The screening of hepatitis B virus and hepatitis C virus infection in HIV-infected inpatients and evaluating correlated characteristics

doi:10.21203/rs.3.rs-2067463/v1

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The screening of hepatitis B virus and hepatitis C virus infection in HIV-infected inpatients and evaluating correlated characteristics

https://doi.org/10.21203/rs.3.rs-2067463/v1

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Background: This study surveyed the prevalence of hepatitis B surface antigen (HBsAg）and hepatitis C virus（HCV）antibody (anti-HCV) among inpatients with HIV infection and analyzed the correlated factors.

Methods: We conducted a retrospective data collection of the HIV-infected inpatients in our hospital from January 2010 to December 2020. We utilized multivariate logistic regression to find the correlated factors.

Results: The proportion of patients screened for HBsAg were 81.8% , which increased from 66.7% in 2010 to 85.7% in 2020. The proportion of patients with anti-HCV screening were 73.9%, which increased from 58.3% in 2010 to 86.7% in 2020. The prevalence of HBsAg-positive was 10.9%, which decreased from 15.0% in the period of 2010-2015 to 9.0% for HBsAg during 2016-2020. There were 4.1% cases with positive anti-HCV. Compared to 4.8% at the period of 2010-2015, there was a similar prevalence of 3.1% for anti-HCV during 2016-2020. Among HBsAg-positive cases, HBV DNA was screened in 70.8% cases. Among anti-HCV positive cases, HCV RNA were screened in 90% cases. The ALB <30 g/L, thrombocytopenia, AST >40 U/L were associated with HBsAg-positive. The AST >40 U/L and higher CD4+ T counts were associated with HIV/HCV coinfection.

Conclusions: The routine screening for both HBV and HCV among HIV-positive inpatients has been greatly improved in the past decade. However, the screening of the complete HBV serological markers in HIV-positive inpatients, and HCV genotyping among HCVRNA-positive cases leaves much to be desired. A concerted effort should be taken for improving HBV vaccine compliance in the HIV-positive population and providing direct-acting antiviral therapies to HCVRNA-positive patients.

human immunodeficiency virus

hepatitis B virus

hepatitis C virus

antiretroviral therapy

In the past 30 years, China has successfully reduced hepatitis B virus (HBV) endemicity from high to intermediate with the HBV vaccination. However, human immunodeficiency virus (HIV)/HBV coinfection remains an urgent concern because most current HIV-positive cases were predominantly born before the routine HBV immunization in China. Compared to less than 5% of HBV infection chronicity among HIV-negative adults, there was more than 10% chronicity among HIV- positive adults (1, 2). Spontaneous acute hepatitis C virus (HCV) resolution was observed in only 14.4%–23% of infections in HIV-positive patients (3, 4). Patients with HBV or HCV coinfection were susceptible to liver damage (5, 6). Compared with HIV monoinfected patients, HBV or HCV-coinfected patients had accelerated progression of cirrhosis, higher liver-related death and all-cause death (7, 8). A poorer increasement of CD4+ T cell count after antiretroviral therapy (ART) was found among HBV/HIV coinfected patients (9). Among HIV seropositive population, the prevalence of HBV or HCV infection was higher than the HIV-negative population (10, 11). The percentage of HBV coinfection was 20–30% in sub-Saharan Africa and Asia, while only at 5–10% in North America, Europe and Australia (12). The HBV co-infection rate was higher in southern China (14.18%) and western China (10.73%) , while lower in northern China (6.36%) (13). The prevalence of HBsAg was higher among cases with age ≥ 40 than cases with age ≤ 40 (14). There was a moderate HBV-coinfection decrease in 2015 in China, compared to 2007 (15). In recent years, an obvious decrease of anti-HCV in the HIV-positive population was observed (14, 15). Intravenous drug user (IVDUs) and men who have sex with men (MSM) had a high prevalence of HCV/HIV co-infection (4, 16). Among HIV-positive individuals with African ancestry in the United Kingdom, the prevalence of anti-HCV and HCV RNA were 1.3% and 0.17%, respectively (17). The prevalence of HCV/HIV coinfection was 29.6% in Nepal (16). Importantly, HBsAg testing practice among the HIV-positive population showed obvious regional differences,with only 0.7% in Kenya compared to 96.0% in South Africa (18). Although HBV or HCV are routinely tested for when starting ART in China, they are not routinely tested for among HIV-positive inpatients. Among HIV/HBV coinfected patients under ART, the seroconversion and reappearance of HBsAg or hepatitis B e-antigen (HBeAg) were frequently observed (19, 20). The reactivation incidence of a former HBV infection (21) and the HBV incidence was observed in follow-up individuals receiving HIV care (22) . The recently acquired HCV infection (RAHC) incidence was also found among MSM with HIV infection (23, 24). The routine examination for HCV infection among inpatients was recommended (25). In order to achieve the global strategy to eliminate HBV and HCV by 2030 (26), we conducted a retrospective study of the screening of HBV and HCV infection among HIV-positive inpatients and evaluated correlated characteristics.

