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 ~  Abstract
 ~  Materials and me...
 ~  Results
 ~  Discussion
 ~  References

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Year : 2003  |  Volume : 21  |  Issue : 4  |  Page : 280-283

A cross sectional serological study of the co-infection of hepatitis b virus, hepatitis c virus and human immunodeficiency virus amongst a cohort of idus at Delhi

National Institute of Communicable Diseases, New Delhi - 110 054, India

Correspondence Address:
National Institute of Communicable Diseases, New Delhi - 110 054, India

 ~ Abstract 

A cross-sectional study was undertaken to find out co-prevalence of various infectious markers like Human Immunodeficiency Virus (HIV), Hepatitis B virus (HBV), Hepatitis C virus (HCV) and Syphilis infection amongst a cohort of injecting drug users (IDUs) in the city of Delhi. A total of 246 IDUs were enrolled during the 3 months period of the study. The results revealed a high prevalence of the viral markers studied i.e., HBV-39.59%, HCV-36.45%, HIV-36.99% and Syphilis-6.09%. A single marker infection was detected amongst 9.14% for HBV, 8.37% for HCV, 4.87% for HIV and 0.83% for Syphilis in samples tested for multiple markers. All the four markers could be detected in 1.76%. Amongst 11.16% and 27.9% of these samples, three and two markers respectively could be detected. The study revealed the problem of IV drug use and high prevalence of infectious markers including HIV in certain populations of Delhi and emphasizes the need for relevant interventions in these localised pockets.

How to cite this article:
Baveja U K, Chattopadhya D, Khera R, Joshi P M. A cross sectional serological study of the co-infection of hepatitis b virus, hepatitis c virus and human immunodeficiency virus amongst a cohort of idus at Delhi. Indian J Med Microbiol 2003;21:280-3

How to cite this URL:
Baveja U K, Chattopadhya D, Khera R, Joshi P M. A cross sectional serological study of the co-infection of hepatitis b virus, hepatitis c virus and human immunodeficiency virus amongst a cohort of idus at Delhi. Indian J Med Microbiol [serial online] 2003 [cited 2021 Mar 2];21:280-3. Available from:

Hepatitis B virus (HBV) carrier rate in India is approximately 3% and antibodies against hepatitis C virus (HCV) are present in 1-1.5% of Indian population.[1] Annually, approximately two lakh people die of HBV or HCV infections alone. There are about 3.9 million HIV infected cases in India and more than 29,000 have AIDS.[2] Drug addicts represent a group for high risk of acquiring parenterally transmitted infections and are very frequently infected with HIV, HCV and HBV. It is very likely that an injecting drug user (IDU) infected with HIV will also be infected with HBV and / or HCV because of the common high risk behaviour on one hand and similar route of transmission of these agents on the other hand.[3]
The pattern of hepatotropic viral infections varies according to the risk group. HIV infected IDUs are more likely to be exposed to HCV, whereas HBV infections are more common in IDUs.[4],[5] IDUs also have other high risk behaviours such as sexual promiscuity resulting in acquisition of sexually transmitted diseases in addition to above infections. During the early phase of annual rounds of HIV sentinel surveillance conducted by National AIDS Control Organisation, IDU sentinel sites were selected only in few North-Eastern states of India with the presumption that drug abuse was mainly limited to these states located in the so called Golden Triangle Tract. However, Sharan (an NGO mainly working with drug addicts) found (unpublished) the presence of IDUs in different pockets of Delhi. The present study was undertaken in collaboration with Sharan as a sentinel study to find out prevalence of HIV, HBV and HCV and Syphilis in drug addicts in pockets of Delhi with an aim to carry out targeted interventions for harm-reduction and control of parenterally transmitted viral infections in such cohorts in the cities.

