Sero-prevalence of Hepatitis B Surface Antigen and Associated Factors Among Female Sex Workers in Hawassa, Ethiopia, 2019


 Background Hepatitis B virus infection is one of the most serious infections and is a major public health problem. Female Sex Workers (FSWs) are considered to be at soaring risk for transmission and acquisition of HBV due to exposure to multiple sexual partners and barriers to the negotiation of consistent condom use. HBV screening services are not widely available in Ethiopia particularly for high risk groups such as persons with multiple sex workers. Hence, this study aimed to assess Sero-prevalence of HBVsAg and associated factors among FSWs in southern Ethiopia.Method A cross-sectional study was conducted from November to February 2019 at Hawassa city in ISHDO confidential clinic on 383 FSWs. A consecutive sampling technique was used to select study participants using standardized questionnaire. Data were entered to SPSS version 20.0 and analyzed for different variables using Logistic regression. HBsAg was detected from plasma samples using ELISA method. ResultsThe prevalence of HBV among FSWs was 9.2%(95%CI:6.3–12.1). The condom use, condom breakage during sex, use of stimulants, duration of prostitute, history of STI, history of genital ulcer, the number of clients used per day, sex during menses, sexual assault, common use of sharp material and the history of abortion were one of the common factors associated with HBV among FSWs. Conclusion The prevalence of HBV among FSWs in this study area was high. Condom use, history of genital ulcer, sexes during menses and sharp material sharing is highly associated with HBV infection among FSWs and emphasis should be given.


Abstract Background
Hepatitis B virus infection is one of the most serious infections and is a major public health problem. Female Sex Workers (FSWs) are considered to be at soaring risk for transmission and acquisition of HBV due to exposure to multiple sexual partners and barriers to the negotiation of consistent condom use. HBV screening services are not widely available in Ethiopia particularly for high risk groups such as persons with multiple sex workers. Hence, this study aimed to assess Sero-prevalence of HBVsAg and associated factors among FSWs in southern Ethiopia.
Method A cross-sectional study was conducted from November to February 2019 at Hawassa city in ISHDO con dential clinic on 383 FSWs. A consecutive sampling technique was used to select study participants using standardized questionnaire. Data were entered to SPSS version 20.0 and analyzed for different variables using Logistic regression. HBsAg was detected from plasma samples using ELISA method.

Results
The prevalence of HBV among FSWs was 9.2%(95%CI:6.3-12.1). The condom use, condom breakage during sex, use of stimulants, duration of prostitute, history of STI, history of genital ulcer, the number of clients used per day, sex during menses, sexual assault, common use of sharp material and the history of abortion were one of the common factors associated with HBV among FSWs.

Conclusion
The prevalence of HBV among FSWs in this study area was high. Condom use, history of genital ulcer, sexes during menses and sharp material sharing is highly associated with HBV infection among FSWs and emphasis should be given.

Plain English Summary
Hepatitis B virus infection is one of the most serious infections and is a major public health problem. Africa has the second largest number of chronic HBV carriers after Asia and is considered as a region of high endemicity. HBV prevalence is highest in the adult population of the Western Paci c Region and Africa. Female Sex Workers (FSWs) are considered to be at soaring risk for transmission and acquisition of HBV due to exposure to multiple sexual partners and barriers to the negotiation of consistent condom use.
Of the 381 study participants who tested for Hepatitis B virus (HBV), 35(9.2%) were positive for hepatitis B surface antigen (HBsAg) test which is more prevalent than other study population. Condom use, history of genital ulcer, sexes during menses and sharp material sharing is highly associated with HBV infection among FSWs. Therefore, efforts by both governmental and non-governmental organizations should be made to give emphasis on diagnosis and treatment of STIs, educate the community on risky sexual behaviors. Further survey should be done on larger sample size and with different study design.

