clinical study prevalence of occult hepatitis b virus...

Hindawi Publishing CorporationBioMed Research InternationalVolume 2013 Article ID 859583 7 pageshttpdxdoiorg1011552013859583

Clinical StudyPrevalence of Occult Hepatitis B Virus Infection in a Cohort ofHIV-Positive Patients Resident in Sicily Italy

Fabio Tramuto1 Carmelo Massimo Maida1 Giuseppina M E Colomba1

Paola Di Carlo2 and Francesco Vitale1

1 Department of Sciences for the Health Promotion and Mother and Child Care ldquoG DrsquoAlessandrordquo Hygiene SectionUniversity of Palermo 133 Via del Vespro 90127 Palermo Italy

2 Department of Sciences for the Health Promotion and Mother and Child Care ldquoG DrsquoAlessandrordquo Infectious Diseases SectionUniversity of Palermo 133 Via del Vespro 90127 Palermo Italy

Correspondence should be addressed to Fabio Tramuto fabiotramutounipait

Received 30 April 2013 Revised 12 July 2013 Accepted 25 July 2013

Academic Editor Esteban Martinez

Copyright copy 2013 Fabio Tramuto et al This is an open access article distributed under the Creative Commons Attribution Licensewhich permits unrestricted use distribution and reproduction in any medium provided the original work is properly cited

Occult hepatitis B virus (OBI) in HIV-infected groups is still debated as well as the associated risk-factors and clinical significanceIn this paper we examined a total of 405 HBsAg-negativeHIV-infected patients enrolled from January 2007 to December 2009Overall the prevalence of OBI was 59 (95 confidence interval (CI

95) 38ndash87) it was more frequently associated with ldquoanti-HBc alonerdquo serological marker (113 adjusted odds ratio = 37 CI

95 14ndash98) although it was also detected in the absence of anyHBV serological marker (49 CI

95 23ndash91) A low prevalence of anti-HCV-positive patients with OBI was found (31 CI95

06ndash87) HIV RNA plasma levels or other immunologicalclinical characteristics were not significantly associated with OBI Allbut one occult HBV infections were sustained by genotype D viral strains OBI is relatively frequent in HIV-infected patientsalthough it does not seem to exert a relevant clinical impact Viral genotypes in occult HBV infections reflect those circulating inthe Mediterranean area

1 Introduction

The term ldquooccultrdquo hepatitis B infection (OBI) is defined bythe presence of HBV DNA in plasma andor liver tissueof subjects who lack detectable hepatitis B surface antigen(HBsAg)

Occult HBV infections are more frequently detected inindividuals with antibodies to hepatitis B core antigen (anti-HBc) [1] often as unique marker of HBV infection [2 3]Nevertheless recent estimates suggest that up to 20 ofindividuals with occult HBV could be negative even for anti-HBc antibodies or any other serological indicator of exposuretoHBV [4] indicating that diagnosis of occult HBV infectionis still an unresolved issue [5]

Theprevalence of occultHBV inHIV-positive individualsremains controversial varying between 0 and 90 [6ndash10]and the clinical significance is still unclear

Nevertheless occult HBV infection has important impli-cations in HIV coinfected groups being associated with

faster rate of liver disease progression toward cirrhosis andhepatocellular carcinoma [11]

Although the impact of occult HBV infection has beeninvestigated in different countries [3 7 9 12ndash14] and clinicalsettings [15] no data are available on the prevalence of OBIamong HIV-positive individuals from our geographic area

A cross-sectional retrospective study was carried outwith the aim of assessing the prevalence risk factors andgenotypic characteristics of occult HBV infection in a cohortof HIV-infected individuals living in Sicily either naıve ortreated with HAART

2 Materials and Methods

21 Study Population A cross-sectional retrospective studywas carried out on a total of 405 HBsAg-negativeHIV-positive subjects (median age 410 years 679males) admit-ted to the Infectious Diseases ward of the University Hospital

2 BioMed Research International

ldquoP Giacconerdquo Palermo Italy from January 2007 to December2009 in day-hospital regimen for clinical followup of HIVinfection

All demographic clinical and laboratory datawere storedaccording to the Italian laws on privacy and the research wasconducted following the Helsinki Declaration statementsThe study was reviewed and approved by the institutionalreview board of the university hospital

22 Laboratory Analysis Plasma samples of HIV-infectedpatients were collected and kept frozen at minus80∘C until fur-ther analysis HBVHCV serological markers of infec-tion were evaluated for routinary examination by the useof third-generation enzyme-linked-immunosorbent assays(Vitros Immunodiagnostics Ortho-Clinical DiagnosticsHigh Wycombe UK) and anti-HCV-positive samples wereconfirmedwith a third-generation recombinant-immunoblotassay (RIBA) (Ortho-Clinical Diagnostics High WycombeUK)

In addition for the baseline evaluation of liver injurysome biochemical parameters were tested alanineaspartateaminotransferase (ALTAST) totaldirectindirect biliru-bin gamma-glutamyl-transferase and alkaline phosphatase(Ortho-Clinical Diagnostics High Wycombe UK)

