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Jpn. J. Infect. Dis., 61, 79-81, 2008 Short Communication Prevalence of Human Immunodeficiency Virus (HIV), Hepatitis B Virus, and Hepatitis C Virus in Three Groups of Populations at High Risk of HIV Infection in Amritsar (Punjab), Northern India Neerja Jindal*, Usha Arora and Kamaldeep Singh Microbiology Department, Government Medical College, Amritsar, India (Received July 30, 2007. Accepted November 14, 2007) SUMMARY: Three groups of populations at high risk of human immunodeficiency virus (HIV) infection, i.e., injecting drug users (IDUs), truckers, and attendees of sexually transmitted disease (STD) clinic of Amritsar (Punjab), Northern India, were studied in order to determine the prevalence of HIV, hepatitis B virus (HBV), and hepatitis C virus (HCV) infections. Of the 157 IDUs, 16.6, 17.8, and 33.7% were found to be positive for HIV, HBV, and HCV infections, respectively. HCV showed significant difference (P < 0.01) and very high rate (8.3%) of co-infection with HIV. In truckers, maximum seropositivity was associated with HIV (19%), i.e., significantly higher than that of HBV (6%; P < 0.01) and HCV (3%; P < 0.01). In STD clinic attendees, the highest rate of seroprevalence was that of HIV (4.3%), followed closely by that of HBV (3.7%), and HCV (2.6%). The present study emphasizes the need for early screening for HBV and HCV infections of all those also at high risk for HIV infection, and the results highlight the importance of relevant targeted interventions in these populations. HIV TRIDOT; J. Mitra). HBsAg and anti-HCV antibodies were detected by third-generation enzyme linked immunoassays (Hepalisa; J. Mitra and HCV Microlisa; J. Mitra). The study received the approval of the hospital ethics committee. The chi-square test was used for statistical analysis. The details of risk factors of the three high-risk populations and the serological test results are given in Tables 1 and 2, respectively. The reported prevalence rates of HIV, HBV, and HCV in IDUs, in whom the parentral route is the predominant mode of transmission, vary widely between developing countries and in the USA, a developed country (3,4). In India as well, the pattern is not uniform. The prevalence of HIV in the present study (16.6%; Table 2) was lower than that reported in studies from Delhi (36.9%) and Manipur (59.6%), but was higher than that of a study from Kolkata (1.46%) (5-7). As regards HBV, the observed rate (17.8%; Table 2) was consistent with that in a study from Kolkata (20%), but lower than that reported in a study from Delhi (39.59%) (4,8). As regards HCV infection, the incidence rate was 33.7% (Table 2), which corroborates with the findings from Delhi (36.45%), but was lower than that from studies in Kolkata (42.92%) and Manipur (92%) (6-8). This variation could be due to differences in the IDUs studied. A high rate of seropositivity has been observed in Manipur, a northeastern state of India, and this high rate is primarily due to the sharing of contaminated needles (9). On the other hand, the majority (63.1%) of the present sample was semi-literate and unskilled workers who shared needles, although 36.9% were literate and skilled workers who were using individual disposable syringes. A statistically significant difference (P < 0.01) observed between the prevalence rates of HIV and HCV infections in our study (Table 2), which demonstrates that although all the three infections in IDUs were transmitted via the parenteral route, this route was the major route for the transmission of HCV. HCV-RNA positivity was observed in almost one-third of the HCV antibody-positive IDUs, which indicates that many HCV-positive cases were chronic in nature. An additional risk Hepatitis B virus (HBV) and hepatitis C virus (HCV) share common route of infection and have high degree of epidemiological similarity with respect to high-risk groups with concomitant human immunodeficiency virus (HIV) (1,2). However, the prevalence rates of these infections vary according to the risk factors involved and the initial burden of infectious markers in the community, which may differ not only from country to country, but also in different regions of the same country. Amritsar, a large town in Northern India, adjacent to the border with Pakistan, is a seat of international drug trafficking and is home to a large number of the young people prone to drug addiction. This region also has a high number of highly mobile long-distance truckers. A third group of high-risk individuals is sexually transmitted disease (STD) clinic attendees. These high-risk groups are important to consider in terms of the HIV epidemic. Therefore, the present study was undertaken in order to determine the prevalence of HIV, HBV (hepatitis B surface antigen [HBsAg]), and HCV (anti-HCV antibodies) infections among injecting drug users (IDUs), truckers, and attendees of an STD clinic in Amritsar in the state of Punjab in Northern India. For a period of 2 years, 157 IDUs who were first-time patients at a detoxification center, 100 truckers who were members of a local trucker’s union, and 350 first-time attendees of an STD clinic at the hospital affiliated with the Government Medical College, Amritsar were included in the study. Their complete and relevant histories regarding sexual behavior, drug abuse, and other risk factors was recorded. Blood samples were collected after written consent was obtained from each subject, and after pretest counseling had been provided. HIV antibodies were detected by ELISA (HIV Microlisa; J. Mitra & Co., New Delhi, India), and reactive samples were subjected to two other rapid/simple tests (Comb AIDS-RS; SPAN Diagnostics, Ltd., Surat, India and *Corresponding author: Mailing address: 113, Race Course Road, Amritsar-143001 (Punjab), India. E-mail: neerjarajender@hotmail. com 79 Table 1. Risk factors among three high-risk groups Characteristic and risk factor Multiple sex partners (MSP) MSM Condom usage Drug addiction Oral Intravenous Needle sharing Injecting drug user (n = 157) Male Female (n = 155) (n = 2) Trucker (n = 100) Male Female (n = 100) (n = 0) STD clinic attendee (n = 350) Male Female (n = 180) (n = 170) 141 (90.9) 0 94 (94) – 180 (100) 4 (2.5) 0 0 0 10 (10) 13 (13) – – 0 14 (7.8) 0 0 0 2 (100) 0 82 (82) 6 (6) 0 – 54 (30) 13 (7.2) 3 (1.7) 0 155 (100) 155 (100) 32 (20.6) 21 (12.35) Figures in parenthesis represent percentage. MSM, man who have sex with men. Table 2. Prevalence of HIV, HBV, and HCV among three high-risk groups Infectious marker Injecting drug user (n = 157) No. positive (%) Overall prevalence HIV Overall prevalence HBV Overall prevalence HCV Prevalence - HIV alone Prevalence - HBV alone Prevalence - HCV alone Coinfection - HIV, HBV & HCV Coinfection - HIV & HBV Coinfection - HIV & HCV Coinfection - HBV & HCV 26 (16.6)a 28 (17.8)b 53 (33.7)c 11 (7.0) 22 (14.0) 38 (24.2) 2 (1.3) 2 (1.3) 11 (7.0) 2 (1.3) High-risk population Trucker STD clinic attendee (n = 100) (n = 350) No. positive (%) No. positive (%) 19 (19.0)d 6 (6.0)e 3 (3.0)f 16 (16.0) 4 (4.0) 2 (2.0) 0 2 (2.0) 1 (1.0) 0 15 (4.3)g 13 (3.7)h 9 (2.6)i 5 (1.4) 6 (1.7) 6 (1.7) 0 7 (2.0) 3 (0.85) 0 Statistical analysis Injecting drug users: a & b (P > 0.05) Not significant; a & c (P < 0.05) Significant. Truckers : d & e (P < 0.01) Significant; d & f (P < 0.01) Significant. STD attendees : g & h (P > 0.05) Not significant; g & i (P > 0.05) Not Significant. attendees (Table 2); this rate is lower than that reported in another study (13). One possible explanation for this discrepancy could be difference in the sexual behavior of the populations attending STD clinics in the two different regions. A seroprevalence of 3.7% for HBsAg was determined in our study, and this difference (P > 0.05) was not significantly different from the HIV seroprevalence (Table 2). This finding indicates that this population is almost at equal risk of both HBV and HIV infections, possibly because of multiple sex partners, the presence of genital ulcer diseases, and/or the absence of HBV-interventional strategies, in particular the lack of hepatitis B vaccination among those in our sample. The prevalence of HCV was 2.6% in this subgroup, which could be ascribed to the effects of tattooing, and to the sharing of razors, toothbrushes, and needles, because the sexual route is not an efficient mode of transmission of HCV. In India, the carrier rate of HBV is approximately 3%, and antibodies against HCV are present in 1 - 1.5% of the general population (14). Therefore, high prevalence rates of these infections in the IDUs, truckers, and STD attendees in our study reveal that these groups have a high probability of infection with HBV and/or HCV, regardless of the status of HIV infection. As hepatopathic viral infections in HIV-positive individuals are often chronic and subclinical, and co-infection can lead to more aggressive liver disease, early screening (monitoring) of all high-risk individuals for HBV and HCV, together with HIV screening, is necessary. In addition, it has behavior in IDUs is multiple-partner sex; this behavior was observed in 90% of our sample (Table 1). This finding could account for the high prevalence of HIV and HBV infections of our study, as both diseases are efficiently transmitted via the sexual route (2). Nationwide, 15 - 30% of truckers are reported to be HIVpositive (10). Our findings of 19% seropositivity fell within this range, and these results are directly related to the high prevalence of significant risk factors of this population. The majority of truckers in our study were sexually active and had long been occupied in this profession, forcing them to be away from their homes for long periods of time. These individuals had highly promiscuous sexual behavior (heterosexual 94%, homosexual 10%), and reported low and irregular condom use (Table 1). Seropositivity for HBV was 6% (Table 2) in this group. Two other studies have reported 15.2 and 5.9 and 5.1 and 21.2% seropositivity for HIV and HBV infections, respectively (11,12) among truckers. Such findings suggest that truckers are at high risk of acquiring both HIV and HBV infections. In the present study, anti-HCV antibodies were detected in 3% of the truckers, which is significantly lower (P < 0.01) than the HIV prevalence rate (19%) (Table 2). This discrepancy could be due to sexual transmission, which is the primary route of transmission of HIV and HBV infections among truckers, and is not an efficient means of transmission of HCV (1,4). HIV seropositivity was observed in 4.3% of STD clinic 80 become crucial to extend vigorous, targeted interventions by establishing health education services, support for behavioral changes (e.g., campaigns for safer sexual practices), public awareness of STDs, and by making both condoms and hepatitis B vaccination available and acceptable options. 7. 8. REFERENCES 9. 1. Tankhiwale, S.S., Khadase, R.K. and Jalgoanker, S.V. (2003): Seroprevalence of anti HCV and hepatitis and surface antigen in HIV infected patients. Indian J. Med. 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