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Hepatitis B virus (HBV) is a DNA virus belonging to the Hepadnaviridae family. It is a virus that infects the liver. 1,2 HBV was discovered in 1965 when Blumberg and co-workers found the Hepatitis surface antigen which was originally called the Australia. 3 As the World Health Organization (WHO) global health impact report of viral hepatitis more than 240 and 150 million populations were affected by chronic liver disease due to HBV and HCV respectively 2 . Africa has the second largest number of chronic HBV carriers after Asia and is considered as a region of high endemicity. 1 HBV prevalence is highest in the adult population of the Western Paci c Region and Africa, where 6.2% and 6.1% respectively. In the Eastern Mediterranean Region, South-East Asia, Europe and population of the Americas, an estimated 3.3%, 2.0%, 1.6%% and 0.7% of the general population are infected, respectively. 4 It is mentioned that Africa is one of the continents with the highest prevalence of HBV and Ethiopia being a member of this continent shares this burden. 2 HBV is most commonly spread through exposure to infected blood and various body uids, as well as through saliva, menstrual, vaginal, and seminal uids and reuse of needles and syringes either in healthcare settings or among persons who inject drugs. Besides, the infection can occur during medical, surgical and dental procedures, through tattooing, or through the use of razors and similar objects that are contaminated with infected blood. 4 The prevalence of HBV among Female sex workers was 28.9% in Gondar, Ethiopia, 5 6% in Makelle, Ethiopia, 6 4.20% in Republic of Congo, 7 17.1% in Nigeria, 8 23.6% in São Paulo, Brazil, 9 10.7% in China. 10 The risk factors associated with HBV among female sex workers were, workplace of sex, inconsistent condom use, and use of the drug. 6 The limited economic options, having many dependents, marital disruption, low education status and hazardous alcohol use and co-infection with other sexual transmitted infections 9 were common factors associated with HBV infection. Also living in the city, 9 drug abuse and anal sex, 11 uses of cracked condom were risk factors. 9 Moreover, a history of multiple sex partners and women who have experienced child sexual abuse 12,13 constitutes the potential risk factors. 14 Therefore, this study aimed to determine the seroprevalence and associated factors of HBV among adolescent and young adult Female sex workers in Hawassa, integrated services on Health development (ISHDO) project con dential clinic.

Study design and population
The study was conducted at integrated services on Health development (ISHDO) project con dential clinic in Hawassa town in southern Ethiopia. It is one of the nongovernmental institutions founded to support marginalized populations to give ISHDO. Hawassa is the capital city of the South region, located on the shores of Lake Hawassa in the Great Rift Valley, 275 km South of Addis Ababa. Hawassa is a good tourist destination and recreational area of the south region. The town is locally called "Fikir Ketema" which means a lovely town. The study was conducted from July 1-November 31st 2019.
A cross-sectional study was conducted on adolescent and young adult Female sex workers. All adolescent and young adult female sex workers in the Hawassa town were the source of the population. About 383 female sex workers were included from eight sub-cities. All Kebeles female sex workers were pre-registered in the registration book. They are usually picked by special assigned ex-sex workers, namely: "Demand creator" by moving home to home and brought them to their special clinic. In this study, all Female sex workers who are living in the town and who had been working as a commercial sex worker for at least 3 months have participated. The age greater than 16 years old female sex workers were included. However, female sex workers who were living outside the town and who live less than 3 months in the city were not included in this study

Specimen collection
Three up to ve milliliters (3-5 ml) of whole blood was drawn to obtain plasma and stored at -20 0 c in the upper compartment of the refrigerator until it tested. HBsAg was detected from plasma samples by using AiD™ antibody sandwich HBsAg ELISA method (WANTAI HBV diagnostics AiD™ HBsAg ELISA). The test was conducted following manufacturer's instructions and the Microplates read at a wavelength of 450 nm using the Enzyme linked immune assay (ELISA) reader. The presence or absence of HBsAg was determined by relating the absorbance of the unknown sample to the cut-off value.

Statistical analysis
Data were entered and cleaned using Epi-Data version 3.1 and exported into SPSS version 21. Binary logistic regression analysis was being performed accordingly. A p-value of less than 0.05 considered as statistical signi cance. The pretest was performed on 5% of the total sample size, to assure the consistency and quality of data.

Socio-demographic characteristics
Out of a total of 383 enrolled subjects, 381(99.5%) were completed information from the questionnaire and also recruited for laboratory blood tests. About 45.7% of the participants were 20-24 ages. The mean (Mean ± SD) age was 22.63 ± 4.3 and the median age was 22. The age range was between 16 and 40. More than three fourth of the group is single and very few 2.9% were married. The majority of (63.5%) of the respondents were from urban. About 306(80.3%) of the study participants were attended formal education, whereas 53.5% of the participants were 5th -8th grade. More than 35% of the study participants have the monthly income range of 1501 to 3000 Ethiopian Birr with a mean and mode of 1992.70 and 1000.00 ETB respectively (Table 1).