Detection of occult HBV infection was carried out inagreementwith the key recommendations of EASL consensusconference [16] In this regard up to 1mL of plasma samplecollected from HBsAg-negative patients was used duringRNA extraction and three different in-house nested-PCRamplification assays were applied to detect pre-SS pre-CoreCore and Pol HBV viral sequences respectively [3]Appropriate negative and positive controls were included ineach PCR reaction

In our study a ldquocase of occult HBV infectionrdquo was definedas a PCR-positivity in at least one of the three HBV domainsdefined after a confirmation of its specificity by sequencing[3]

Viral nucleotide sequences obtained from each PCR-positive sample were submitted to the web-based genotypingprogram at the National Center for Biotechnology Informa-tion (NCBI) (httpwwwncbinlmnihgovprojectsgenoty-pingformpagecgi) to identify the corresponding HBV gen-otype

All tests were performed at the Molecular EpidemiologyLaboratory of the Department of Sciences for Health Promo-tion and Mother and Child Care ldquoG DrsquoAlessandrordquo Hygienesection University of Palermo Italy

23 Statistical Analysis Descriptive statistics were calculatedand reported for sociodemographic and clinical characteris-tics Median and interquartile ranges (IQRs) were used fordescription of continuous variables while frequency analysesfor categorical variables were described with the use ofpercentages

According to data distribution comparisons of con-tinuous variables were conducted by using Students 119905-testor Mann-Whitney 119880 test while categorical variables werecompared with the Chi-square test or Fisherrsquos exact test as

appropriate A 119875 value lt 005 was considered to indicatestatistical significance

A logistic regression analysis was used to examine theassociation between occult HBV status and specific sero-logical pattern of viral infection and the results were ex-pressed as odds ratios (ORs) with 95 confidence intervals(CIs)

Statistic analysis was performed by using STATA forApple (version 121MP StataCorp College Station TXUSA)

3 Results

Table 1 describes the sociodemographic and serological char-acteristics of the study populationThe study group consistedof 405HBsAg-negativeHIV-positive subjects (275males and130 females M F ratio = 21) with a median age of 410 years(IQR = 142 years) females were slightly younger than males(403 years versus 417 years resp)

More than two-thirds of subjects (785 119899 = 318405)reported promiscuous sexual activity as risk behaviour asso-ciated to HIV positivity while intravenous drug use (IVDU)was prevalent among HIVHCV coinfected patients (449119899 = 4498)

The cohort of subjects presented in this paper mainlyconsisted of native Italians (827 119899 = 335405) 156 (119899 =63405) were Africans and only a minority originated fromother geographic regions including Eastern Europe (17 119899 =7405)

According to the HBVHCV serological status five dif-ferent categories were identified One hundred eighty-threeHIV-positive individuals (452) were negative to all of theserologicalmarkers ofHBV infection performed in this study88 (217) were anti-HBs + anti-HBc positive 71 (175)showed the serological profile ldquoanti-HBc alonerdquo and 63(156) were positive to anti-HBs as unique marker of infec-tion Overall 242 of HIV-positive subjects (119899 = 98405)were coinfected with HCV the anti-HBc alone pattern wasmore frequently detected in HCV c-infected individuals thanin HCV-negative subjects (388 versus 107 OR = 53119875 lt 0001)

DNA sequences of hepatitis B viruses were detectedin 24 out of 405 patients (Table 2(a)) corresponding to acumulative prevalence of occult HBV of 59 (CI

95 38ndash87)

HBV DNA resulted more frequently associated to theserological pattern anti-HBc alone (113 119899 = 871)followed by anti-HBs + anti-HBc (68 119899 = 688) and noHBV markers (49 119899 = 9183) Moreover HBV DNAsequences were detected in 3 out of 98 patients coinfectedwith HCV (31) of whom two showed the pattern anti-HBcalone

HIV RNA plasma levels were lower among HBV DNA-negative than -positive individuals (18 log

10HIV RNA

copiesmL versus 28 log10

HIV RNA copiesmL) althoughabout half of OBI cases (417 119899 = 1024) had undetectableHIV viral load (le50 HIV RNA copiesmL)

Overall one hundred forty-five subjects (358) werenaıve to HAART The most part of patients with known

BioMed Research International 3

Table 1 Socio-demographic and serological characteristics of 405 HBsAg-negativeHIV-infected individuals

Characteristic (119899 () bycolumn) No HBV markers Anti-HBs + Anti-HBc Anti-HBc alone Anti-HBs alone Anti-HCV

Study population ( by row) 405 183 (452) 88 (217) 71 (175)lowast 63 (156) 98 (242)998779

SexMale 275 (679) 125 (685) 59 (667) 50 (704) 41 (641) 75 (765)Female 130 (321) 58 (315) 29 (333) 21 (296) 22 (359) 23 (235)M F ratio 21 21 20 24 19 33