 ~ Materials and methods Top

The sample size and the study design were the same as being followed at NACO identified sentinel sites at Manipur for the annual HIV sentinel surveillance round.[6] The study population comprised of a known population of IDUs staying in low income slum namely Yamuna Bazar area at Delhi. A cross sectional study was conducted over a period of 3 months. A total of 246 blood samples were collected from IDUs.
Inclusion criteria
1. Male IDUs above 15 years of age residing within a radius of 3 km surrounding Sharan Centre at Yamuna Ghat.
2. The IDUs were alert, had been residing in the area for last 6 months and understood the content of counselling as well as the consent form for HIV testing that was included in the study.
The participants were the first consecutive 246 IDUs who consented to participate in the study and gave blood for testing after pretest counselling during the period. The blood sample (5mL) was collected in a clean dry test tube, coded and transferred to the laboratory at NICD on the same day for testing. The serum was separated and stored at 2-8C till tested. Testing was completed within a week of receipt of sample.
Serological tests were performed for HBV, HCV, HIV and Syphilis using commercially available kits and following the manufacturer's instructions.
HBsAg was detected in subject's serum using Genedia HBsAg ELISA 3.0 (Korea Green Cross Corp, Korea). ELISA performed as per the instructions of the manufacturer and result was interpreted as reactive or nonreactive. Anti-HCV antibodies were detected in the serum using Innotest HCV Ab III (Innogenetics, Belgium) EIA. The sera samples which were reactive in Innotest HCV Ab III assay were subjected to the supplementary Line Immuno Assay (Innogenetics INNO-LIA HCV Ab III update, Belgium). The results were expressed as reactive, non-reactive and indeterminate on the basis of the bands developed on the strip. Anti-HIV antibodies were detected using the commercial assays for screening and confirmation of the results. Innotest HIV-1/HIV-2 Ab. S.P. (Innogenetics, Belgium) was used as the screening assay and test was performed and interpreted as per the manufacturer's instructions. The serum found to be reactive in the screening assay was subjected to the supplementary confirmatory tests viz. rapid tests as well as Line Immuno Assay using INNOLIA HIV-1/HIV-2 Ab (Innogenetics, Belgium). The rapid tests used were Immunocomb Bispot HIV-1 & HIV-2 test and Capillus test. All the tests were performed and interpreted as per the instructions of the manufacturer. A serum found to be reactive for anti-HIV antibodies in all three ELISA/Rapid tests and confirmed by INNOLIA was considered to be positive for HIV-antibodies. Syphi TEST-RPR antigen tests (Rashmi Diagnostics Pvt. Ltd., Bangalore) was used as screening assay for detecting reagin antibodies as per the manufacturer's instructions. Serum samples reactive in RPR test were subjected to Treponema pallidum haemagglutination test (TPHA, Omega Diagnostics Ltd., Alloa, Scotland, U.K.) according to the manufacturer's instructions. The sample reactive in RPR and TPHA tests was interpreted as being positive for syphilis.
Statistical analysis
The statistical significance of the prevalence of infections obtained was tested using Chi square test.

 ~ Results Top

Characteristics of the target population
Situation assessment of the target population under study was carried out by Sharan (NGO) and the following characteristics were observed in IDUs in Delhi. The first use of abusive drugs was at the age of 13-18 years, and age range of IDUs was 15-65 years (largest proportion of IDUs were 21-40 years old). Male to female ratio was 100 : 3.5. Majority of the subjects were semi-literate with an average of 3 years spent in school. About 70% belonged to the lower socio-economic strata. Most were underemployed daily wagers. Some were engaged in petty crimes (pick-pocketing, small time drug dealing, petty thieving, etc). In Delhi, the bulk of IDUs were drivers, cycle rikshaw pullers, rag pickers, porters at railway stations, etc. The cohort under study belonged to low socio-economic status, low literacy status and shared practice of similar risk behaviour of drug abuse.
Serological results
The table outlines the results of serological tests in all subjects. Ninety one out of 246 (36.99%) subjects were confirmed to be HIV-1 positive. Twelve (4.87%) of these IDUs had only HIV infection and were negative for all the other infectious markers in samples tested for multiple markers.
HBsAg was positive in 78/197 (39.59%) IDUs. HBsAg as a single infectious marker was detected in 18 (9.13%) IDUs. Anti-HCV antibodies were detected in 99/203 (48.76%) individuals by ELISA, out of which 74 (36.45%) were confirmed by INNOLIA test.
RPR test was positive in 15/246 (6.09%) cases. RPR as a single infectious marker was found in two (0.83%) cases only.
As expected, most of IDUs carried multiple infectious markers transmitted parenterally. Out of 197 samples that could be tested for all the markers three (1.76%) IDUs were positive for all the 4 markers studies, twenty two (11.16%) were positive for three and 55 (27.9%) for two markers in various permutations and combinations.
Statistical calculations using Chi square revealed that the difference in prevalence of Syphilis and HIV was statistically significant (P<0.05). However, the difference in prevalence of other infectious markers such as HBsAg and HCV vis-a-vis HIV was not statistically significant (P>0.05).
NC = Percentage not calculated due to small sample size
[1] Sample not tested for HBV (HBsAg)
[2] Samples not tested for HBV (HBsAg) and HCV
[3] Prevalence indicates number of samples positive among samples tested for multiple markers (i.e., all 4 or 3 or 2 markers)