Prevalence and determinants of HBV
Of the 381 study participants who tested for HBV, 35(9.2%) were positive for HBsAg test. The condom use, condom breakage during sex, use of stimulants, duration of prostitute, History of STI, history of genital ulcer, the number of clients used per day, sex during menses, sexual assault, a common use of sharp material and the history of abortion were one of the common factors associated with HBV among Female sex workers (Table 3). In

Discussion
Globally the prevalence of HBV infection can be divided into high (> 8%), intermediate (2-8%) and low (< 2%). Hence as the prevalence of HBV among Female sex workers in this study area found to be 9.2%, the prevalence is labeled as high occurrence.
This study revealed that the overall prevalence of HBV among female sex workers in hawass city was 9.2% (CI: 95% 6.3-12.1). This is lower than the study conducted in Gondar which was 11.9%, 5 Nigeria 17.1%, 8 Cameroon 36%, 15 Argentina 14.4%, 16 Shanghai, China 12.3%, 17 in Goiânia, Brazil 17.1% 18 and Southern Brazil 23.1%. 19 On the other hand this study is higher than the study conducted in Mekelle, Ethiopia 6%, 6 Iran 1.2%, 20 Rwanda 2.5%, 21 Congo 7.3%, 7 Italy 3.5%, 22 Venezuela 3.8%, 23 and Afghanistan 6.54%. 11 This variation of ndings across various studies might be due to diagnostic tools and reporting biases, differences in socio-demographic, differences in socio economic environments. Prevalence estimates also are likely to be in uenced by stigma and discrimination and also study settings. Also unemployment status of the females might be enforced to engage in risky sexual services. 11 Also, the history of previous vaccination, high prevalence of HBV among general population, use of illegal injecting drugs, consumption of alcohol, breaking of the condom during sex, a long period of prostitute engagement, anal sex and the presence of other sexual transmitted infections among female sex workers may be contributed. 24,25 The major determinants of HBV were, low adherence to the condom use, history of genital ulcer, history of sexual transmitted infections, sexes during menses, sexual assault and shared use of sharp materials were statistically signi cant (p < 0.05). This is similar to the study conducted in Nigeria. 8 In Studies indicated that History of STI were predictors of exposure to HBV. 18,20,30 Consistently, result of this study re ected the odds of participants who have history of STI which were more than 2 times to be positive as compared with participants who don't have [AOR = 2.15, (1.02,6.93)]. The most common history of STI was Neisseria gonorrhea and syphilis. Also genital ulcers were seen among 27.6% participants. These infections can cause in ammation and ulcer around the genital area. Thus, it may increase the risk of becoming infected with HBV.
In this study, educational status, history of blood transfusion and alcohol consumption were not statically signi cant association with HBV as other studies done in Teresina-PI, Northeastern Brazil among sex workers, in three Afghan cities among female sex workers, in Mekelle among commercial sex workers and in Tehran, Iran among female sex workers found out. 6,9,20,27,28 Even though the female sex workers who did not vaccinated previously for HBV were more in number for HBV infection than those who vaccinated, there is no statistical signi cant association in this study. However, similar studies were done in Argentina shown that none vaccinated people developed HBV infection more likely than vaccinated peoples. 16 This indicates that vaccination is one of the prevention mechanisms of HBV infection.
According to this study, those who have previous sexual transmitted infection especially syphilis were statistically signi cant with the infection of HBV which is similar to the study done in, Iran and other different countries. 18,20,30 Also Female sex workers who are not avoiding sex during menses were more than ve times affected by HBV infection which is inconsistent with the study of Mekelle, Ethiopia. 6 This study also showed that previous sexual assaulted female sex workers had more than two times the probability to develop HBV infection than those of not harassed. This correlates with studies from North America and South Africa have shown that women who have experienced sexual abuse are more likely to acquire HBV infection. 12,13 As study done in Northeastern Brazil 27 sharing of sharp materials for tattooing and another purpose is signi cantly in uencing HBV infection among female sex workers (p < 0.05) in this study area. Also history of genital ulcer and the habit of unsafe abortion was statistically signi cant among female sex workers to acquire HBV. 18 Also, age, marital status, residence, monthly income, presence of steady partners, and type of sex usually used has no statistically signi cant association in this study area. This is similar to the study of Mekelle, Ethiopia. 6 Ethical approval was obtained from the Hawassa University Institutional Review Board Committee. A permission letter was granted from the Southern Nation, Nationality and People Regional Health Bureau to respective health institu tions. Written consent was obtained from each participant prior to data collection. After informing each respondent about the aim and purpose of the study, participants were asked for their voluntary participation. Those respondents were assured they could withdraw from the study anytime if they felt unhappy. They were also informed that all data obtained from them would be kept con dential by using codes instead of any personal identi ers.

Consent for publication
Not applicable Availability of data and material All data and materials in this manuscript could be deposited in publicly available repositories. All relevant data is included in the paper, the full data available from the Family Guidance Association (FGA) of the Southern Ethiopia, Hawassa.

Competing interests
The authors have declared that no competing interests exist. Funding