Age (years median (IQR)) 410 (142) 410 (125) 439 (144) 438 (112) 320 (202) 451 (58)le20 years 15 (37) 6 (33) 3 (34) 2 (28) 4 (63) 1 (10)21ndash30 years 63 (155) 23 (126) 8 (91) 7 (99) 25 (397) 3 (31)31ndash40 years 108 (267) 57 (311) 24 (273) 15 (211) 12 (190) 13 (133)ge41 years 219 (541) 97 (530) 53 (602) 47 (662) 22 (349) 81 (827)

Mode of HIV transmissionHeterosexual 197 (486) 92 (503) 34 (386) 40 (563) 31 (492) 35 (357)Homosexual 121 (299) 63 (344) 24 (273) 9 (127) 25 (397) 15 (153)IVDU 71 (175) 21 (115) 23 (261) 21 (296) 6 (95) 44 (449)Otherunknown 16 (40) 7 (38) 7 (80) 1 (14) 1 (16) 4 (41)

Geographic originItaly 335 (827) 160 (874) 67 (761) 51 (718) 57 (905) 91 (929)Africa 63 (156) 20 (109) 17 (193) 20 (282) 6 (95) 7 (71)Eastern Europe 4 (10) 2 (11) 2 (23) 0 (0) 0 (0) 0 (0)Other 3 (07) 1 (05) 2 (23) 0 (0) 0 (0) 0 (0)

lowast

Anti-HCV positive versus anti-HCV negative = 388 versus 107 (OR = 53 CI95 30ndash93 119875 lt 0001)998779119899 = 29405 (72) HIVHCV coinfected subjects negative to all of the serological markers of HBV infection

IVDU Intravenous drug use

HAART regimens (751 119899 = 160213) were taking a therapyincluding lamivudine with similar proportions betweenHBV DNA-negative and -positive subjects (745 119899 = 149200 versus 846 119899 = 1113) The median time of exposureto antiretrovirals did not differ between OBI and non-OBIpatients

Immune status was also explored comparing the twoHBV DNA groups The CD

4

+ cell counts of HIV-infectedpatients were found to be similar between groups (388cellsmL versus 419 cellsmL 119875 = 0758) and a higher pro-portion of subjects with CD

4

+ counts le 200 cellsmL wasobserved in the HBV-DNA negative group in respect to theHBV DNA-positive group (229 119899 = 75328 versus 200119899 = 420) although the difference was not statistically sup-ported

Plasma concentrations of biochemical indicators of liverdamage were substantially similar in the two HBV groupsconsidered either in the cohort as a whole or in HAART-naıve subjects (data not shown)

Finally eachHIV-positive patient with occult HBV infec-tion was genetically characterized for viral HBV genotypeclassification Almost the totality of patients with OBI werecollected during the period 2008-2009 and were infectedby genotype D viruses only one subject native of sub-Saharan Africa harboured a genotype E hepatitis B virus(Table 2(b))

4 Discussion

In the present study a cohort of 405 HBsAg-negativeHIV-infected individuals was investigated in order to assess theimpact of occult HBV infection in Sicily and an overallprevalence of 59 (CI

95 38ndash87) was foundIn Italy the prevalence of OBI has been previously evalu-

ated in different clinical settings [3 9 14 17ndash19] and to ourknowledge this is the first work carried out in our geographicarea on a cohort of HIV-infected patients

In this specific high-risk group several studies have beenconducted worldwide and the available data on the frequencyof occult HBV infection are widely divergent ranging from0 to more than 90 [6ndash10] mostly depending on differ-ences in terms of sensitivity limit of the assay used (stan-dardnested PCR real-time PCR etc) number of HBVDNAdomains examined biological compartment explored (liverplasma or both) and composition of the study populations[1 20 21]

This work confirms that occult HBV can be detectedeither in patientswith serological evidence of past ldquoapparentlyresolvedrdquo HBV infection but also in individuals with noevident history of exposure to HBV [22]

The prevalence of OBI presented in this paper is quitesimilar to that reported in European countries such as TheNetherlands [6] consistently higher than that observed in


Table 2 Clinical virological and biochemical characteristics of 405 HBsAg-negativeHIV-infected individuals according to the detectionof occult HBV infection (a) and genotypicserological characterization of 24 OBI positive subjects (b)

(a)Characteristic (119899 () by column) Total HBV DNA negative HBV DNA positive CI95 or 119875 valueStudy population (119899 () by row) 405 381 (941) 24 (59) 38ndash87Serological markers of infection◻

No HBV markers 183 (452) 174 (951) 9 (49) 23ndash91Anti-HBs + anti-HBc 88 (217) 82 (932) 6 (68) 25ndash142Anti-HBc alone 71 (175) 63 (887) 8 (113)lowast998779 50ndash210Anti-HBs alone 63 (156) 62 (984) 1 (16) 01ndash85Anti-HCV 98 (242) 95 (969) 3 (31) 06ndash87

HIV viral loadHIV RNA [log10 copiesmL median (IQR)) 18 (30) 18 (30) 28 (31) 0834HIV RNA (le50 copiesmL) 196 (479) 186 (949) 10 (51) 0775

