Syphilis and Hepatitis B Co-infection among HIV-Infected, Sex-Trafficked Women and Girls, Nepal

Sex trafficking may play a major role in spread of HIV across South Asia. We investigated co-infection with HIV and other sexually transmitted diseases among 246 sex-trafficked women and girls from Nepal. Those who were HIV positive were more likely than those who were HIV negative to be infected with syphilis and/or hepatitis B.


The Study
Data for this study were extracted from medical records of 395 women and girls examined at Maiti Nepal, a large nongovernment organization in Kathmandu, Nepal, which provides shelter and healthcare for sex-traffi cking victims repatriated to Nepal. Upon intake and pending verbal consent, all sex-traffi cking victims at Maiti Nepal are routinely tested for HIV and STIs. We excluded records of 149 because they lacked HIV test or accompanying syphilis or hepatitis B test documentation. Study protocols were approved by the Harvard School of Public Health Human Subjects Committee.
Standard HIV antibody testing was performed by using HIV ELISA, rapid testing, or Western blot. Syphilis testing was performed by using a nontreponemal serologic test, the Venereal Disease Research Laboratory test; all samples tested had titers >1:8 dilution, which strongly suggests true syphilis infection. (11) Serologic detection of the hepatitis B virus surface antigen was indicative of hepatitis B infection.
Age at time of HIV testing ranged from 13 to 40 years (median age 20 years), median age at the time of traffi cking was 17 years (range 7-32 years), and median duration of brothel servitude was 12 months (range <1 month-13 years). A series of Fisher exact tests conducted to assess for potential biases in selection for diagnostic testing showed no differences in demographic or experiential variables (i.e., current age, age at traffi cking, duration in brothel), and Mc-Nemar tests showed no relationship between likelihood of testing for syphilis or hepatitis B based on a positive HIV test result (all p>0.05). Because of the paired nature of the data, the McNemar test involving a continuity correction was used to assess associations between 1) HIV status and co-infection with syphilis, 2) HIV status and co-infection with hepatitis B, and 3) HIV status and co-infection with hepatitis B or syphilis. Of

Conclusions
Our fi ndings demonstrate that HIV-infected sextraffi cking victims are more likely to be infected with other STIs, specifi cally syphilis and hepatitis B, than those not infected with HIV. Current evidence of HIV and STI co-infection implies a need to strengthen clinical practice among providers caring for persons at risk for HIV or other STIs, particularly high-risk populations such as those traffi cked for sexual exploitation or otherwise exposed to commercial sex work. Our fi ndings strongly indicate the need for syphilis and hepatitis B screening for HIV-infected persons and HIV screening for syphilis-and hepatitis B-infected persons. Clinical expertise alone may be insuffi cient to guide treatment decisions in the presence of undetected co-infection (12,13), resulting in missed case detection, incomplete or partial treatment, and suboptimal clinical follow-up.
Appropriate diagnosis of co-infection by comprehensive STI and HIV screening is also important for averting potential development of pathogen drug resistance, a disastrous scenario in a region that is already coping with high rates of syphilis, hepatitis B, and HIV infection. From a clinical perspective, accurate diagnosis of syphilis, hepatitis B, and HIV, alone or in combination, is critical for informed selection of medications to be used in combinations or regimens that reduce the likelihood of inciting drug resistance for the other pathogens. Furthermore, success of STI treatment depends not only on the potency of the antiviral medication but also on the patient's immunocompetence (14). A decision about when to modify a potentially failing or failed STI treatment regimen may thus be better informed by knowledge of HIV status.
Current data highlight prior calls for secondary prevention efforts (i.e., prevention of subsequent transmission) for this population because migration and repatriation of such women and girls has been described as a major factor in the spread of HIV and STIs across South Asia (4). Evidence from the World Health Organization shows that effective treatment of a variety of STIs can reduce HIV transmission rates because many STIs are increasing the risk for HIV acquisition (15). Therefore, treatment of prevailing STIs at the time of repatriation could potentially lessen risk for future HIV acquisition and reduce subsequent transmission to sex partners. The ability to properly treat and reduce the propagation of STIs represents an avenue by which to improve the health of the individual patients as well as potentially reduce rates of HIV in the region.
Finally, these data underscore the need for efforts by both government and nongovernment organizations to expand support for appropriate healthcare services to sextraffi cked women and girls and to develop comprehensive screening guidelines and treatment programs. Currently, most of the few nongovernment organizations serving this vulnerable population are unable to provide the quality of care indicated by our fi ndings. Such improvements are urgently needed to help reduce the alarmingly high rates of HIV and co-occurring STIs among victims of sex traffi cking and to curb the spread of these co-occurring epidemics throughout the region.