 ~ Discussion Top

The infectious consequences of drug injection poses a global problem with more than 60 countries documenting HIV infection among persons practising illicit drug injection today.[7] Problem of injecting drug use (IDU) along with high prevalence of associated infections is rapidly spreading in some developing countries including India.[8],[9]
In USA, seroprevalence of HIV, HBV and HCV among IDUs showed a considerable decline from as high as 24%, 84%, 85.3% during 1988-89 to 0.69%, 3.73%, 4.60% in the year 93-94 for the three markers, respectively.[10] On the other hand, a developing country like Brazil reported seroprevalence rates among IDUs as high as 62%, 75% and 75% for HIV, HBV and HCV respectively.[11]
In the present study prevalence of HBV (39.59%) was found to be considerably higher compared to studies conducted in eastern India i.e., Kolkata (20% positivity for HBsAg) while incidence of HCV was found to be lower (36.45%) compared to a study from Manipur (92% positivity).[12],[13] In the present study, difference in prevalence of HIV and Syphilis was statistically significant while difference in prevalence of HBsAg and HCV was not significant. These findings indicate that the main route of transmission of various infectious markers in this cohort was parenteral. The other risk behaviour i.e., sexual promiscuity prevalent in the cohort did not result in transmission of the STD studied (Syphilis), may be due to the use of condom.
From the present study it can be concluded that IDUs are not restricted to the Golden Triangle Tract as was believed earlier. Drug abuse is prevalent in metropolis and other cities. The prevalence of various infectious markers transmitted parenterally will depend upon the initial disease burden of these markers in the community. Targeted interventions are required for such population groups located in HIV low prevalence states with high transmission of HIV due to risk behaviour. 

 ~ References Top

1.Acharya SK. Hepatology in India. Sailing without a mast. Trop Gastroenterol 1999;20:145.  Back to cited text no. 1    
2.National AIDS Control Organisation : 2001. Sentinel Surveillance Report. (Restricted circulation).  Back to cited text no. 2    
3.Zeldis JB, Jain S Kuramoto IK, Richards C, et al. Seroepidemiology of viral infecions among intravenous drug users in northern California. West J Med 1992;156:30-35.  Back to cited text no. 3    
4.Bodsworth NJ, Cooper DA, Donovan B. The influence of human HIV type-1 on the development of the Hepatitis B carrier state. J Infect Dis 1991;163:1138-1140.  Back to cited text no. 4    
5.Chambost H, Gerolami V, Halfou PI, et al. Persisted hepatitis C virus RNA replication in haemophilics : role of co-infection with HIV. Br J Haematol 1995;91:703-707.  Back to cited text no. 5    
6.WHO. Carrying out HIV sentinel surveillance; a guide for programme managers. 1992 WHO publication SEA/AIDS/68.  Back to cited text no. 6    
7.WHO collaborative study group on drug abuse, programme on substance abuse: multi-city study of HIV infection among IDUs. In : final report of the WHO/PSA 1994.  Back to cited text no. 7    
8.Sarkar S, Panda S, Naik TN, et al. Rapid spread of HIV among injecting drug users in north-eastern states of India. Bull Narc 1993;45:91-105.  Back to cited text no. 8    
9.Garfein RS, Vlahov D, Galai N, Doherty MC, Nelson KE, Richard S. Viral infections in short term injecting drug users: The prevalence of Hepatitis C, Hepatitis B, Human Immunodeficiency and Human T-lymphotropic virus. Am J Pub Hlth 1996; 86:655-61.  Back to cited text no. 9    
10.Vlahov D, Anthony JC, Munoz A, et al. The ALIVE study: a longitudinal study of HIV-1 infection in intravenous drug users : description of methods. J Drug Issues 1991;21:759-763.  Back to cited text no. 10    
11.deCarvalho HB, Mesquita F, Massod E, et al. HIV and infections of similar transmission patterns in drug injectors community of Santos, Brazil. J AIDS Hum Retrovir 1996;12:84-92.  Back to cited text no. 11    
12.Panda S, Chatterjee A, Bhattacharjee S, Ray B, Saha MK, Bhattacharya SK. HIV, hepatitis B and sexual practices in the street recruited injecting drug users of Kolkatta ; risk perception virus observed risks. Int J STD AIDS 1998;9:214-218.  Back to cited text no. 12    
13.Saha MK, Chakraborty S, Panda S, Naik TN, Manna B, Chatterjee A, Detels R, Bhattacharya SK. Prevalence of HCV and HBV infection amongst HIV seropositive intravenous drug users and their noninjecting lives in Manipur, India. Indian J Med Res 2000;111:37-39.  Back to cited text no. 13    
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2004 - Indian Journal of Medical Microbiology
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