Need for early diagnosis
The study, to be published shortly, involved patients from cancer units. The results showed that the age profile of liver cancer patients was affected by HIV. Liver cancer in Africans occurs at a young age: between the ages of 30 and 40 years. But we found that it occurs at a significantly younger age in those who are infected with HIV and hepatitis B.
Liver cancer is the third most common cause of death among the seven million people who die from cancer annually across the globe.
Early death from liver cancer could be reduced if HIV-positive people were more rigorously screened for hepatitis B.
Diagnosing hepatitis B in HIV-infected people is important because it is treatable. But it often goes undiagnosed. Second, hepatitis B appears to be more aggressive in HIV as viral loads are higher and it is more difficult to clear. The rates of liver cancer may be higher and the risk of onward transmission is greater.
Our study is significant because it highlights the need for early diagnosis of hepatitis B. Screening for the infection is not currently taking place and, as a result, patients are presenting with cancer at a young age, with a late-stage malignancy that could be prevented.
Tackling hepatitis B
Hepatitis B is inflammation of the liver, transmitted through contact with the blood or the body fluids of an infected person. It affects more than 75 million people in Africa.
Hepatitis B is an important international public health problem. We know that more people die from viral hepatitis (that is chronic hepatitis B and C) than from malaria, HIV or tuberculosis. About 240 million people worldwide have chronic hepatitis B infection. Globally, roughly 10% of all people living with HIV are estimated to have chronic hepatitis B co-infection.
A safe and effective vaccine for hepatitis B was developed more than 20 years ago, making it possible to eliminate the infection. But more resources are needed to tackle the two big challenges around hepatitis: early diagnosis and mother-to-child transmission, which is often underestimated and overlooked.
The main challenge is around getting recognition from public health experts and politicians that viral hepatitis is an important public health issue. Cost effective, rapid tests that perform well are available to identify those who have active infection. These tests need to be rolled out to primary care clinics and to hospitals.
The other challenge is around mother-to-child transmission of the disease. Part of the problem is that routine screening for hepatitis B during pregnancy is still nonexistent in most parts of sub-Saharan Africa. As a result, highly infectious pregnant women remain unidentified and their infants are infected. This perpetuates the cycle of infection in communities.
Receiving the hepatitis B vaccine at birth can prevent the transmission of the hepatitis B virus from an infected mother to her baby. Previous research has shown that pregnant women with both hepatitis B and HIV are at high risk of transmitting the infection to their infants.
Yet in South Africa and many other sub-Saharan countries, the vaccine is only administered when the baby is six weeks old, leaving the infant vulnerable to infection at the time of birth.
To change this, the first dose of the vaccine must be brought closer to the time of birth to reduce the risk of perinatal infection and for the implementation of routine screening for hepatitis B virus infection during pregnancy and when HIV is diagnosed.
A dedicated approach
The increasing availability of drugs for the treatment of hepatitis infection has exposed the lack of cost-effective methods for diagnosis and monitoring in resource-poor settings.
And earlier this year the World Health Assembly ratified a strategy of elimination. This is the first ever strategy for the elimination of viral hepatitis. No country has yet eliminated infection. The strategy aims to:
reduce the number of new viral hepatitis infections by 90%; and
reduce the annual deaths from chronic viral hepatitis from 1.4 million to less than 0.5 million by 2030.
To prevent hepatitis B-related liver cancer, the hepatitis B vaccine must be available to all those who need it. In particular, the hepatitis B birth dose vaccine should be administered to all infants in order to prevent the onward transmission of hepatitis B from mother to child. Then we need to screen, including those with HIV, for hepatitis B infection.
In this way the prevalence of chronic infection in African communities will be reduced and those most at risk of developing liver cancer will be identified. The tools to eliminate the impact of this infection are in our hands, the question is: do we have the will to use them?