HAART regimenNaıve 145 (358) 138 (952) 7 (48)HAART including lamivudine 160 (395) 149 (931) 11 (69)HAART without lamivudine 53 (131) 51 (962) 2 (38)HAART not specified 47 (116) 43 (915) 4 (85)Months of treatment (median (IQR)) 552 (539) 549 (551) 581 (312) 0954

Immunological parameters (119899 = 348)CD4+ cell counts (median (IQR)) 390 (386) 388 (382) 419 (368) 0758

le200 cellsmL 79 (227) 75 (949) 4 (51)201ndash499 cellsmL 143 (411) 136 (951) 7 (49)ge500 cellsmL 126 (362) 117 (929) 9 (71)

(b)Case no Sex Age (years) Geographic origin Year of sampling Risk factor Anti-HBs Anti-HBc Anti-HCV Genotype1 F 223 Eastern Europe 2007 Hetero minus minus minus D2 F 268 Sub-Saharan Africa 2008 Hetero minus + minus D3 F 362 Sub-Saharan Africa 2009 Hetero minus minus minus D4 M 410 Sub-Saharan Africa 2009 Hetero minus + minus E5 M 400 Italy 2008 Hetero minus + minus D6 M 518 Italy 2008 Hetero + + minus D7 F 426 Italy 2008 Hetero minus minus minus D8 F 303 Italy 2008 Hetero minus minus minus D9 M 439 Italy 2008 Hetero minus minus + D10 M 344 Italy 2008 IVDU + + minus D11 F 380 Italy 2008 Hetero minus + minus D12 M 478 Italy 2008 Omo minus minus minus D13 M 531 Italy 2009 IVDU + + minus D14 M 600 Italy 2009 Hetero minus + minus D15 M 447 Italy 2009 Hetero + + minus D16 F 398 Italy 2009 Hetero + minus minus D17 F 389 Italy 2009 Hetero minus + minus D18 F 476 Italy 2009 Hetero minus minus minus D19 M 403 Italy 2009 Omo minus minus minus D20 M 432 Italy 2009 IVDU minus + + D21 F 394 Italy 2009 Hetero + + minus D22 M 352 Italy 2009 Omo + + minus D23 M 469 Italy 2009 Hetero minus + + D24 M 297 Italy 2009 Omo minus minus minus D◻

Frequency and pattern of HBV serological markers are not mutually exclusivelowastOR = 37 (14ndash98) Mantel-Haenszel OR adjusted for anti-HCV positivity998779OR = 40 (15ndash107) Mantel-Haenszel OR adjusted for anti-HCV positivity Analysis restricted to 145 HAART-naıve patientsCI95 95 confidence interval OR odds ratio IQR interquartile range Hetero heterosexual Omo homosexual IVDU intravenous drug use


Spain [13] France [21] or Taiwan [23] (07 06 and 23resp) but lower than that reported in countries either at lowor high rates of chronic HBV [7 20 24]

In Sicily the impact of OBI has been recently investigatedin different groups of subjects belonging to low- and high-risk HBV exposure such as general population intravenousdrug users patients with hepatocellular carcinoma andimmigrants from geographic areas with high rate of HBVinfection [3 14]

In accordance to other authors [9 22 25 26] our findingsadd consistency to the role of the anti-HBc alone profile as themost adequate serological surrogate of OBI being the onlyfactor significantly associated to a greater probability of OBIdetection although higher prevalence of anti-HBc alone doesnot necessarily reflect significantly higher frequency of OBI[3 9 14 22 25 26] HIV infection has been proposed to havea major effect on OBI leading to more consistent levels insymptomatic HIV as compared to asymptomatic HIV [27]being significantly associatedwith lowerCD

4

+ cell counts [6]In our experience although HBV DNA-positive patients

showed higher levels of HIV RNA the median CD4

+ cellcounts were not significantly different when compared toHBV DNA-negative group and OBI cases were quite simi-larly represented independently to CD

4

+ plasma levelsOverall the contribution of occult HBV to liver dam-

age remains unclear Although ALTAST flares have beenobserved in HCV-positive patients in association with occultHBV [28] in our series we did not find abnormal levelsof biochemical indicators of liver injury in OBI-positivepatients in accordance to the overall trend in the literature[9 18 29] also in correlation to the immunosuppressed stateof HIV-positive subjects [12 30]

In general HCV coinfection has been considered as oneof the main reasons for inducing OBI [31] and prevalences ofoccult HBV infection have been reported to be significantlyhigher in HCV chronically coinfected patients as comparedto HCV-negative individuals [32 33]

In Italy the impact of OBI in cohorts of HIV-positivepatients coinfected with hepatitis C virus was recently inves-tigated either in plasma samples or liver biopsies [9 18]reporting consistent prevalences of OBI and suggesting astrong correlation with HCV Nevertheless in accordancewith other recently published studies [34 35] in our cohortoccult HBV infection was uncommon among anti-HCVpositive subjects and the high frequency of HAART-treatedindividualswithin this specific group (most of themassuminga lamivudine-based therapy) could partially explain the lowprevalence found [36 37]