Study population

We retrospectively collected the records of HIV-positive inpatients in the First Affiliated Hospital of China Medical University from January 1, 2010 through December 31, 2020. The Clinical Research Ethics Committee of China Medical University approved this study.

Study design

Clinical and laboratory data were acquired from the cases’ medical records, which were implemented by three authors simultaneously. We analyzed the trend of screening rates for HBsAg and anti-HCV among inpatients. We also described the distribution modes of HBV serological markers among cases with complete serological results.We reported the data of HBV DNA detection for HBsAg-positives samples, HCV RNA detection among anti-HCV positive cases, and HCV genotyping among cases with positive HCV-RNA. We analyzed the factors that might be categorical variables of HBsAg and HCV/HIV co-infection, including age; sex, education level; local residents of Shen yang or not; body mass index (BMI); World Health Organization (WHO) HIV clinical stage classification; died in hospitalization or not; ART status before admission; CD4+T cell count; hemoglobin (HB); platelet (PLT) count; glutamic alanine transaminase (ALT); aspartate aminotransferase (AST); alkaline phosphatase (ALP); gamma-glutamyl transferase (GGT); total bilirubin (TBIL); serum albumin (ALB); serum creatinine (Scr), prothrombin time (PT) and serum sodium concentration.

Definitions

The complete HBV serological markers consisted of HBsAg, hepatitis B surface antibody (HBsAb), HBeAg, hepatitis B e antibody (HBeAb) and hepatitis B core antibody (HBcAb), which were quantified by chemiluminescence immunoassay (CLIA) using an “Alinity " instrument (Abbott Laboratories, Lake Forest, IL, USA). The isolated HBsAb was defined as positive HBsAb with negative HBsAg, HBeAg, HBeAb and HBcAb. The isolated HBcAb was defined as positive HBcAb with negative HBsAg and HBsAb. HCV coinfection was defined as HIV-positive individuals with both positive anti-HCV and positive HCV-RNA. Thrombocytopenia was defined as a platelet count less than 100,000/μL. Abdominal ultrasound examination or computed tomography scans were the diagnostic procedures for liver cirrhosis.

Statistical analysis

The data were illustrated as numbers and percentages. We compared conditions between HBsAg-positive patients and HBsAg-negative patients and between HIV/HCV coinfected patients and HIV mono-infected patients, respectively. Proportions for categorical variables were compared using the chi-squared test or Fisher’s exact test. Univariate and multivariate logistic regression models were employed to assess factors associated with HIV/HBV coinfection and HIV/HCV coinfection, respectively. The odds ratios (OR), adjusted odds ratios (AOR), and 95% confidence intervals (CI) were displayed. Variables with P < 0.10 in univariate analysis were included in the multivariate logistic models. Only variables with P < 0.05 were kept in the final multivariate models. Data were analyzed using the SPSS software for Windows version 22.0 (Chicago, IL,USA).

The prevalence of screening for HBsAg and anti-HCV among inpatients with HIV infection

