This seroprevalence surveillance study in healthy, HIV-infected and -uninfected children and adolescents residing in a South African urban setting, suggests that South Africa has an intermediate HAV seroprevalence. Seroprevalence rates < 90% by 10 years of age (68.6%) are reported. Increased age and informal dwellings are statistically associated with HAV seropositivity, whilst HIV status does not significantly influence HAV seropositivity rates when adjusted for the other variables.
Although HIV-infection in children and adolescents, and maternal HIV status, did show a higher likelihood of the child/adolescent being anti-HAV IgG positive, HIV-infection did not prove to be a significant indicator of HAV seropositivity in multivariate analysis. Our HIV-infected cohort had majority (71.83%) immune and virological control. Virological testing yielded a 64% suppression rate, 16% low-level viremia, and 20% viremia. For South Africa, between July 2019 and June 2020, among all children and adolescents (aged 1–15 years) with an HIV viral load test, 49% were virally suppressed, 24% had low-level viraemia, and 27% had a viremia with VL > 1 000 copies/ml.12 Hence, our cohort demonstrated slightly better virological control compared to the national average. The HIV status did not have a significant impact on HAV seroprevalence; therefore, we suggest that countries with a high HIV burden should consider similar prevention strategies in HIV-infected and -uninfected children and adolescents.
Our data clearly illustrate that South Africa has now progressed to country with an HAV intermediate endemicity rate, with HAV seroprevalence by 10 years of age only 68.6%, and > 90% seropositivity only reached beyond 15 years of age. Considerations for prevention strategies, such as HAV immunisation, should include cost analyses. Cost-effectiveness of universal hepatitis A vaccination is well documented in other intermediate HAV endemicity regions such as Argentina, Brazil, Chile, and Mexico. Patterson et al reviewed patients presenting with hepatitis A at tertiary level hospitals Cape Town, South Africa, and calculated the total cost per hepatitis A hospitalisation of $1935.41 for adult patients and $563.06 for paediatric patients. Furthermore, more than 1 in every 10 hepatitis A cases (13.3%) developed complicated hepatitis A or resulted in death. 13 Further to the high cost and morbidity/mortality, Bruckmann et al showed that HAV is currently the leading cause of paediatric acute liver failure requiring transplantation in South Africa, with even further expenses and disease burden to the health sector. 14
The study was limited by participant enrolment in a single urban centre. However, Kalafong Provincial Tertiary Hospital, services a wide community of informal settlement households with poor access to clean water and sanitation. The General Household 2018 survey, released by Statistics South Africa15, showed that 13.1% of South African households were living in informal dwellings, 89.0% had access to an improved source of water, and 83.0% of households had improved sanitation. Our study participants were more frequently living in informal dwellings (26.7%), had less access to clean water sources inside the household (43.6%), and had less access to proper sanitation (77.9%) compared to the general South African average in 2018. This would likely have overestimated the HAV seroprevalence, making it even more evident that South Africa has reached an intermediate HAV endemicity.