though a national network is available for monitoring the burden of HIV (National AIDS Control Organization (NACO)); we must impress on trends of such infections in various tertiary care centers and compare them with the national scenarios. A thorough literature search revealed that there were only fewer other studies from around the globe that have reported HIV, HBV and HCV Seroprevalence among the hospital patients [9,15]. We aimed to study the Seroprevalence and trends of HIV, HBV and HCV viral infections in patients attending tertiary care teaching hospital over a period of 5 years (2008-2012).

Study Design
This is a prospective study conducted over a 5 year period (2008-2012).

Methodology
We performed a prospective study of patients presenting at the Prathima institute of medical Sciences, a rural tertiary care teaching hospital based general and surgical practice that includes, inpatient, and outpatient surgical consultations and all trauma and emergency services over a period of 5-years (Jan 2008 to Dec 2012). Data collected included, Age, sex, HIV, hepatitis B, and hepatitis C test results. The study was approved by institutional review board and an informed verbal consent was obtained from each study subject.
A total of 16796 study subjects were screened over a five year period to assess the prevalence of infectious disease markers. Year wise distribution of samples included from 2008-2012 were 3735, 2743, 2947, 2947, 3521 and 3850 respectively. All the subjects below 15 years were excluded from the study.

Laboratory Analysis
Five milliliters of blood was collected from each subject, the blood was allowed to clot and then centrifuged at 1000 rpm for 10 minutes. Screening for anti-HIV I and II was performed based on National AIDS Control Organization (NACO) guide lines where three different ELISA methods (conventional ELISA, Immunocomb and tridot) were performed including immunocomb for confirmation [16]. HBsAg detection and anti-HCV antibody test was carried out by commercially available enzyme linked immunosorbent assay (ELISA) provided by J Mitra and co. Pvt. Ltd. Samples were processed as per the manufacturers' guidelines.

Statistical Methods
Percentage and analysis of the data was performed using Microsoft word and Excel to generate graphs, tables etc.

RESULTS AND DISCUSSION
Of the 16796 respondents tested included 6324(37.6%) out patients (OP) and 10472(62.3%) in-patients (IP). A total of 570(3.3%) showed seropositivity to one of the three viral infections tested. 10,170(60.5%) male and 6,626 (39.45%) females were included in the study. The mean age of the study subjects were 40.5 years with a range of 17 years -85 years. Among the population tested 258(1.5%) were seropositive for antibodies against HIV-1. None showed HIV-2 seroprevalence (0%). Prevalence of hepatotrophic viruses including Hepatitis B and Hepatitis C was found to be 305(1.8%) and 7(0.04%) respectively. Co-infection of HIV-1 with Hepatitis B was observed only in 10 (0.06%) cases. Results revealed an increasing trend in Hepatitis B and Hepatitis C seropositivity over a 5 year period as shown in the Fig. 1.

Fig. 1. Graph depicting HIV, HBV and HCV incidences over a 5 year period
Year wise samples and HIV 1, Hepatitis B and Hepatitis C prevalence is shown in Table 1. The present study revealed that there was a slight increasing trend for Seroprevalence of HIV-1 antibodies among the tested population. Hepatitis B surface antigen Seroprevalence has shown a gradual increasing trend during the last five years. The Seroprevalence rates of Hepatitis C viral infection also showed an increasing trend through a five year period.
Hepatitis C viral infection also showed an increasing trend through a five year period. Bloodborne viral infections also known as transfusion transmitted viral infections (TTI's) have been a cause of concern in the hospitals, though a significant improvement has been achieved regarding the testing methodologies over time. Our study also revealed a low HIV-HBV coinfection (0.06%) and there was neither co-infection with HCV nor a triple infection including HIV/HBV/HCV in the subjects included in the study.  [5]. Co-infection rates of HIV-HBV (0.2%) and HBV-HCV (0.1%) were significantly low and there was no triple infection [5]. Ganesh et al. in their study from south India have included patients with liver disease and normal controls that revealed HIV, HBV and HCV prevalence rates of 5.2%, 9.5% and 5.6% respectively [22]. Only 1.4% among the control population was positive for HBV and all were negative for HIV and HCV [22]. Anupkumar et al. in their study from central India that included tribal population attending STD clinic has shown the prevalence of HIV, HBV and HCV at 0%, 3.4% and 3.9% respectively [23]. Spyros et al. from Greece have evaluated the Seroprevalence of HIV, HBV and HCV among the orthopedic patients and found that 0.1%, 1.7% and 2% prevalence rates respectively [24]. A study from Ethiopia by Tessema et al. in blood donors at a university teaching hospital revealed that 9.5% of them have either of HIV(3.8%), HBV(4.7%) and HCV(0.7%) and 0.8% had multiple infections [25]. Obi et al. in their recent study from Owerri, Nigeria have reported a 23%, 0.2% and 0% prevalence rates for HIV, HBV and HCV respectively among pregnant women attending ante-natal clinic [6]. Ozgur et al. in their study from north Anatolia that included all preoperative patients in a hospital showed prevalence rates of 0%, 3.4% and 1.8% for HIV, HBV and HCV respectively [26]. Denue et al. from Nigeria have studied the Seroprevalence of HBV (12.3%) and HCV (0.5%) among HIV positive patients attending a tertiary health institution [15].
Previous studies in Seroprevalence of TTI's among the blood donors also revealed that the rate of positivity in replacement donors (patient relatives/unknown person obliges on who is not a voluntary donor) was higher than voluntary blood donors. A study by Chatterjee et al. from North India have demonstrated that the pre conversion seronegativity (Window period) can be minimized by using the advanced diagnostic techniques including the fourth generation serological tests (ELISA) and the nucleic acid tests (NAT) [27]. From the current study as well as a survey of relevant literature it is evident that Transfusion transmitted viral infections are a cause of concern in the hospital as well as to general population. A Scenario where population getting infected with HIV is on decline, there is an increasing trend in the infection rates with hepatotrophic viruses including HBV and HCV which should be considered as alarming sign.

CONCLUSION
Existing literature clearly indicates that there is an upward trend in the prevalence rates of hepatitis B and hepatitis C infection as compared to HIV-1 post HAART era among various groups of population. Considering the fact that both these hepatotrophic viruses are responsible for chronic infections and severe morbidity and their ability to eventually cause hepatocellular carcinoma, there is urgent needs to develop mechanisms to diagnose such TTI's and initiate measures for control and prevention. Hepatitis B vaccination though is freely available now and has been included in the immunization schedule, the developing and financially poor countries still have minimal access. Health care workers should increase the awareness among the rural and urban population, the significance of such TTI's and initiate preventive measures. Physicians must provide necessary counseling, immunization and treatment to population at high risk including the patients on haemodialysis, thalessaemia patients, other patients requiring repeated blood and blood product replacement therapies, drug addicts, children born to seropositive mothers, health care and emergency medical and public safety workers. Government policies should be aimed at identifying the risk groups and highlighting the importance of supply of safe blood and blood products and ensuring their constant supply, avoiding reuse of syringes, regular and mandatory maternal screening for TTI's to prevent perinatal transmission, extensive immunization programmes, hygiene, improved living conditions, proper nutrition, and access to quality health care.

CONSENT
All authors declare that 'written/verbal informed consent was obtained from the patient/Patient guardian (in case minor) (or other approved parties) for participation in the study.

ETHICAL APPROVAL
All authors hereby declare that all experiments have been examined and approved by the appropriate ethics committee and have therefore been performed in accordance with the ethical standards laid down in the 1964 Declaration of Helsinki.