Keywords
hepatitis C virus - injection use - hepatitis C viral load
Introduction
Hepatitis C virus (HCV), is a bloodborne, enveloped, RNA icosahedral virus belonging
to the family Flaviviridae and genus Hepacivirus. Infection with HCV can be debilitating leading to chronic hepatitis and life-threatening
complications like cirrhosis, hepatocellular carcinoma, and liver failure, with considerable
morbidity.[1] HCV infection is commonly transmitted through unsafe injection use, unscreened blood
donors, surgery, in utero transmission from mother to child, unsafe sexual behavior,
tattooing, and body piercing.[2] People who inject drugs (PWIDs) are particularly vulnerable to HCV infection and
are reported to have high (>30%) positivity.[3] Worldwide, approximately 50 million people have chronic condition with annual 1
million new HCV infections.
In India, approximately 5.5 million people are currently living with chronic HCV infection.
In addition, India sees approximately 1,40,000 new infections and 26,000 deaths annually
due to HCV infection. India is one of the 10 countries accounting for 80% of all global
HCV infection among PWIDs and one of the 6 countries sharing half of global HCV burden.[4] India has launched the National Viral Hepatitis Control Program (NVHCP), aiming
to eliminate hepatitis due to HCV by 2030 by improving access to diagnosis and treatment.
Under the program, a network of laboratory facilities is created to promote HCV diagnosis.[5]
Different studies have shown hepatitis C infection to be common among preliminary
screenings for viral infections in Himachal Pradesh.[6]
[7] Moreover, there is evidence of significantly increased percentage of HCV infection
in PWIDs from Himachal Pradesh.[8] In the state of Himachal Pradesh, laboratories have been established in almost every
district for HCV testing. Hence, the present study was carried out to assess epidemiology
of HCV and its associated factors using laboratory-based information under NVHCP.
Methods
It was a retrospective record-based assessment performed from April 2023 to December
2024 at a district hospital in Una, Himachal Pradesh, India. Assessment was done for
routinely collected variables under NVHCP, and data were analyzed using R studio (4.3.1).
The chi-square test for categorical variables was used for their association with
HCV positivity. Means were compared with Student's t-test and both were assessed at 5.0% significance level. Logistic regression was done
and odds ratio (OR) was also calculated to assess strength of association between
independent variables and dependent variable (HCV positivity). For viral load, linear
regression was done to assess strength and direction of association with age and duration
of drug use. OR for logistic and coefficient for linear regression with 95% confidence
interval (95% CI) was reported.
Results
A total of 283 records were analyzed. Out of these, 241 (85.2%) were males and 42
(14.8%) were females, with a ratio of 5.4:1. The average and median age of the patients
was 32.4 years and 28 years (range: 14–79 years), respectively. All the patients were
screened for hepatitis C viral load, which was performed by Truenat HCV RNA assay
(Molbio Diagnostics, Goa, India). Patients with detectable load were considered positive
and those with undetectable level as negative. Accordingly, 167 patients (59%) were
positive, while 116 patients (41%) were negative. The mean hepatitis C viral load
was 0.95 × 105 IU/mL.
Majority of the patients (69.6%) belonged to rural area with a male preponderance
(60.8%) and higher number of positive patients (41.3%). Patients belonging to urban
area (30.4%) constituted 17.7% of the positive patients. [Table 1] enlists the association of HCV positivity with basic characteristics of patients.
Table 1
Association of HCV positivity with basic characteristics under National Viral Hepatitis
Control Program (NVHCP) in one district of Himachal Pradesh
|
Characteristics
|
Negative
|
Positive
|
OR (95%CI)
|
|
Male
|
91 (37.8%)
|
150 (62.2%)
|
2.42 (1.2–4.7)
|
|
Female
|
25 (59.5%)
|
17 (40.5%)
|
|
Rural
|
80 (40.6%)
|
117 (59.4%)
|
1.0 (0.6–1.7)
|
|
Urban
|
36 (41.9%)
|
50 (58.1%)
|
|
ART
|
20 (41.7%)
|
28 (58.3%)
|
0.9 (0.5–1.8)
|
|
No ART
|
96 (40.9%)
|
139 (59.1%)
|
|
Pregnant
|
4 (36.4%)
|
7 (63.6%)
|
0.7 (0.1–3.2)
|
|
Nonpregnant
|
18 (41.9%)
|
13 (58.1%)
|
|
PWID
|
75 (36.9%)
|
128 (63.1%)
|
1.8 (1.1–3.0)
|
|
Non-PWID
|
41 (51.2%)
|
39 (48.8%)
|
Abbreviations: ART, antiretroviral therapy; CI, confidence interval; OR, odds ratio;
PWIDs, people who inject drugs.