There were 1002 hospitalized HIV-infected cases in our hospital between January, 2010 and December, 2020. The proportion of patients screened for HBsAg was 81.8% (820/1002), which increased from 66.7% in 2010 to 85.7% in 2020 overall (P=0.045) (Figure 1). Among 820 individuals tested, 89 (10.9%) cases were HBsAg-positive. There were 37.1% (33/89) patients who were aware of their HBV-infected condition before hospitalization. The HBsAg prevalence was 12.5% (52/415) in the 30-50 year age group and 11.6% (20/172) in the < 30 years age group, while only 7.3% (17/233) in the > 50 years age (P > 0.05). For HBsAg-positive samples, there were 70.8% (63/89) cases with HBV DNA detection including 46 cases with beyond 10,000 IU/ml, 13 cases with HBV DNA between 100 IU/ml and 10,000 IU/ml, and 4 cases with HBV DNA under 100 IU/ml. Compared to 15.0% prevalence of HBsAg in the period of 2010-2015, there was a moderate decrease to 9.0% during 2016-2020 period (P=0.01). At discharge, there were 95.5% (85/89) HBsAg-positive cases who received tenofovir disoproxil fumarate (TDF) or tenofovir alafenamide (TAF) -containing ART (Figure2). The percentage of patients screened for anti-HCV were 73.9% (740/1002), which increased from 58.3% in 2010 to 86.6% in 2020 overall (P=0.001) (Figure1). There were 4.1% (30/740) cases with positive anti-HCV. The positive anti-HCV prevalence was 5.5% (11/201) in > 50 years age and 4.4% (16/362) in the 30-50 years age group, while only 1.9% (3/161) in < 30 years age (P > 0.05). Compared to 4.8% in the period of 2010-2015, there was a similar prevalence of 3.1% for anti-HCV during 2016-2020 (P > 0.05). There were 90.0% (27/30) anti-HCV positive cases with HCV RNA detection and 9 of these tested negative for HCV RNA. Among 18 cases with positive HCV-RNA (HIV/HCV coinfection), 4 cases were tested for genotypes. At discharge, there were 50% (9/18) HCVRNA-positive cases who received anti-HCV therapy (Figure2).

Distribution of HBV serological markers among cases with complete serological results

There were 487 cases with complete HBV serological makers and 47 cases (9.7%) were HBsAg-positive. Among the 47 HBsAg-positive cases, 48.9% (23/47) cases were HBeAg-positive. Isolated HBsAb positivity among inpatients with HIV infection was 26.5% (129/487). The highest isolated HBsAb prevalence was 40.6% (43/106) in the < 30-years age group. The lowest isolated HBsAb prevalence was 16.2% (24/148) in the > 50-years age group. Among the 440 HBsAg-negative cases, there were 43.9% (193/440) cases with positive HBcAb including 92 cases with isolated anti-HBc. The pattern of all negative for HBV serological testing among inpatients with HIV infection was 24.2% (118/487) (Table I).

Clinical characteristics at baseline among HIV/HBV coinfected patients

Among HBsAg-positive participants, 11.2% (10/89) cases had cirrhosis (4 cases at Child-Pugh class B and 6 cases at Child-Pugh class C). Compared with the patients with HIV monoinfection, the cases with HBV coinfection were more likely to have thrombocytopenia (p = 0.001), ALB <30 g/L (p = 0.036), ALT >50 U/L (p = 0.038), AST >40 U/L (p=0.001), ALP >100 U/L(p = 0.002) and PT >13.7 S (p = 0.003) (Table II). The multivariate logistic regression analysis showed that thrombocytopenia (P=0.001), ALB < 30g/L (P=0.024) and AST >40 U/L (P = 0.004) were the characteristics for HBsAg-positive cases (Table III).

Clinical characteristics at baseline among HIV/HCV coinfected patients

Among the 18 HIV/HCV coinfected patients, 2 cases had cirrhosis at Child-Pugh calss A. There were 55.6% (10/18) patients who were aware of their HCV-infected status before hospitalization. Compared with the patients with HIV monoinfection, the cases with HCV coinfection were more likely to present with ALT >50 U/L (p = 0.018), AST > 40U/L (p < 0.022), ALP > 100 U/L (p = 0.014) and age <30 (p = 0.047), while less likely to have CD4+T counts <200 /µL (p = 0.001) (TableII). The multivariate logistic regression analysis showed that AST >40 U/L (P = 0.013) and higher CD4+T counts (P = 0.001) were the characteristics for HCV RNA-positive cases (Table III).

The screening for both HBV and HCV in HIV-positve inpatients in our hospital has greatly improved in the past decade, but still falls short of the 2030 target of 90% viral hepatitis B and C diagnosis(26). As one of the populations most affected by HBV and HCV infection, testing for hepatitis B and C in the HIV-positive population was recommended (26). HBsAg testing practice among the HIV population varies widely across countries, which remaining below 50% in most countries across sub-Saharan Africa (18). Although we observed that HBsAg screening increased considerably over time, the screening of complete HBV serological markers has leaves much room for improvement.

