- Due to overlapping vulnerabilities, some people are co-infected with HIV and hepatitis B or C
- A study found that testing for all three viruses compared to HIV alone is cost effective
- Triple testing could move the world closer to eliminating these viruses as public health issues
Due to shared routes of infection, some populations are vulnerable to coinfection with HIV and/or hepatitis B virus and/or hepatitis C virus. Testing for all three viruses is not always done. This can allow some infections to go undiagnosed, cause harm and spread. Coinfection with these blood-borne viruses can accelerate the course of illness caused by each one.
About the three viruses
HBV and HCV are collectively referred to as viral hepatitis. These viruses infect the liver and gradually injure this vital organ, leading to persistent fatigue, the formation of scarred liver tissue, serious infections, liver failure and increased risk of liver cancer and death. Treatment for HBV is available to help manage the infection and allow people to live long, healthy lives. Treatment for HCV can cure this viral infection. Treatment for HIV (antiretroviral therapy, ART) can make a person healthier and, in many cases, allow for near-normal life expectancy. Furthermore, a person with HIV who is on effective treatment cannot pass on the virus to their sexual partners. However, if left untreated, HIV can severely damage the immune system.
Testing for all three viruses could help uncover previously undiagnosed infections and allow healthcare personnel to offer treatment.
Worldwide, it is estimated that collectively there are more than four million infections of HBV, HCV and HIV each year. What’s more, annual deaths from all three viruses are estimated to be 1.7 million. A team of researchers in the UK notes that without systemic intervention HBV and HCV will cause “more deaths [globally] annually than HIV, malaria and tuberculosis combined” by 2040.
Although much progress has been made against HIV, with many people being tested and offered treatment when a positive test occurs, in contrast, progress against viral hepatitis (hepatitis B and C viruses) is lagging.
A major barrier to progress against infection with all three viruses is access to testing. To begin to remedy this, in 2022 the World Health Organization (WHO) released guidelines on the care and treatment of HIV and viral hepatitis. The WHO guidelines recommended testing for these three viruses in the following populations:
- people who use drugs (PWUD)
- gay, bisexual and other men who have sex with men (gbMSM)
- incarcerated people
However, the three viruses are not limited to these populations.
An important review
Researchers in the UK recently conducted a systematic review of studies to explore the issue of triple-virus testing vs. HIV testing alone. The researchers examined 175 studies that involved 14 million people undergoing viral testing. They also assessed cost-effectiveness of triple testing. On average, 2% of people in the studies tested positive for at least one of the viruses.
The researchers reviewed the following populations (in the studies) who underwent testing:
- general population
- blood donors
- gbMSM
- incarcerated people
- pregnant people
- people seeking health care
- people experiencing homelessness
- PWUD
- refugees and asylum seekers
The researchers found that when triple testing was instituted “for each individual diagnosed with HIV, another five would be diagnosed with HBV and three with HCV.” Comparing the cheapest approved tests available, the researchers found that “testing for HIV, HBV and HCV using three individual tests would only be marginally more expensive than isolated HIV testing.”
The researchers stated that their findings justify “the expansion of isolated HIV testing into triple [virus] testing in not just the WHO’s recommended risk groups but for all vulnerable groups.”
Achieving success
For a program of triple testing to have a successful impact on society, the researchers made the following points:
- “Low-priced and affordable tests need to be made accessible to all risk groups globally.”
- “Healthcare staff need to be adequately trained to deliver these tests.”
- “Universal access to appropriate and affordable treatment must be provided.”
The researchers stated that programs that offer testing and treatment “need to be culturally appropriate to both the region and vulnerable individuals they are serving.” They cautioned that “in many countries, religious and cultural beliefs often influence blood-borne virus stigmatization, creating difficulties in increasing the uptake and acceptance of testing, irrespective of test availability. It is only if these problems, amongst many others, are also addressed that the [goal of eliminating these viruses as public health threats by 2030] will be achieved.”
For the future
The UK team calls for further research to consider the feasibility of expanding triple-virus testing into prevention. For instance, they stated that people who test negative for HBV could be offered vaccination, which is a highly effective form of prevention. People who tested negative for HIV could be offered pre-exposure prophylaxis (PrEP), a highly effective form of prevention for that virus.
The UK team raised the possibility of adding other infections to the list of tests that could be done at the same time. One example would be syphilis, which has similar routes of transmission to the three viruses. Ultimately, one can envision testing for HIV, HBV, HCV and syphilis.
Commentary
Infectious disease specialist Dr. Chloe Orkin, a professor at Queen Mary University in London, England, reviewed the analysis done by the researchers. In a commentary in the journal Open Forum Infectious Diseases, Dr. Orkin gave examples of triple-virus testing in the UK and Europe that helped uncover previously undiagnosed infections. She encouraged universal access to testing for all three viruses. Making such virus testing routine so that patients would have to opt-out if they do not wish to be tested could help increase acceptance of such testing and reduce stigma that is still associated with blood-borne viruses.
Bear in mind
The review of studies of triple testing has validated the WHO’s approach to virus elimination. It can help bring vulnerable populations, public health staff, healthcare personnel, community groups and governments together and move the world forward to help eliminate HIV, HBV and HCV as public health issues by 2030.
—Sean R. Hosein
Resources
Elimination of hepatitis by 2030 – World Health Organization
Hepatitis B in Canada: 2021 surveillance data update – PHAC
Read online | Download the infographic
Hepatitis C in Canada: 2021 surveillance data update – PHAC
Read online | Download the infographic
HIV in Canada: 2022 surveillance highlights – PHAC
Read online | Download the infographic
Trends in HIV pre-exposure prophylaxis [HIV-PrEP] use in nine Canadian provinces, 2019-2022 – PHAC
Read online | Download the infographic
Hepatitis C testing and diagnosis – CATIE
Blueprint to inform hepatitis C elimination efforts in Canada — Canadian Network on Hepatitis C
Harm Reduction Fundamentals: A toolkit for service providers — CATIE
REFERENCES:
- Hill A and Beard N. Combined “test and treat” campaigns for HIV, hepatitis B and hepatitis C: A systematic review to provide evidence to support WHO treatment guidelines. Open Forum Infectious Diseases. 2024; in press.
- Orkin C. Should HIV testing be replaced with combined blood borne virus (BBV) testing? Open Forum Infectious Diseases. 2024; in press.