OR for HCV positivity was not found to be significantly associated with rural area,
antenatal women, and patients on antiretroviral therapy (ART). However, HCV positivity
was found to be significant for males and PWIDs. Approximately, one-fifth of the PWIDs
belonged to urban area (n = 57), whereas, rural area had 2.5 times (n = 146) more PWIDs compared with urban area.
Among HCV-positive individuals, the mean viral load was statistically similar among
drug users [PWID: 0.9 (1.4); non-PWID: 0.6 (1.1)], gender [males: 0.9 (1.5); females:
0.5 (0.6)], and area [rural: 0.8 (1.4); urban: 1.0 (1.4)]. There was no significant
association between age of patients (0.01; 95% CI: 0.04–0.07) or duration of drug
use (0.14; 95% CI: −0.38–0.68) and hepatitis C viral load.
Discussion
Current assessment showed HCV positivity among males and PWIDs. This association might
be possibly driving the disease transmission. It is alarming to note that high frequency
of HCV infection was detected in PWIDs under 40 years of age and accounted for 61%
of HCV-positive individuals in our study. Intravenous drug use (IVDU) is a menace
not only in India, but also all over the globe. IVDU poses a significant risk for
HCV infection and results in uneven distribution of HCV prevalence worldwide.[9] Evidence also shows that globally 43.6% and in South-East Asia region around 21.2%
new HCV infections occur among PWIDs and mostly these PWIDs are males.[10]
A significant number of male PWIDs belonged to rural area and in line with our assessment,
a study also showed differential distribution of HCV infection among PWIDs in rural/urban
areas (rural: 71.0%; urban: 46.8%).[11] It could be inferred that individuals from rural areas might lack awareness regarding
hepatitis C infection transmission through IVDU and need awareness. In contrast to
our result, a study from Himachal Pradesh found young college-going males from urban
area to be the predominant intravenous drug users.[2] Nevertheless, the problem of IVDU needs to be addressed with a focus on tracking,
testing, and treating PWIDs. Therefore, it is suggested that an early linkage of PWIDs
with primary care providers will help in the diagnosis and management of HCV infection
in vulnerable and high-risk groups of people.[12]
In the present study, hepatitis C viral load was nonsignificantly associated with
duration of IVDU, supporting the existing literature.[13] However, results are unequivocal for this type of association. A few studies depicted
a stable hepatitis C viral load over time in certain populations, meanwhile others
have shown substantial variations.[14] Such ambiguities could be the result of sample size, variations in quantifying methods,
and other confounding factors like follow-up duration and study design.
Not only to HCV, PWIDs are prone to human immunodeficiency virus (HIV) infection as
well. HIV weakens the cellular immune responses in patients leading to faster advancement
of chronic HCV. Consequently, treatment of HCV in HIV-coinfected patients ought to
be a high priority.[4] In our study, some of the PWIDs were on ART for HIV/acquired immune deficiency syndrome
(AIDS) treatment. Surveillance of HCV and HIV is important for formulating public
health interventions in PWIDs. More qualitative research is required for estimation
of HCV and HIV prevalence among PWIDs and for providing solutions and measures that
can be practiced for tackling infections. Future investigations aiming to delineate
the ongoing scenario for HCV and HIV infection acquisition and spread in hospital
setting and in general population should be designed. None of the patients in our
study had co-infection with HBV.
There are some limitations to the study. We have analyzed all the available records
and baseline data of the patients presenting at our hospital. Patients were not followed
up in the study. This will take time and in future we are planning another study with
follow-up and treatment. Additionally, we could not get the reports on status of liver
cirrhosis of the patients. Hence, data on cirrhosis versus non-cirrhosis could not
be included in the current study.
This is a hospital-based study and might not mirror the real-world reality of HCV
infection. However, as a first ever report from Una district of Himachal Pradesh on
HCV, it provides the guidance and pilot work for future studies. To conclude, our
results confirm that HCV screening at a secondary-level hospital is timely placed
to monitor the progress of HCV spread under NVHCP. Still, there is a need to share
information with National HIV/AIDS Control Program, as it provides care and support
to PWID—as a key population—under targeted intervention project.[15] This will help in monitoring HCV and HIV incidences and progress toward achieving
elimination targets set by World Health Organization for 2030.