The HBsAg-positive rates was 10.9% in this study, which is higher than 6.1%-7.43% of the general population (27, 28). In this study, the HBsAg prevalence had no statistical age difference, while the highest HBsAg prevalence was previously reported in patients who were 41-50 years of age (27). Isolated HBsAb positivity in this study was 26.5%, which was higher than 7.7% in HIV-positive population (29), while similar to 27% in general population (27, 30). Considering the high prevalence of occult hepatitis B (OBI) in HIV-positive patients (31), detecting HBV DNA was necessary, especially among the HBsAg-negative patients with positive HBcAb (32). There was a higher HBV DNA load and HBeAg percentage among coinfected individuals compared to HBV mono-infected cases (33). The prevalence of HBeAg among HBsAg-positive cases in this study was 48.9%, which was previously reported from 24.4% to 48.5% in the HIV-positive population (33, 34), and higher than 31.04% in the general population (27). The prevalence of isolated HBcAb can be high in HCV or HIV-infected patients, and other types of immunocompromised patients. Isolated HBcAb positivity was 18.9% in this study, which is within the range of 7% to 40% previously reported. The thrombocytopenia, ALB<30g/L, and AST>40U/L were the correlated characteristics of HBsAg-positivity in this study. Higher ALT level and lower PLT count were correlated with advanced fibrosis among HIV/HBV coinfected patients (35). The PT and international normalized ratio were reported to be significantly high among coinfected individuals (33). HIV/HBV coinfected patients are associated with lower CD4+ T cell counts (36).

In this study, we observed that anti-HCV screening increased considerably over time, which was identical to a previous report (25). The anti-HCV positivity was only 4.1% in this study, which is higher than 0.88%-3.0% in the general population (26, 28). Most of the HIV-positive cases in our study were due to sexual transmission and had a lower HCV infection than IVDUs and former plasma donors. Only screening for anti-HCV among HIV-infected patients was not enough, 90% of anti-HCV-positive cases were screened by HCV RNA in this study, while HCV genotyping leaves much to be desired. Moreover, we should also pay attention to a high rate of occult hepatitis C (OCI) in HIV-positive patients with IVDUs (37). Higher AST levels and higher CD4+T cell counts were found among HIV/HCV coinfected inpatients because the abnormal liver tests were the main cause of hospital admission in a number of HIV/HCV coinfected patients. An AST >40 IU/L was correlated with HCV co-infection (38). Furthermore, the improving anti-HCV and anti-HIV testing among general outpatients and inpatients resulted in earlier discovery of HIV/HCV coinfected cases .

The limitations of our study were the small sample size and a lack of follow-up detection so that the HBV or HCV incidence rates were not obtained. We only enrolled inpatients in our hospital, which allowed us to collect detailed information from medical records. This study highlight the necessity of frequent monitoring of complete HBV serum markers and HBVDNA among the HIV-positive population. Despite being on lamivudine- and tenofovir -including ART , HBV viremia was still found in 28.6% of HIV/HBV-coinfected patients (39). Although the immunogenicity of the HBV vaccination in HIV-infected patients is inferior to the HIV-seronegative population, this could be obviously improved by a double dose of the HBV vaccine (40). Among cases with isolated HBcAb, monitoring and vaccination should also be recommended (41, 42). Indeed, a poor vaccine compliance was found among the HIV-infected population, which was associated with a lack of insurance coverage and low educational level (43). For the anti-HCV-positive cases, HCVRNA and HCV genotyping should be recommended. The direct-acting antiviral therapies (DAAs) achieved identical efficacy between patients with HCV monoinfection and patients with HIV/HCV coinfection.

There is more work to be done to shrink the viral hepatitis epidemics in HIV-positive populations. Improving the public knowledge level of HBV or HCV should be achieved. The routine monitoring of HBV or HCV serological and virological markers should be recommended as part of HIV clinic care. HBV vaccination is a priority for people living with HIV for preventing horizontal transmission of HBV. It is crucial to keep TDF or TAF in the anti-HIV regimen among HIV/HBV-coinfected cases, even in those with a clinically cured HBV infection. Importantly, optimizing the provision of DAA to HIV/HCV coinfected patients, monitoring for the recurrence and reinfection of HCV, and tracking RAHC incidence, will liminate of the barriers to achieve HCV radication.

