Hepatitis B and C Virus, Human Immunodeficiency Virus Co-infection among Pregnant Women in Semi-rural Health District, Cameroon

Background In are highly endemic to the pregnant woman. These viruses pose a high risk of vertical transmission and have been reported as the most important causes of maternal mortality. The aim objective of this study was to determine the hepatitis B, C and HIV virus co-infection among pregnant women in the Bafia health district. Methods A cross-sectional study was conducted from may to july 2018 in 145 pregnant women attending the health district of Bafia. HIV was diagnosed and confirmed using the Determine and Oraquick HIV1/2, HBV by NOVA test (HBV Multi Panel One Step) and HCV by ACCURATE test. Statistical analysis was performed using the Epi info software version 7.2.1.0. Furthermore, statistical association was performed using Odds Ratio (OR) and Fisher Exact test where appropriate, with corresponding 95% confidence interval (CI). The probability was considered statistical significant for all values p<0.05.


Background
Human Immunodeficiency Virus (HIV), Hepatitis B Virus (HBV) and Hepatitis C Virus (HCV) are major public health problems in the worldwide. The severity of these infections is related to the risk of transition to chronicity and exposing patients to cirrhosis and liver cancer [1]. The World Health Organization (WHO) estimates that about 2 billion people are infected with HBV, ~248 million people are chronically infected with the HBV, and more than 686 000 die from complications (cirrhosis and hepatocellular carcinoma) related to Hepatitis B each year [1]. About 110 million people are infected with HCV (ie antibody anti-HCV) and ~80 million people have chronic infection. Of the 36.7 million people infected with HIV (including 2.6 million children) around the world, ~70% live in sub-Saharan Africa, with constant risks of Mother-To-Child Transmission (MTCT) [2]. Due to the common modes of transmission (blood, sexual, blood transfusion and mother-to-child transmission) [3,4], these morbid infections could sustain a vicious cycle of reinforcement mutual. Mother-To-Child Transmission (MTCT) of HBV is an essential link in the maintenance of infection, especially in highly endemic countries. This risk is estimated at 10-40% if the mother carries HBsAg and 70-90% if the HBe antigen (HBeAg) is detected in the maternal serum. However, even in the absence of HBeAg (pre-core mutant) the risk of HBV transmission exists and the interpretation must take into account the viremia (threshold to be defined: > 7 log IU/ml) [5]. Viral hepatitis in pregnancy is associated with a high risk of maternal and child complications leading to spontaneous abortion, premature delivery, intrauterine growth restrictions and low birth weight [6]. Co-infection of HBV and HCV has become a factor of co-morbidity and mortality among people living with HIV (PLHIV) [7]. HIV infection increases the transition to the chronicity of acute hepatitis B and hepatitis C by increasing viral replication. It also increases the frequency of HBV reactivation in inactive HBV carriers, and accelerates the rate of progression of fibrosis, the development of cirrhosis and hepatocellular carcinoma (HCC) [8].
In Cameroon, the prevalence of HBV varies from 6 to 12% in pregnant women [6,9] and to our knowledge, there are very few national data available on the seroprevalence of HCV in pregnant women but also the co-infection of HBV and HCV infections in pregnant women living with HIV. In addition, the high prevalence of HIV infection during pregnancy in Africa (7.8% in Cameroon) suggests significant rates of vertical HIV infection, in the context of ongoing risks of mother-to-child transmission [10]. The prevalence of HIV-1 in infants born from mother-to-child transmission is 11.5% (434/3789) in Cameroon [11], suggesting possible T-cell immunity impaired and lower response to vaccination in these potentially vulnerable populations [12]. The risk of HCV transmission from mother to child is 4-8% in the perinatal period and 10-25% in children born to mothers co-infected with HIV [13]. Although UNAIDS has developed a program to prevent mother-to-child transmission of HIV, no program currently exists for viral hepatitis B and C [14]. A study conducted by Kaba and collaborator in three health areas in the West (Bafoussam, Bangangté and Bangoua) showed that in a population of 143 pregnant women received antenatal care (ANC) during the period from October to December 2015, 18 women (12.6%) were screened positive for HIV versus 14 (9.79%) positive for HBV-HBsAg and 14 (9.79%) for hepatitis C virus [15].

Study objectives
The objectives of this study was: (i) to determine the seroprevalence of HIV, HCV and HBV, (ii) to distribute serological markers of HIV, HBV, HCV based on socio-demographic characteristics, (iii) to show the co-infection between serologic markers of HIV, HBV and HCV in pregnant women in Bafia Health District.

Study design and population
A cross-sectional study was carried out from May to July 2018 in pregnant women attending the health district of Bafia. Bafia is a city of Cameroon located in the Center region, Mbam and Inoubou department, 120 km north of Yaoundé. It is the third largest city in the Central Region after Yaoundé and Mbalmayo. The health district of Bafia includes: a health center within it, the district hospital of Bafia, main health structure of the city which is endowed with the main specialties (general medicine, pediatrics, gynecology, odonto-stomatology, surgery, etc.) and several integrated health centers in certain neighborhoods and villages.
Sample and strategy of enrollmentThe minimum sample size was calculated using the following standard formula: N= z 2 p (1-p)/d 2 . With ''z''= the standard deviation of 1.96 (95% confidence interval), ''p''= the prevalence of HIV among pregnant women in Cameroon (7.8%) found by Bilong et al. [10] and ''d''= degree of precision (0.05) for a minimum sample size N= 110.46. One hundred and forty five (145) pregnant women were enrolled in our study. The type of sampling was accidental nonprobabilistic and the enrollment technique for the participants was the interview via a well-formulated anonymized questionnaire containing sociodemographic data (age, marital status, level of education, profession, parity and age of pregnancy). The criteria for selecting pregnant women were as follows:    attributed to the fact that pregnant women in this age group are at the peak of their reproductive years and are exposed to multiple sexual activities which is the main risk factor for HIV [30].  [34]. This high rate of anti-HCVAb in this age group may be explained by the fact that these women are at the peak of their reproductive years and are exposed to multiple sexual activities [30]. baby. HCV transmission from mother-to-child is 4 to 8% of births when women are infected with HCV and 17 to 25% of births when women are co-infected with HIV and HCV [36]. This co-infection could increase the risk of vertical transmission of these two viruses [37]. This risk of mother-to-child transmission of the C virus would be greater in cases of high viral load and HIV/HCV co-infection of up to 15 to 20% [37].

Study limitations
The investigation of HCV RNA not performed in pregnant women with anti-HCV antibodies (33.79%; 49/145) is the main limitation of our study. Of note, conforming HCV infection by a direct testing approach (HCV RNA or Ag) will help in detecting those with on going from those with past infection/exposure. Also lack of HBV-DNA PCR assay did not allow us in determining the contribution of OBI on the epidemiological burden of HBV during pregnancy in this semi-urban setting.

Declarations
Ethics approval and consent to participate Ethical approval was obtained (N°2018/07/1059/CNERSH/SP) from the National Ethics Committee of Research on Human Health of Cameroon and the administrative authorization from the Bafia Health District Chief. A written and verbal information note, informed consent from adult, parental consent or guardian for children were obtained. Confidentiality was secured by the use of unique identification codes attributed to each of the study participants.

Consent for publication
Not applicable.

Availability of data and material
The datasets used during the current study are available from the corresponding author on reasonable request.

Figure 1
Seroprevalence of HIV, HCV and HBV in the study population