The positive association between HIV and chronic hep-atitis B infection is well known in terms of higher levelsof HBV DNA and detection of HBV antigens [38 39]especially before the availability of HAART More recentlythe widespread introduction of HAART in clinical practicecommonly associated withHIVHBVdually active drugs (ielamivudine tenofovir and emtricitabine) plays an importantrole in the suppression of virus replication [17] leading tolower levels of OBI in HAART-treated HIV-positive subjects

However as similarly reported by other authors in Italy[9 40] in our study population occult HBV infections

were found either in HAART naıve or treated patients andlamivudine-based HAART did not exert an important effecton HBV DNA detectability

Finally in this study the most part of occult infectionswere sustained by genotype D HBV viral strains which isconsistent with the genotypes circulating in Sicily [14] Inthis regard although it has been suggested that in occultHBV infection preferentially occurring genotype D viruses[9 35 41ndash43] HBV genotypes other than D including the Cgenotype [44 45] as well as A G and E genotypes [14 22 46]have been detected in OBI

Our findings should be interpreted in light of the possiblelimitations of this study including the cross-sectional retro-spective design the use of a single time point testing withoutany followup and the biological compartment explored todetect HBV-DNA Moreover the limited sample size mayhave reduced our ability to detect differences between groupsand the results as such may not be generalizable to othersettings

Nevertheless despite these limitations our results addevidence to the knowledge in this field in a geographic areawhere the increasing trend in migration flows could play animportant role in promoting a modification of the local HBVepidemiology

5 Conclusions

The surveillance of occult HBV infection and its geneticvariability is recommended to better evaluate the viraldynamics and their role in the outcome of the liver damagein HIVHCV coinfected as well as in healthy individuals withHBV serological pattern suggestive of latent HBV infection

Conflict of Interests

All authors report no conflict of interests

References

[1] G Raimondo T Pollicino I Cacciola and G SquadritoldquoOccult hepatitis B virus infectionrdquo Journal of Hepatology vol46 no 1 pp 160ndash170 2007

[2] S Urbani F Fagnoni GMissale andM Franchini ldquoThe role ofanti-core antibody response in the detection of occult hepatitisB virus infectionrdquo Clinical Chemistry and Laboratory Medicinevol 48 no 1 pp 23ndash29 2010

[3] F Vitale F Tramuto A Orlando et al ldquoCan the serologicalstatus of ldquoanti-HBc alonerdquo be considered a sentinel markerfor detection of ldquooccultrdquo HBV infectionrdquo Journal of MedicalVirology vol 80 no 4 pp 577ndash582 2008

[4] M Torbenson and D L Thomas ldquoOccult hepatitis Brdquo TheLancet Infectious Diseases vol 2 no 8 pp 479ndash486 2002

[5] S Levicnik-Stezinar U Rahne-Potokar D Candotti N Lelieand J Allain ldquoAnti-HBs positive occult hepatitis B virus carrierblood infectious in two transfusion recipientsrdquo Journal ofHepatology vol 48 no 6 pp 1022ndash1025 2008

[6] J W T Stuart M Velema R Schuurman C A B Boucherand A IM Hoepelman ldquoOccult hepatitis B in persons infectedwithHIV is associatedwith lowCD4 counts and resolves during


antiretroviral therapyrdquo Journal ofMedical Virology vol 81 no 3pp 441ndash445 2009

[7] S Gupta and S Singh ldquoOccult hepatitis B virus infection inART-naive HIV-infected patients seen at a tertiary care centrein north Indiardquo BMC Infectious Diseases vol 10 article 53 2010

[8] M Hofer H I Joller-Jemelka P J Grob R Luthy and MOpravil ldquoFrequent chronic hepatitis B virus infection in HIV-infected patients positive for antibody to hepatitis B coreantigen onlyrdquo European Journal of Clinical Microbiology andInfectious Diseases vol 17 no 1 pp 6ndash13 1998

[9] G Morsica F Ancarani S Bagaglio et al ldquoOccult hepatitis Bvirus infection in a Cohort of HIV-positive patients correlationwith hepatitis C virus coinfection virological and immunolog-ical featuresrdquo Infection vol 37 no 5 pp 445ndash449 2009

[10] M Rodrıguez-Torres J Gonzalez-Garcia N Brau et alldquoOccult hepatitis B virus infection in the setting of hepatitis Cvirus (HCV) and human immunodeficiency virus (HIV) co-infection clinically relevant or a diagnostic problemrdquo Journalof Medical Virology vol 79 no 6 pp 694ndash700 2007

[11] D Kremsdorf P Soussan P Paterlini-Brechot and C BrechotldquoHepatitis B virus-related hepatocellular carcinoma paradigmsfor viral-related human carcinogenesisrdquo Oncogene vol 25 no27 pp 3823ndash3833 2006

[12] T G Bell E Makondo N A Martinson and A KramvisldquoHepatitis B virus infection in human immunodeficiency virusinfected southern African adults occult or overtmdashthat is thequestionrdquo PLoS ONE vol 7 no 10 Article ID e45750 8 pages2012