HBsAg, hepatitis B surface antigen ; anti-HCV, hepatitis C virus antibody;HBV, hepatitis B virus; HIV, human immunodeficiency virus; HCV, hepatitis C virus; IVDUs, intravenous drug user; MSM, men who have sex with men ;RNA , ribonucleic Acid; ART, antiretroviral therapy; HBeAg , hepatitis B e-antigen ;RAHC, recently acquired HCV infection; DNA, deoxyribonucleic acid; BMI, body mass index; WHO, World Health Organization; HB, hemoglobin; PLT, platelet; ALT, glutamic alanine transaminase; AST, aspartate aminotransferase; ALP, alkaline phosphatase; GGT, gamma-glutamyltransferase; TBIL, total bilirubin; ALB, albumin; Scr, serum creatinine; PT,prothrombin time ; HBsAb, hepatitis B surface antibody ; HBeAb, hepatitis B e antibody ; HBcAb , hepatitis B core antibody;CLIA, chemiluminescence immunoassay; OR, odds ratios; AOR, adjusted odds ratios; CI, confidence intervals; OBI, occult hepatitis B; OCI, occult hepatitis C; TDF, tenofovir disoproxil fumarate; TAF, tenofovir alafenamide; DAAs, direct-acting antiviral therapies;

Competing interests

The authors declared no potential conflicts of interest.

Funding

This work was supported by the “double first-Class” university and discipline construction funds of China Medical university (3110119068 to Ying Wen).The funders had no role in the study design, data collection and analysis.

Authors’ Contributions

Cheng Bo Li and Sheng Liu were responsible for data collection, statistic analysis and article revising. Ying Zhou, Yu Wang, Wen Wang, Xu Lu, Cui Ming Sun, and Pei Liu were participated in the clinical diagnosis and treatment. Ying Wen took part in designing,writing and revising.

Acknowledgement

The authors extend their sincere thanks to all participants in the study. The authors also thank the statistic assistance of Qing Hai Hu from Key Laboratory of AIDS Immunology of Ministry of Health and Department of Laboratory Medicine in the First Affiliated Hospital of China Medical University.

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TableI The distribution of HBV markers different modes among HIV-positive inpatients

		HBsAg+ HBeAg+ HBcAb+ [n (%)]	HBsAg+ HBeAg- HBcAb+ [n (%)]	HBsAg- HBSAb- HBcAb+ [n (%)]	HBsAg- HBSAb+ HBcAb+ [n (%)]	HBsAg- HBSAb+ HBcAb- [n (%)]	HBsAg- HBSAb- HBcAb- [n (%)]
age	<30	6(1.2)	4(0.8)	8(1.6)	3(0.6)	43(8.8)	42(8.6)
	30-50	8(1.6)	11(2.3)	51(10.5)	51(10.5)	62(12.7)	50(10.3)
	>50	9(1.9)	9(1.9)	33(6.8)	47(9.7)	24(4.9)	26(5.3)
sex	male	22(4.5)	18(3.7)	88(18.1)	88(18.1)	124(25.5)	103(21.2)
sex	female	1(0.2)	6(1.2)	4(0.8)	13(2.7)	5(1.0)	15(3.1)
total	487(100.0)	23(4.7)	24(4.9)	92(18.9)	101(20.7)	129(26.5)	118(24.2)