[13] F A Di Lello J Macıas C C Cifuentes J Vargas J C Palo-mares and J A Pineda ldquoLow prevalence of occult HBVinfection among HIV-infected patients in southern SpainrdquoEnfermedades Infecciosas y Microbiologia Clinica vol 30 no 6pp 312ndash314 2012

[14] F Tramuto CMMaida GM Colomba et al ldquoOccult hepatitisB infection in the immigrant population of sicily Italyrdquo Journalof Immigrant and Minority Health vol 15 no 4 pp 725ndash7312012

[15] S M Alavian S M Miri F B Hollinger and S M Jazay-eri ldquoOccult hepatitis B (OBH) in clinical settingsrdquo HepatitisMonthly vol 12 no 8 Article ID e6126 8 pages 2012

[16] G Raimondo J Allain M R Brunetto et al ldquoStatementsfrom the Taormina expert meeting on occult hepatitis B virusinfectionrdquo Journal of Hepatology vol 49 no 4 pp 652ndash6572008

[17] A Costantini K Marinelli G Biagioni et al ldquoMolecular analy-sis of hepatitis B virus (HBV) in anHIV co-infected patient withreactivation of occult HBV infection following discontinuationof lamivudine-including antiretroviral therapyrdquo BMC InfectiousDiseases vol 11 article 310 2011

[18] P Fabris M R Biasin M T Giordani et al ldquoImpact of occultHBV infection in HIVHCV co-infected patients HBV-DNAdetection in liver speciments and in serum samplesrdquo CurrentHIV Research vol 6 no 2 pp 173ndash179 2008

[19] D Ferraro P Pizzillo N Urone E Iannitto A Craxi and RDi Stefano ldquoViral sequence analysis of occult HBV infectionand its reactivation in immunosuppressed patientsrdquo Journal ofBiological Regulators amp Homeostatic Agents vol 26 no 3 pp457ndash465 2012

[20] K Azadmanesh M Mohraz A Aghakhani et al ldquoOcculthepatitis B virus infection inHIV-infected patientswith isolatedhepatitis B core antibodyrdquo Intervirology vol 51 no 4 pp 270ndash274 2008

[21] D Neau M Winnock A Jouvencel et al ldquoOccult hepatitis Bvirus infection inHIV-infected patientswith isolated antibodiesto hepatitis B core antigen aquitaine cohort 2002-2003rdquoClinical Infectious Diseases vol 40 no 5 pp 750ndash753 2005

[22] C Firnhaber C Y Chen D Evans et al ldquoPrevalence of hepatitisB virus (HBV) co-infection in HBV serologically-negativeSouth African HIV patients and retrospective evaluation of theclinical course ofmono- and co-infectionrdquo International Journalof Infectious Diseases vol 16 no 4 pp e268ndashe272 2012

[23] S Liang T Chen S S Lee et al ldquoRisk factors of isolatedantibody against core antigen of hepatitis B virus associationwith HIV infection and age but not hepatitis C virus infectionrdquoJournal of Acquired Immune Deficiency Syndromes vol 54 no2 pp 122ndash128 2010

[24] A Ramezani M Mohraz A Aghakhani et al ldquoFrequency ofisolated hepatitis B core antibody in HIV-hepatitis C virus co-infected individualsrdquo International Journal of STD and AIDSvol 20 no 5 pp 336ndash338 2009

[25] R T Gandhi A Wurcel H Lee et al ldquoIsolated antibody tohepatitis B core antigen in human immunodeficiency virustype-1-infected individualsrdquo Clinical Infectious Diseases vol 36no 12 pp 1602ndash1605 2003

[26] M J Mphahlele A Lukhwareni R J Burnett L M Moropengand J M Ngobeni ldquoHigh risk of occult hepatitis B virusinfection in HIV-positive patients from South Africardquo Journalof Clinical Virology vol 35 no 1 pp 14ndash20 2006

[27] L I Compston C Li F Sarkodie S Owusu-Ofori O Opare-Sem and J Allain ldquoPrevalence of persistent and latent virusesin untreated patients infected with HIV-1 from Ghana WestAfricardquo Journal ofMedical Virology vol 81 no 11 pp 1860ndash18682009

[28] R Kannangai P Vivekanandan D Netski et al ldquoLiver enzymeflares and occult hepatitis B in persons with chronic hepatitis Cinfectionrdquo Journal of Clinical Virology vol 39 no 2 pp 101ndash1052007

[29] N M Araujo M Branco-Vieira A C M Silva et al ldquoOcculthepatitis B virus infection in HIV-infected patients evaluationof biochemical virological andmolecular parametersrdquoHepatol-ogy Research vol 38 no 12 pp 1194ndash1203 2008

[30] W H Gerlich C Bremer M Saniewski et al ldquoOccult hepatitisB virus infection detection and significancerdquoDigestive Diseasesvol 28 no 1 pp 116ndash125 2010

[31] V Carreno J Bartolome I Castillo and J A Quiroga ldquoOcculthepatitis B virus and hepatitis C virus infectionsrdquo Reviews inMedical Virology vol 18 no 3 pp 139ndash157 2008