TableII Comparison of the baseline clinical features

Characteristics	HBSAg+ (n, %)	HBsAg- (n, %)	P1	HCV-RNA+ (n, %)	HCVAb- (n, %)	P2
n	89(100.0)	731(100.0)		18(100.0)	710(100.0)
Age <30 30-50 >50	20(22.5)	152(20.8)		0(0.0)	158(22.3)
	52(58.4)	363(49.7)		10(55.6)	363(51.1)
	17(19.1)	216(29.5)	0.113	8(44.4)	190(26.8)	0.047^*
Education	27(30.3)	213(29.1)	0.814	4(22.2)	216(30.4)	0.606
Sex(male)	86(96.6)	662(90.6)	0.056	16(88.9)	650(91.5)	0.690
Local residents	45(50.6)	341(46.7)	0.485	11(61.1)	332(46.8)	0.228
WHO clinical stage III-IV	60(67.4)	492(67.3)	0.983	9(50)	493(69.4)	0.078
HB<9g/dl	12(13.5)	68(9.3)	0.209	2(11.1)	73(10.3)	0.909
ART	32(36.0)	224(30.6)	0.311	7(38.9)	232(32.7)	0.582
Thrombocytopenia	16(18.0)	45(6.2)	0.001^*	3(16.7)	53(7.5)	0.148
ALT>50U/L	31(34.8)	180(24.6)	0.038^*	9(50)	180(25.4)	0.018^*
AST>40 U/L	43(48.3)	208(28.5)	0.001^*	10(55.5)	215(30.3)	0.022^*
ALP>100 U/L	38(42.7)	196(26.8)	0.002^*	10(55.5)	204(28.7)	0.014^*
GGT>60U/L	49(55.1)	362(49.5)	0.324	12(66.7)	356(50.1)	0.166
TBIL>17.1 µmol/L	1(1.1)	17(2.3)	0.728	0(0.0)	18(2.5)	1.000
Serum ALB<30g/L	46(51.7)	266(36.4)	0.036^*	3(16.7)	278(39.2)	0.053
PT>13.7 S	51(57.3)	298(40.8)	0.003^*	7(38.9)	303(42.7)	0.748
Serum Na<135µmol/L	29(32.6)	222(30.4)	0.669	6(33.3)	225(31.7)	0.882
Scr>104 μmol/L	4(4.5)	13(1.8)	0.090	1(5.6)	17(2.4)	0.394
CD4<200 /µL	74(83.1)	557(76.2)	0.219	8(44.4)	556(78.3)	0.001^*
BMI<18	9(10.1)	118(16.1)	0.106	2(11.1)	110(15.5)	0.751
Death	4(4.5)	36(4.9)	0.859	1(5.6)	33(4.6)	0.857

*P value <0.05, statistically significant with the use of chi-square test or Fisher’s exact test.

P1, between HBSAg+and HBSAg- patients with HIV infection; P2, between HIV/HCV-coinfected and HIV-monoinfected patients

ART, antiretroviral therapy; HB, hemoglobin; Scr, serum creatinine; ALT, alaninetransaminase; AST, aspartate aminotransferase; BMI, body mass index; ALP, alkaline phosphatase; GGT, gamma-glutamyltransferase; TBIL, total bilirubin; DBIL, direct bilirubin; PT, prothrombin time

Table III Factors associated with HIV/HBV-coinfected and HIV/HCV-coinfected inpatients

	HIV/HBV-coinfected				HIV/HCV-coinfected
Factors	OR(95%Cl)	P1 value	Adjust OR(95%Cl)	P2 value	OR(95%Cl)	P3 value	Adjust OR(95%Cl)	P4 value
ALT>50U/L
No	1.000				1.000
Yes	1.636(1.198-3.029)	0.039			2.944(1.151-7.532)	0.024
AST>40U/L
No	1.000		1.000		1.000
Yes	2.350(1.505-3.670)	0.043	1.959(1.235-3.109)	0.004	2.878(1.120-7.392)	0.028	3.380(1.292-8.841)	0.013
ALP>100U/L
No	1.000				1.000
Yes	2.034(1.296-3.192)	0.002			3.100(1.207-7.967)	0.019
Thrombocytopenia
No	1.000		1.000
Yes	3.341(1.798-6.208)	0.001	3.061(1.621-5.780)	0.001
ALB<30g/L
No	1.000		1.000		1.000
Yes	1.870(1.202-2.910)	0.006	1.698(1.074-2.685)	0.024	0.311(0.089-1.083)	0.067
PT>13.7 S
No	1.000
Yes	1.950(1.249-3.044)	0.003
Scr>104 μmol/L
No	1.000
Yes	1.383(0.388-4.933)	0.090
WHO clinical stage III-IV
No					1.000
Yes					0.440 (0.172-1.124)	0.078
CD4<200 /µL
No					1.000
Yes					0.222(0.086-0.571)	0.002	0.195(0.075-0.510)	0.001

P1, P-value in a univariable analysis for HIV/HBV-coinfected patients; P2, P-value in the multivariable logistic regression models for HIV/HBV-coinfected patients; P3, P-value in a univariable analysis for HIV/HCV-coinfected patients; P4, P-value in the multivariable logistic regression models for HIV/HCV-coinfected patients;

No competing interests reported.

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The screening of hepatitis B virus and hepatitis C virus infection in HIV-infected inpatients and evaluating correlated characteristics

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