[32] C Cardoso A L Alves F Augusto et al ldquoOccult hepatitis Binfection in Portuguese patients with chronic hepatitis C liverdisease prevalence and clinical significancerdquo European Journalof Gastroenterology amp Hepatology vol 25 no 2 pp 142ndash1462013

[33] I Elgohry A Elbanna and D Hashad ldquoOccult hepatitis B virusinfection in a cohort of Egyptian chronic hemodialysis patientsrdquoClinical Laboratory vol 58 no 9-10 pp 1057ndash1061 2012

[34] M A Abu ElMakaremM Abdel Hamid A Abdel Aleem et alldquoPrevalence of occult hepatitis B virus infection in hemodialysispatients from egypt with or without hepatitis C virus infectionrdquoHepatitis Monthly vol 12 no 4 pp 253ndash258 2012

[35] M K Arababadi A A Pourfathollah A Jafarzadeh et alldquoHepatitis B virus genotype HBsAgmutations and co-infectionwith HCV in occult HBV infectionrdquo Clinics and Research inHepatology and Gastroenterology vol 35 no 8-9 pp 554ndash5592011


[36] N Coppola G Tonziello M Pisaturo et al ldquoReactivation ofovert and occult hepatitis B infection in various immunosup-pressive settingsrdquo Journal of Medical Virology vol 83 no 11 pp1909ndash1916 2011

[37] P Filippini N Coppola R Pisapia et al ldquoImpact of occult hep-atitis B virus infection in HIV patients naive for antiretroviraltherapyrdquo AIDS vol 20 no 9 pp 1253ndash1260 2006

[38] N J Bodsworth D A Cooper and B Donovan ldquoThe influenceof human immunodeficiency virus type 1 infection on thedevelopment of the hepatitis B virus carrier staterdquo Journal ofInfectious Diseases vol 163 no 5 pp 1138ndash1140 1991

[39] S C Hadler F N Judson P M OrsquoMalley et al ldquoOutcome ofhepatitis B virus infection in homosexual men and its relationto prior human immunodeficiency virus infectionrdquo Journal ofInfectious Diseases vol 163 no 3 pp 454ndash459 1991

[40] S Bagaglio L Porrino A Lazzarin and GMorsica ldquoMolecularcharacterization of occult and overt hepatitis B (HBV) infectionin an HIV-infected person with reactivation of HBV afterantiretroviral treatment interruptionrdquo Infection vol 38 no 5pp 417ndash421 2010

[41] B Pinarbasi DOnel F Cosan et al ldquoPrevalence and virologicalfeatures of occult hepatitis B virus infection in female sexworkers who work uncontrolled in Turkeyrdquo Liver Internationalvol 29 no 2 pp 227ndash230 2009

[42] S Ramia A I Sharara M El-Zaatari F Ramlawi and Z Mah-foud ldquoOccult hepatitis B virus infection in Lebanese patientswith chronic hepatitis C liver diseaserdquo European Journal ofClinical Microbiology and Infectious Diseases vol 27 no 3 pp217ndash221 2008

[43] K MWeinberger T Bauer S Bohm andW Jilg ldquoHigh geneticvariability of the group-specific a-determinant of hepatitis Bvirus surface antigen (HBsAg) and the corresponding frag-ment of the viral polymerase in chronic virus carriers lackingdetectable HBsAg in serumrdquo Journal of General Virology vol81 part 5 pp 1165ndash1174 2000

[44] Y Fang X Teng W Xu et al ldquoMolecular characterizationand functional analysis of occult hepatitis B virus infection inChinese patients infected with genotype Crdquo Journal of MedicalVirology vol 81 no 5 pp 826ndash835 2009

[45] Z Fang H Zhuang X Wang X Ge and T J HarrisonldquoHepatitis B virus genotypes phylogeny and occult infection ina region with a high incidence of hepatocellular carcinoma inChinardquo World Journal of Gastroenterology vol 10 no 22 pp3264ndash3268 2004

[46] M R Pourkarim P Lemey S Amini-Bavil-Olyaee et alldquoMolecular characterization of hepatitis B virus strains circu-lating in Belgian patients co-infected with HIV and HBV overtand occult infectionrdquo Journal of Medical Virology vol 83 no 11pp 1876ndash1884 2011

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ldquoP Giacconerdquo Palermo Italy from January 2007 to December2009 in day-hospital regimen for clinical followup of HIVinfection

All demographic clinical and laboratory datawere storedaccording to the Italian laws on privacy and the research wasconducted following the Helsinki Declaration statementsThe study was reviewed and approved by the institutionalreview board of the university hospital

22 Laboratory Analysis Plasma samples of HIV-infectedpatients were collected and kept frozen at minus80∘C until fur-ther analysis HBVHCV serological markers of infec-tion were evaluated for routinary examination by the useof third-generation enzyme-linked-immunosorbent assays(Vitros Immunodiagnostics Ortho-Clinical DiagnosticsHigh Wycombe UK) and anti-HCV-positive samples wereconfirmedwith a third-generation recombinant-immunoblotassay (RIBA) (Ortho-Clinical Diagnostics High WycombeUK)

In addition for the baseline evaluation of liver injurysome biochemical parameters were tested alanineaspartateaminotransferase (ALTAST) totaldirectindirect biliru-bin gamma-glutamyl-transferase and alkaline phosphatase(Ortho-Clinical Diagnostics High Wycombe UK)

Detection of occult HBV infection was carried out inagreementwith the key recommendations of EASL consensusconference [16] In this regard up to 1mL of plasma samplecollected from HBsAg-negative patients was used duringRNA extraction and three different in-house nested-PCRamplification assays were applied to detect pre-SS pre-CoreCore and Pol HBV viral sequences respectively [3]Appropriate negative and positive controls were included ineach PCR reaction

In our study a ldquocase of occult HBV infectionrdquo was definedas a PCR-positivity in at least one of the three HBV domainsdefined after a confirmation of its specificity by sequencing[3]

Viral nucleotide sequences obtained from each PCR-positive sample were submitted to the web-based genotypingprogram at the National Center for Biotechnology Informa-tion (NCBI) (httpwwwncbinlmnihgovprojectsgenoty-pingformpagecgi) to identify the corresponding HBV gen-otype

All tests were performed at the Molecular EpidemiologyLaboratory of the Department of Sciences for Health Promo-tion and Mother and Child Care ldquoG DrsquoAlessandrordquo Hygienesection University of Palermo Italy

23 Statistical Analysis Descriptive statistics were calculatedand reported for sociodemographic and clinical characteris-tics Median and interquartile ranges (IQRs) were used fordescription of continuous variables while frequency analysesfor categorical variables were described with the use ofpercentages

According to data distribution comparisons of con-tinuous variables were conducted by using Students 119905-testor Mann-Whitney 119880 test while categorical variables werecompared with the Chi-square test or Fisherrsquos exact test as

appropriate A 119875 value lt 005 was considered to indicatestatistical significance

A logistic regression analysis was used to examine theassociation between occult HBV status and specific sero-logical pattern of viral infection and the results were ex-pressed as odds ratios (ORs) with 95 confidence intervals(CIs)

Statistic analysis was performed by using STATA forApple (version 121MP StataCorp College Station TXUSA)

3 Results

Table 1 describes the sociodemographic and serological char-acteristics of the study populationThe study group consistedof 405HBsAg-negativeHIV-positive subjects (275males and130 females M F ratio = 21) with a median age of 410 years(IQR = 142 years) females were slightly younger than males(403 years versus 417 years resp)

More than two-thirds of subjects (785 119899 = 318405)reported promiscuous sexual activity as risk behaviour asso-ciated to HIV positivity while intravenous drug use (IVDU)was prevalent among HIVHCV coinfected patients (449119899 = 4498)

The cohort of subjects presented in this paper mainlyconsisted of native Italians (827 119899 = 335405) 156 (119899 =63405) were Africans and only a minority originated fromother geographic regions including Eastern Europe (17 119899 =7405)

According to the HBVHCV serological status five dif-ferent categories were identified One hundred eighty-threeHIV-positive individuals (452) were negative to all of theserologicalmarkers ofHBV infection performed in this study88 (217) were anti-HBs + anti-HBc positive 71 (175)showed the serological profile ldquoanti-HBc alonerdquo and 63(156) were positive to anti-HBs as unique marker of infec-tion Overall 242 of HIV-positive subjects (119899 = 98405)were coinfected with HCV the anti-HBc alone pattern wasmore frequently detected in HCV c-infected individuals thanin HCV-negative subjects (388 versus 107 OR = 53119875 lt 0001)

DNA sequences of hepatitis B viruses were detectedin 24 out of 405 patients (Table 2(a)) corresponding to acumulative prevalence of occult HBV of 59 (CI

95 38ndash87)

HBV DNA resulted more frequently associated to theserological pattern anti-HBc alone (113 119899 = 871)followed by anti-HBs + anti-HBc (68 119899 = 688) and noHBV markers (49 119899 = 9183) Moreover HBV DNAsequences were detected in 3 out of 98 patients coinfectedwith HCV (31) of whom two showed the pattern anti-HBcalone

HIV RNA plasma levels were lower among HBV DNA-negative than -positive individuals (18 log

10HIV RNA

copiesmL versus 28 log10

HIV RNA copiesmL) althoughabout half of OBI cases (417 119899 = 1024) had undetectableHIV viral load (le50 HIV RNA copiesmL)

Overall one hundred forty-five subjects (358) werenaıve to HAART The most part of patients with known









lowast





4


4




4 Discussion





















4




4











5 Conclusions




References

























































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology









lowast





4


4




4 Discussion





















4




4











5 Conclusions




References

























































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology















4




4











5 Conclusions




References

























































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology



















































Volume 2014

Zoology






















Advances in

Virolog y



Volume 2014




Enzyme Research



Microbiology

clinical study prevalence of occult hepatitis b virus...

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